CASE SCENARIO:

A 40-year-old male patient named Morel Mackernasey went to Dr. Leorio Paradinight’s clinic for a checkup. Upon interviewing the patient, he
stated, “My chest hurts and I'm having trouble breathing.” His BP exceeded normal range value, 150/90 mmHg. The patient’s heart rate was 111
bpm and his respiration was 22 breaths per minute. The doctor noticed that the patient was having a cool, clammy skin and took the patient’s
temperature and resulted 36.2º C. The doctor asked the patient to rate the pain. 0 for the lowest and 10 for the highest. The patient stated, “It
hurts a lot. Most probably 9.”

NURSING CARE PLAN

PATIENT’S NAME: Morel Mackernasey
AGE: 40
PHYSICIAN: Dr. Leorio Paradinight

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Futile tissue • The patient will no Independent: The goal was met.
Perfusion R/T longer be in pain after
“My chest hurts and myocardial disruption, 8 hours of nursing • Instruct the patient • To minimize further After 8 hours of
I'm having trouble inadequate cardiac interventions. to alert the nurse as risks. nursing intervention,
breathing.” as output, potential soon as they the patient was able
verbalized by the pulmonary • Demonstrate a experience chest pain. to:
patient. obstruction. clear understanding
of the condition and • Evaluate and record • Provides guidelines • The patient showed
Objective: the significance of the the patient's reaction on the disease pain relief.
treatment plan. to the drug. progression.
BP: 150/90 mmHg • The patient
RR: 22 cpm • Exemplify pain demonstrated a clear
PR: 111 bpm relief • If there’s a • Aids in the diagnosis understanding of the
Temperature: 36.2º C by ensuring balanced precipitating incident, of chest pain and the condition and the
Cool Clammy Skin vital sign, absence of consider the frequency, evaluation of the risk significance of the
muscle spasms, and duration, severity, and of angina. medication regimen.
Method used: disorientation. position of the pain.
Pain Scale: 9/10 • The client was
BMI: 29.5 • Observe for signs • To prevent reduction relieved as evidenced
such as neuropathy, in cardiac output. by the patient’s report
nausea, fatigue, in accordance to
dizziness, tachycardia, dyspnea.
and an urge to
micturate.
• During anginal • Decreases
episodes, keep the myocardial oxygen
patient completely still. demand, which lowers
the risk of tissue
damage.

• If the patient is having • To reduce hypoxia

trouble breathing, raise and the subsequent
the head of the bed. shortness of breath.

• Monitor heart rate • Serve as a basis for

and rhythm. any modifications
in the system's
functions.

• Monitor vital signs • Serve as a basis for

every 5 minutes during any modifications
initial anginal attack. in the system's
functions.

• Stay with the patient • To alleviate

when in discomfort or emotional distress and
seems to be in distress. apprehension.

• Provide a calm and • To alleviate mental

comfortable and emotional tension
environment.

• Serve light fare. • Reduces myocardial

After meal, give the workload associated
patient an hour to rest. with digestion
function, lowering the
risk of anginal
paroxysm.

• Administer • Increase the amount

supplementary oxygen. of oxygen required for
myocardial absorption.
 Dependent:

• As advised, • To prevent anginal

administer Nitoglycerin. pain.

• Administer Isosorbide • To prevent anginal

Dinitrate as ordered. attacks.

• Administer • Decreases Angina

Acebutolol as ordered. pectoris.

• Administer Bepridil • Extends coronary

as ordered. arteries.

• Administer • Decreases headaches

Acetaminophen as induced by cerebral
ordered. vessel dilation.

• Administer Morphine • To relieve chest pain.

Sulphate as ordered.

• Take note on the • Will provide a

changes in the ECG. precedent against
which overarching
concept shifts can be
compared.

GROUP LEADER:
VERANIA, MA. TRISHA KAYE C.
MEMBERS:
CABINGAS, ASHLEY
DATUIN, CAMILLE ROSE
GLUMALID, CLEO
PEREZ, JERICO FRED
INSTRUCTOR:
MR. CHRISTIAN CALUZA