- Student's Name: Inaya Medical Collage

………………….. Nursing Department

.
- Student’s ID: ……..

Nursing Care Plan

MRN: Patient's name:Age:Sex:
Nationality:Occupation:Date of admission:
Admission Diagnosis: MIName of operation:
Date of operation:Post operative days:

Dat Nursing Diagnosis Patient’s goal Nursing D

e intervention ue
da
te
10/9/  Acute Pain  Verbalize 1. Monitor and document characteristic of pain, noting verbal 12/9
2021 R/T Tissue relief/contro reports, nonverbal cues (moaning, crying, grimacing, /202
ischemia AEB l of chest restlessness, diaphoresis, clutching of chest) and BP or heart 1
Reports of pain within rate changes.
chest pain with appropriate 2. Obtain full description of pain from patient including location,
radiation. time frame intensity (using scale of 0–10), duration, characteristics
 for (dull, crushing, described as “like an elephant in my chest”),
administered and radiation. Assist patient to quantify pain by comparing it
medications. to other experiences.
3. Review history of previous angina, anginal equivalent, or MI
pain. Discuss family history if pertinent.
4. Instruct patient to do relaxation techniques: deep and slow
breathing, distraction behaviors, visualization, guided
imagery. Assist as needed.
- Student's Name: Inaya Medical Collage
………………….. Nursing Department
.

 Risk  Maintain 1. Auscultate BP. Compare both arms and obtain lying, sitting,
for Decreased hemodynam and standing pressures when able.
Cardiac ic stability, 2. Evaluate quality of pulses on both pulse points.
Output R/T e.g., BP, 3. Presence of murmurs or friction rubs.
Changes in cardiac 4. Monitor heart rate and rhythm. Document dysrhythmias via
rate, rhythm, output telemetry.
within 5. Provide small and easily digested meals. Limit caffeine intake
electrical
normal and caffeine-containing products.
conduction
range,

adequate
urinary
output,
decreased
frequency/a
bsence of
dysrhythmia
s.
- S tuden
t’s ID: ……..
Dat Nursing Diagnosis Patient’s goal Nursing Du
e intervention e
dat
e