Carly Hickey

8/30/2022
Simulation Day 1: Health Assessment: Focused Exam-Chest Pain Brain Foster
Care Plan

Nursing Diagnosis #1: Acute pain related to artery occlusion as evidenced by sinus tachycardia with
PVCs, and patient statement 6/10 on the pain scale.
Nursing Interventions x4:
o Using a self-report paint tool, asked the client to identify a comfort function goal that will allow the
client to perform necessary or desired activities easily. (Ackley pg. 677)
o Regularly reassess the client for the presence of pain and response to pain management
interventions, including effectiveness and the presence of adverse effects related to pain
management interventions. Review the clients pain flowsheet and medication administration record
to evaluate effectiveness of pain relief, previous 24-hour opioid requirements, and occurrence of
side effects. (Ackley pg. 678)
o Discuss and evaluate the client's understanding of the total plan for pharmacological and non-
pharmacological treatment, including the medications prescribed and their indication, proper dosing
schedule, and adverse effects and what to do should they occur. (Ackley pg. 681)
o Provide educational materials on various aspects of pain control to improve client understanding of
pain, and pain related interventions. (Ackley pg. 681)

Nursing Diagnosis #2: Ineffective health management related to lack of knowledge of post-cardiac
procedure care, as evidenced by poor diet, sedentary lifestyle prior to hospitalization, and new
placement of cardiac stent.
Nursing Interventions x4:
o Establish a collaborative partnership with the client for purposes of meeting health related goals.
(Ackley pg. 453)
o Help the client identify and modify barriers to effective self-management. (Ackley pg. 453)
o Help the client self-manage his or her own health through education about strategies for changing
habits such as overeating, sedentary lifestyle, and smoking. (Ackley pg. 453)
o Identify the client and or family’s current knowledge in adjust teaching accordingly. Teach the client
and family about all aspects of the therapeutic regimen, providing it's much knowledge as the client
and family will accept, in a culturally congruent manner. (Ackley pg. 455)

Nursing Diagnosis #3: Readiness for enhanced health management, related to health maintenance, as
evidenced by agreement and verbalized comprehensive knowledge of his instructions for post-stent
recovery and long-term heart-health.
Nursing Interventions x4:
o Collaborate with the client to identify strategies to maintain strength and develop additional
strengths as indicated. (Ackley pg. 458)
o Help the client maintain existing support and seek additional support as needed. (Ackley pg. 458)
o Review therapeutic regimens and their optimal integration with daily living routines. (Ackley pg.
459)
o Teach disease process and therapeutic regimens to client and peer supporters for management of
disease processes. (Ackley pg. 460)

Reference:
Ackley, B., & Ladwig, G. (n.d.). Nursing Diagnosis Handbook: An Evidenced-Based guide to Planning Care
(12th ed.). Evolve.