ASSESSMEN DIAGNOSI PLANNIN INTERVENTIO EVALUATI

T S G N ON
Subjective: Ineffective After 1 hour Independent: After
“Parang cardiac of nursing nursing
naninikip yung tissue interventio 1. Monitor VS: intervention
dibdib ko”, as perfusion ns, patient skin s, the patient
verbalized by related to may include temperature is:
the patient reduced relief of and
coronary symptoms peripheral Relieved of
Objective: thrombus of ischemia, pulses pain:
and absence of 2. Supplementa  Absence
(+) Chest Pain atherosclero respiratory l Oxygen of
(+) Levine tic plaque as difficulties, 2L/min by Levine
Sign evidenced adequate means of sign
(+) SOB by chest tissue nasal  Not
(+) Cold and pain, perfusion, cannula irritable
clammy skin shortness of and 3. Keep patient
(+) Restless breath, cold prevention on bed; bed Shows no
and clammy or early rest to signs of
skin, recognition reduce respiratory
V/S: restlessness of any cardiac difficulties:
 T: and unstable complicatio workload  RR:
36.3ºc vital signs ns 18cpm
Dependent:  Absence
 RR:23c
4. Administer of SOB
pm Streptokinas
 PR:110b e 1.5U + 90cc Maintain
D5W to run adequate
pm for 1 hr via tissue
 BP:130/ soluset. perfusion
90 5. Hooked to  Within
cardiac normal
mmHg monitor. range of
 O2: 6. Monitor ECG O2
93%
every 30 saturati
minutes on: O2
before, 96%
during and
after
Streptokinas
e infusion.
7. Administer
Aspirin
80mg, 4 tabs
– to be
chewed.
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATIO EVALUATIO
N N
SUBJECTIVE: Acute pain After 30-1 hour 1. Administer Aspirin After 30-1
“Sobrang sakit ng related to of appropriate 80 mg, 1 tab to be hour of
dibdib ko, para kong shifting of nursing chewed now as appropriate
dinadaganan” as aerobic interventions the ordered nursing
verbalized by the respiration to client will interventions,
unaerobic describe 2.Administer the goal was
Pain Scale: 10/10 respiration as satisfactory pain Clopidogrel 75 mg/tab, met, patient
(+) Crushing Pain evidenced by control at a level 3 tablets swallowed described
crushing pain of less than 6/10 now as ordered satisfactory
OBJECTIVE: with scale of on a rating scale pain control at
10/10, facial of 0 to 10, relief 3.After 45 minutes, a level of 6/10
(+) Facial grimace grimace, Levine of signs and administer Morphine on a rating
(+) Levine sign sign, symptoms and 2 mg and Paracetamol scale of 0 to
(+) Diaphoresis diaphoresis, improve vital 1 amp IV as ordered 10, relieved of
(+) Irritable irritability and signs signs and
unstable vital 4.Administer symptoms and
V/S: signs supplemental oxygen improved vital
 T: 36.3ºc by means of nasal signs
cannula
 RR:23cpm
 PR:110bpm 5.Assess the patients
vital signs and
 BP:130/90
characteristic of pain
mmHg at least 15 minutes
after the
 O2: 93%
administration of
medication

6.Assist patient to rest

with back elevated

7.Instruct patient to do
relaxation techniques:
deep and slow
breathing and
distraction behaviors.

ASSESSME DIAGNOS PLANNIN INTERVENTI EVALUATIO

NT IS G ON N
Subjective: Ineffective After Independent: After nursing
“Hindi ako breathing 30mins of interventions,
makahinga ng pattern r/t nursing 1. Monitor the patient
maayos” as chest pain interventio vital established a
verbalized by as ns, the signs; normal
the patient evidenced patient will note rate respiratory
 by establish a and depth pattern as
Objective: shortness of normal of evidenced by:
breath, respiratory respiratio
(+) SOB pursed lip pattern as n's Absence of
(+) Pursed lip breathing, evidence by 2. Suppleme signs and
breathing use of absence of ntal symptoms of
(+) Use of accessory signs and Oxygen pain and
accessory muscle and symptoms 2L/min hypoxia:
muscle unstable of hypoxia by means  Shortness
vital signs and stable of nasal of breath
V/S:  Pursed-lip
vital signs cannula
 T: 36.3ºc
3. Assist breathing
 RR:23cp patient to  Use of
m rest with accessory
 PR:110b back muscle
pm
elevated;
reposition
 BP:130/ of patient Stable vital
90 every 2 signs:
 T: 36.5ºc
mmHg hours
4. Instruct  RR:20cp
 O2: 93%
patient to m
do  PR:98bp
relaxation
m
technique
s: deep  BP:120/8
and slow 0 mmHg
breathing.  O2: 95%

Dependent:
5. Suppleme
ntal
Oxygen 2-
3L/ min
by means
of nasal
cannula
6. Administer
Morphine 2
mg and
Paracetamol
1 amp IV as
ordered for
chest pain

ASSESSMEN DIAGNOSIS PLANNING INTERVENTIO EVALUATIO

T N N
Objective: Risk for After 1 hour of 1. Monitor After
Patient is under bleeding r/t nursing patients’ appropriate
the medication thrombolytic interventions, vital signs nursing
of the therapy of the the patient will 2. Instruct interventions,
following: prototype drug, be free of patient to goal was met,
streptokinase possible signs of use soft the patient is
Streptokinase and aspirin bleeding, engage bristled free from
1.5 M units in appropriate toothbrush possible signs
behaviors and 3. Instruct the of bleeding,
Aspirin 80 mg lifestyle changes patient to engaged in
to prevent the avoid appropriate
occurrence of forceful behaviors and
bleeding blowing, lifestyle
episodes. coughing, changes to
sneezing, prevent the
and occurrence of
straining to bleeding
have a episodes.
bowel
movement
4. Avoid
intramuscu
lar
injection
5. Instruct
patient to
monitor
signs of
bleeding in
gums, nose
and
color/consi
stency of
the stool
6. Encourage
the patient
to increase
dietary
fiber intake