III. Among the five (5) nursing problems, create a nursing care plan (based on the scenario).

Limit assessments from the

scenario. Provide realistic nursing care (Philippine setting) and jive your assessments to desired outcome and nursing
intervention.

Name: Malcolm Winchester Sex: Male

Age: 45 Years old Chief complaint: Chest pain and pressure

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: After 8 hours of - Establish a quiet A quiet environment Goal met.
- Patient nursing environment reduces the patient's Patient was
verbalized that intervention, the energy demands. able too
his blood patient will be manifest
pressure was a able to: regular heart
“little high” Ineffective - Elevate the head of the Elevation aids in chest rate and
- Patient reports a Tissue - Display vital bed expansion and rhythm.
stressful job. Perfusion signs within oxygenation.
- Patient related to acceptable limits,
expresses that he Decreased dysrhythmias
does not have a Cardiac absent/controlled - Check for calf With forced bed rest,
formal exercise Output ,and no tenderness, diminished decreased cardiac
regimen symptoms of pedal pulses, swelling, output, and venous
- Patient is a failure. local redness, or pallor pooling, the risk of
smoker. of extremity. thrombophlebitis rises.
- Patient Specifically, the
complained of patient will be
chest pain. able to: - Elevate legs, avoiding Reduces venous
 pressure under the knee return and preload and
Objective: - demonstrate or in a position may lower the risk of
- HPN and type 2 adequate cardiac comfortable to the thrombus or embolus
diabetes run in output as patient. formation.
the family. evidenced by
vital signs within
acceptable limits, - Reposition patient Prolonged immobility
dysrhythmias every two (2) hours. should be avoided for
absent/controlled patients on bed rest
, and no due to deconditioning
symptoms of effects and risks such
failure (e.g., as pressure ulcers,
hemodynamic especially in patients
parameters with edema. In
within acceptable edematous areas,
limits, urinary decreased circulation
output increases the risk of
adequate). pressure ulcers.
- report
decreased
episodes of - Instruct patient on In order to avoid
dyspnea, angina. eating small frequent heartburn and acid
- take part in feedings indigestion,
activities that
reduce the - Teach the patient Anginal pain is
workload on the relaxation techniques frequently caused by
heart. and how to use them to emotional stress,
reduce stress. which can be
alleviated with
non-pharmacological
measures such as
 relaxation.

- Provide oxygen and Oxygenation

monitor oxygen increases the amount
saturation via pulse of oxygen circulating in
oximetry, as ordered. the blood, increasing
the amount of
available oxygen to
the myocardium and
thus reducing
myocardial ischemia
and pain.

Collaborative:
- Collaborate with other To provide a holistic
healthcare professionals care for the patient