ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE
Subjective: Ineffective cardiac Build-up of plaque After 8 hours of Independent: After 8 hours of
“Ang sikip ko ng tissue perfusion r/t ↓ nursing intervention, 1. Initially assess, 1. These data assist nursing interventi
dibdib ko nurse reduced coronary Partial blockage of the patient will be document, and in determining the the patient was ab
parang nahihirapan blood flow. coronary arteries able to: report to the cause and effect to:
akong huminga” ↓ a. Report beginning physician the ff: of the chest a. Reports begin
Decreased blood flow relief of chest discomfort and relief of chest
Objective: ↓ discomfort or provide a baseline discomfort or
 v/s: Chest pain symptoms with which post symptoms
BP – 180/60mmHg b. Appear therapy b. Appears
RR – 10cpm comfortable and symptoms can be comfortable a
PR – 105bpm is free from signs compared. free from sign
 responsive but and symptoms and symptom
uncomfortable c. BP, RR, PR, will a. The patient’s a. There are many c. BP, RR, PR, ha
Lab results” return to pre- description of conditions returned to p
 urine output - < discomfort level. chest discomfort, associated with discomfort lev
500 cc d. Adequate cardiac including location, chest discomfort. d. Adequate car
output as intensity, There are output as
evidenced by: radiation, characteristics evidenced by:
Stable/improving duration and the clinical findings pf Stable/improv
ECG factors that affect ischemic pain and ECG
Heart rate & it. symptoms. Heart rate &
rhythm b. The effect of b. MI decreases rhythm
Urine output coronary ischemia myocardial Urine output
e. Will show no on perfusion to contractility and e. Shows no adv
adverse effects the heart, to the ventricular effects from
from medications. brain, to the compliance and medications.
kidneys, and to may produce
the skin. dysrhythmias. The goal was met

2. Ensure physical 2. An ECG during

rest: backrest symptoms may be
elevated to useful in the
promote comfort. diagnosis of
ongoing ischemia.

3. Provide restful 3. Physical rest

environment, and reduces
 allay fears and myocardial
anxiety by being oxygen
calm and consumption.
supportive. Fear and anxiety
precipitate the
stress response;
this results in
increased levels of
endogenous
catecholamines,
which increase
myocardial
oxygen
consumption.
Dependent:

1. Obtain a 12-lead 1. An ECG during

ECG recording symptoms may be
during useful in the
symptomatic diagnosis of
events, as ongoing ischemia.
prescribed, to
assess for ongoing
ischemia.

2. Administer 2. Oxygen therapy

oxygen as increases the
prescribed by the oxygen supply to
physician. the myocardium.

3. Administer 3. Medication
medication therapy is the first
therapy line of defense in
(Nitroglycerin, preserving
Morphine, Beta- myocardial tissue.
blocker, Aspirin)
as prescribed by
the physician and
evaluate the
patient’s response
continuously.