NURSING CARE PLAN

CASE SCENARIO:
Jamie Lee, A 57 years old an office worker, come to the emergency reported that he is experience blurry vision,
dizziness, nausea and vomiting. His blood pressure was 180/120mmHg.His weight is 209lbs. He has a family
history of hypertension. He also stated the he used to smoke 1-2packs of cigarettes and drink alcohol for the last 5
years. And no any physical activity.

ASSESSMENT NURSIN PLANNING EVALUATION

DIAGNOSIS
GOAL/EXPECTED NURSING RATIONALE
OUTCOME INTERVENTION

SUBJECTIVE: Acute Pain related to After the nursing INDEPENDENT: After the nursing
“Sobrangsakit ng ulo” increased intervention, the intervention, the goal
As patient verbalization. cerebrovascular patient will able to  Established  To build a trust was met.The patient
pressure as verbalized methods rapport with to the patient. was able to
verbalized by the relief of pain. the patient. verbalizedmethods
patient. relief of pain.
 Provided  To optimizing
comfort for quality of life
OBJECTIVE: the patient. by anticipating
and
-Dizziness preventing.
-Nausea
-Vomiting  Asked the  Facilitates
-Headache patient about diagnosis of
-Shortness of breath the specifics problem and
-Blurry Vision of pain the initiation of
Pain Scale:6/10 location, appropriate
characteristi therapy.
cs, Helpful in
intensity(0- evaluating the
10 effectiveness
scale)onset,
 andduration. of therapy.
Also, Note
non- verbal
cues.

 Encouraged
the patient to  It reduces
take bed rest stimulation
during acute and promotes
pain. relaxation

 Minimized or
if possible  .Vasoconstricti
avoid ng activities
vasoconstrict increase
ion activities cerebrovascul
like ar pressure
prolonged and induce
coughing headaches.
and bending
over.

 Assissted
the patient
 Dizziness and
with
blurry vision
ambulation
frequently are
as needed.
associated
with vascular
 Provided headache.
more liquids,
 These
and advised
measures
to take a soft
promote
diet.
general
Recommend
comfort. These
or provided
comfort
non-
measures
pharmacolog
reduce
ical
 measures cerebrovascul
like a calm ar pressure,
and quiet blocks
environment, sympathetic
and comfort nervous
measure. system
response and
relieves
headache.
DEPENDENT:

 Administered
medication
as indicated.  To reduce or
control pain.

CASE SCENARIO:
This 49-year-old married white male school teacher was a 2 pack/day smoker with a history of diabetes mellitus,
hyperlipidemia and obesity, and a family history of coronary artery disease. He was awakened from his sleep at
03:00 with crushing substernal chest pain which radiated to his left arm and was accompanied by shortness of
breath. When paramedics arrived, they found the patient cool, clammy, bradycardic and hypotensive. Intravenous
fluids and atropine were given and he was transported to a suburban hospital. 
On arrival in the emergency department at the hospital, the patient was in considerable distress. He was still
bradycardic. He had no jugular venous distention. He had decreased breath sounds with occasional expiratory
wheezes. At 04:01 his white blood cell count was 7,900/cu mm, hematocrit 45.8%, platelets 246,000/cu
mm, creatine phosphokinase (CPK) 89 IU/L and troponin-I <0.4 ng/ml. Electrocardiogram showed ST-segment
elevation in leads II, III, AVF and V4-V6. Chest x-ray showed borderline cardiomegaly without signs of pulmonary
edema. 
The patient was treated with morphine, atropine and aspirin, but he remained bradycardic and hypotensive. He
had decreasing  pulse oximeter blood oxygen saturation despite supplemental oxygen and he became cyanotic. He
was intubated. A transcutaneous pacemaker was placed. A dopamine drip was started, resulting in an increase in
the patient's blood pressure. He was started on heparin and emergency cardiac catheterization showed non-critical
disease of the left anterior descending and left circumflex arteries but a dominant right coronary artery which was
totally occluded proximally.  
 
  

ASSESSMENT  NURSING PLANNING  EVALUATION 

DIAGNOSIS 
    GOAL/ NURSING RATIONALE   
EXPECTED INTERVENTION 
OUTCOME 
SUBJECTIVE:    After 8hrs of       
 “ Nasakit ang di nursing INDEPENDENT:    The goal was met. 
intervention: 
bdib ko at  nararamda  Monitored  Variation of appearance  
  
man ko rin ang sakit   characteristics of and behavior of patients
Acute pain relat The client will pain, noting verbal in pain may presents a The
maging sa kaliwang b verbalize relief of
ed to Tissue reports, nonverbal challenge in assessment.  client   verbalized
raso ko.” As ischemia pain or ischemic relief of pain or
cues, and v/s.   
verbalized by the (coronary artery signs and     ischemic signs and
occlusion) as symptoms within   symptoms within
patient. 
evidenced by  appropriate time   appropriated time
  substernal frame for frame for
 Improved  Regular and careful
  chest pain with administered respiratory assessment of respiratory administered
OBJECTIVE:  radiation to Left medication.  function  function can help the medication. 
 Cold and clammy   arm and   nurse detect early signs
 bradycardic  abnormal   of pulmonary
 HoTN  breathing    complications. 
 chest pain     
 abnormal breath  
sounds: expiratory  
. 
wheezes   
 Decreased Sp02%  Instructed and  pt t
became cyanotic  o report pain  Decrease external stimuli,
  immediately. w/c
  Provide quiet may aggreviate anxiety
environment, calm and cardiac strain. Limit
activities and coping abilities and
comfort measures. adjustment to current
Approach them situation 
 calmly and  
confidently.   
   
   
DEPENDENT:   
   
   
 Administered  Increase amt of oxygen
supplemental available for myocardial
oxygen by means uptake and thereby may
of nasal cannula or relieve discomfort
face mask, as associated with tis 
indicated.  sue ischemia. 
   
 
 
 
 Administered  Medication therapy is the
medication therapy first line of defense in
as prescribed and preserving myocardial
evaluated the pt’s r tissue 
esponse Morphine use to control
continuously  MI pain. Analgesics may
use to reduce pain and
workload on the heart. 

CASE SCENARIO: CONGENITAL HEART FAILURE 

 
Martha is a 60-year-old lady who is admitted to accident and emergency (A&E) with breathlessness – her
respiratory rate is 40 per minute and her oxygen saturation is 89%. On admission, her pulse is 175 beats per minute
(bpm) and irregular. Her blood pressure is 90/50 mmHg. Martha is put on high-flow oxygen, a continuous cardiac
monitor, hourly observation of vital signs and an intravenous cannula is inserted. Martha is administered intravenous
digoxin and furosemide in A&E and is catheterized to enable accurate fluid balance. Martha is married with three
grown-up children and smokes 20 cigarettes a day. She is then transferred to a medical ward with a cardiac
specialty.  
She is breathless and on oxygen therapy 35% via the mask. She has peripheral oedema and is fluid overloaded.
Furosemide is being administered intravenously. She is on stage 2 of the heart failure care plan but is not receiving
glyceryl trinitrate (GTN) due to hypotension. 
Martha is tachycardic and attached to a cardiac monitor which is showing atrial fibrillation between 110 and
115 bpm. Urinary output is greater than 70 mL/hour. 
Martha is very distressed but knows where she is and why. She is unable to eat or drink at the moment due to her
breathlessness. She is a life-long smoker. She lives with her husband in a third-floor flat with a lift. She still works
part time as a cleaner for a local company. 

ASSESSMENT  NURSING PLANNING  EVALUATION 

DIAGNOSIS 
    GOAL/ NURSING RATIONALE   
EXPECTED INTERVENTION 
OUTCOME 
SUBJECTIVE:  After 8hrs of INDEPENDENT:    The Goal was met: 
 Upon nursing Established Rapport     
Ineffective    
admission she is intervention:    To build trust
breathlessness.  Tissue Perfusion   between  Demonstrated behaviors
  related to  Patient will   the nurse nad the pt to improve circulation. 
  decrease demonstrate    
  , also to lessen may  Displayed vital signs
  cardiac output behaviors to
improve   feel anxious.  within acceptable limits 
  as evidenced by   Elevate the
circulation.   
OBJECTIVE:  breathlessness, head of the
   
 breathlessness  edema and  Display vital bed. 
 Elevation improves
 V/S:  abnormal v/s signs within  
RR: 40 rpm    chest expansion and
acceptable
Sp02%: 89%  limits    oxygenation 
PR: 175 bpm and    
irregular     
BP:90/50 mmHg   
 Teach the  
 Distressed,
inability to eat or drink patient  
that moment  relaxation  Anginal pain is often
 O2 therapy35% techniques and precipitated by
via mask  how to use
emotional stress
 Peripheral them to reduce
edema  stress.  that can be relieved
  by non-
  pharmacological
  measures such as
 
  relaxation. 
   
   
   To prevent
 Instruct patient
heartburn and acid
on eating small
frequent indigestion 
feedings   
   
   
 
DEPENDENT:   
  Administered o  
r assisted with  The vasodilator
self- nitroglycerin
administration
enhances blood flow
of vasodilators,
 as ordered.  to the myocardium.
  It reduces the
 
  amount of blood
  returning to the
  heart, decreasing
  preload, decreasing
 
its workload. 
 
   
 Provide oxygen  Oxygenation
and monitor increases the
oxygen amount of oxygen
saturation via
pulse oximetry, circulating in the
as ordered.  blood and,
  therefore, increases
  the amount of
  available oxygen to
  the myocardium,
  decreasing
  myocardial ischemia
  and pain. 
   
 

 
 
 

CASE SCENARIO: ANGINA PECTORIS

The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of
breath.  Symptoms began approximately 2 days before and had progressively worsened with no associated,
aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic
obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support
at night when sleeping and has requested to use this in the emergency department due to shortness of breath and
wanting to sleep.

She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain,
abdominal distension, nausea, vomiting, and diarrhea.

She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiring blankets, increased
urinary frequency, incontinence, and swelling in her bilateral lower extremities that are new-onset and worsening.
Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak,
fatigued, and short of breath.

There are no known ill contacts at home. Her family history includes significant heart disease and prostate
malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2
years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known
foods, drugs, or environmental allergies.

Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension,
hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity.  Past
surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and
nephrectomy.
Her current medications include fluticasone-vilanterol 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3
times per day, hydrochlorothiazide 25 mg by mouth daily, albuterol-ipratropium inhaled every 4 hours PRN,
levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, clopidogrel 75 mg by mouth daily,
isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily.

Physical Exam

Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, BMI 40.2, and
O2 saturation 90% on room air.

Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral
lower extremities and strong pulses in all four extremities.

Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral
rhonchi, decreased air movement bilaterally. Patient barely able to finish a full sentence due to shortness of breath.

Abdominal: Soft. Obese. Bowel sounds are normal. No distension and no tenderness

Skin: Skin is very dry

 Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses

ASSESSMENT  NURSING PLANNING  EVALUATION 

DIAGNOSIS 
    GOAL/ NURSING RATIONALE   
EXPECTED INTERVENTION 
OUTCOME 
SUBJECTIVE:     
  After 8 hrs of INDEPENDENT:  After 8 hrs of
 She reports difficulty Decreased Cardiac  Established  To build trust
nursing nursing
breathing at rest, Output related to Rapport.  between the nurse
intervention:    and the pt  intervention: The
forgetfulness, mild fatigue, Inotropic
 The client will   .  Goal was met. 
feeling chilled, requiring changes( prolonged
display  Maintained  Decreases O2  Displayed
blankets, increased myocardial ischemia and
hemodynamic bed or chair rest in demand therefore hemodynamic stability 
urinary incontinence, and effects of medications) stability  position comfort reducing  
swelling in her bilateral  The client will during acute Demonstrated
myocardial 
lower extremities that are demonstrate workload, & risk of decrease episodes of
episodes. 
new-onset and worsening  decrease episodes   decompensation.  dyspnea, angina 
  of dyspnea, angina       
OBJECTIVE:   Verbalized      
 SOB  knowledge of the    Verbalized
 Dyspnea  disease   knowledge of the
 Edema  process, individual     disease process,
 V/S:  risk factors and  Encouraged  Timely individual risk factors
TEMP: 97.3 F,   treatment plan.  Immediate reporting ofinterventions can and treatment plan. 
HR: 74bpm  pain for prompt reduce O2
RR: 24,  administration of consumption and
 BP 104/54,   meds as indicated  minimize cardiac
BMI 40.2    complication. 
 O2 saturation 90% on room air.     
 
 Obese
   
 Monitored and  Desired effect
documents effects or is to decrease
adverse response myocardial O2 demand
by decreasing
to medications, noting ventricular stress.
BP, HR and rhythm.  Drugs with negative
  inotropic properties can
  decrease perfusion to
  an already ischemic
  myocardium. 
   
   
   
   
   
DEPENDENT:   Timely
 Encouraged interventions can
Immediate reporting ofreduce O2
pain for prompt consumption and
administration of minimize cardiac
meds as indicated  complication 
   
   
 Administer  
supplemental O2 as IncreaseO2 available
needed.  for myocardial uptake
  to improve contractility