Patient’s Name : Patient A Attending Physician: 

Medical Diagnosis : 

NANDA Nursing Diagnosis:  [00132] Acute Pain related to Myocardial ischemia resulting from Coronary Artery occlusion as evidenced by Patient complaints of chest pain
accompanied by diaphoresis, slight shortness of breath, nausea, Unstable angina and ST elevation result from ECG

NANDA Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International
Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Cues/Defining Characteristics Nursing Outcomes Classification (NOC) Nursing Interventions Classification (Nic) Evaluation

Subjective: NOC 1: Client Satisfaction: Pain NIC 1: Pain Management NOC 1: Client Satisfaction: Pain
Management a) Perform a comprehensive assessment Management
● Patient complaints of chest [301602] Pain level regularly monitored of pain to include location, characteristics, [301602] Pain level regularly
pain accompanied by 1- Not at all satisfied onset/duration, frequency, quality, intensity or monitored
diaphoresis, slight 2- Somewhat satisfied severity of pain, and precipitating factors. 4- Very satisfied
shortness of breath, 3- Moderately satisfied During the course of patient’s
nausea. 4- Very satisfied b) Encourage patient to discuss his/her hospitalization, his pain level is regularly
5- Completely satisfied pain experience, as appropriate. monitored as during the admission the
● Patient verbalized that he patient complaints chest pain
develops an aching in his [301604] Actions taken to relieve pain c) Observe for nonverbal cues of accompanied by diaphoresis, slight
chest and slight, regular Not at all satisfied discomfort, especially in those unable to shortness of breath, nausea. Early in the
palpitations. The ache is Somewhat satisfied communicate effectively. morning the next day, the patient awakes
still present when he goes Moderately satisfied with nausea and diaphoresis. Moreover,
to bed, when he wakes Very satisfied d) Use therapeutic communication on the third day, the patient has no
several times during the Completely satisfied strategies to acknowledge the pain experience further chest pain, but he reports that his
night, and when he gets up and convey acceptance of the patient’s response nausea persists after meals.Two days
in the morning, seven [301608] Information provided about to pain later, Patient A's LDH value rises to 310
hours after retiring options for pain management IU/L; other enzyme levels remain
(Unstable Angina) . Also, 1-Not at all satisfied e) Utilize a developmentally appropriate essentially the same as the admission
stated that he drinks some 2-Somewhat satisfied assessment method that allows for monitoring values. On day four, a treadmill test is
soda water. 3-Moderately satisfied of change in pain and that will assist in done at 50% effort with negative results.
4-Very satisfied identifying actual and potential precipitating Lastly, Patient A is discharged on day
5-Completely satisfied factors (e.g., flow chart, daily diary). seven.
Objective:
● Unstable Angina
● Patient appears in distress
● VS: -BP: 145/90 mmHg
-HR: 55 bpm
Laboratory:
● Serum Cardiac Enzyme
● LDH: 219 IU/L
Diagnostic:
● ECG: ST Elevation
Medication:
● IV morphine sulfate
● amiodarone IV
● Propanolol
[301601] Pain controlled
1- Not at all satisfied
2- Somewhat satisfied
3- Moderately satisfied
4- Very satisfied
5- Completely satisfied
NOC 2: Pain Control
[160502] Recognizes pain onset
1- Never demonstrated
2- Rarely demonstrated
3- Sometimes demonstrated
4- Often demonstrated
5- Consistently demonstrated
[160501] Describes causal
Factors
1-Never demonstrated
2-Rarely demonstrated
3-Sometimes demonstrated
4-Often demonstrated
5-Consistently demonstrated
[160503] Uses preventive measures
1-Never demonstrated
2-Rarely demonstrated
3-Sometimes demonstrated
4-Often demonstrated
5-Consistently demonstrated
[160504] Uses non-analgesic
measures
1-Never demonstrated
f) Consider type and source of pain when
selecting pain relief strategy.
g) Promote adequate rest/sleep to
facilitate pain relief
h) Control environmental factors that
may influence the patient’s response to
discomfort (e.g., room temperature, lighting,
noise)
i) Verify level of discomfort with patient,
note changes in the medical record, inform
other health professionals working with the
patient
j) Evaluate the effectiveness of the pain
control measures used through ongoing
assessment of the pain experience.
NIC 2: Pain Management
a) Explore with patient the factors that
improve/worsen pain.
b) Provide information about the pain,
such as causes of the pain, how long it will last,
and anticipated discomforts from procedures.
c) Teach the use of nonpharmacological
techniques (e.g., biofeedback, TENS, hypnosis,
relief relaxation, guided imagery, music therapy,
distraction, play therapy, activity therapy,
acupressure, hot/cold application, and massage)
[301604] Actions taken to relieve pain
5- Completely satisfied
The patient’s relief of pain is obtained
with IV morphine sulfate. Additionally,
patient is treated with 0.5 mg IV atropine
sulfate after which his heart rate
increases to 70 bpm and his blood
pressure increases to 130/68 mm Hg.
Also, unifocal PVCs are then treated with
150 mg of amiodarone IV over 10
minutes followed by an amiodarone drip
at 1 mg/minute for 6 hours, then 0.5
mg/minute for 12 hours.
[301608] Information provided about
options for pain management
4-Very satisfied
During the hospitalization of Patient A
he undergone different laboratory and
diagnostic test to thoroughly diagnose
and give him the appropriate pain
management for his condition. In
addition, he was provided with various
medications to attend his needs which
results to a positive outcome.
[301601] Pain controlled
5- Completely satisfied
At the 4th day of Patient A’a
hospitalization he reported that he has no
further chest pain, but his nausea persists
after meals. Hence, on the 7th day he got
discharged.
NOC 2: Pain Control
[160502] Recognizes pain onset
5- Consistently demonstrated
Prior to admission, Patient A claimed
2-Rarely demonstrated
3-Sometimes demonstrated
4-Often demonstrated
5-Consistently demonstrated
[160505] Uses analgesics as recommended
1-Never demonstrated
2-Rarely demonstrated
3-Sometimes demonstrated
4-Often demonstrated
5-Consistently demonstrated
[160509] Recognizes associated
symptoms of pain
1-Never demonstrated
2-Rarely demonstrated
3-Sometimes demonstrated
4-Often demonstrated
5-Consistently demonstrated
[160511] Reports pain
Controlled
1-Never demonstrated
2-Rarely demonstrated
3-Sometimes demonstrated
4-Often demonstrated
5-Consistently demonstrated
before, after, and, if possible, during painful
activities; before pain occurs or increases; and
along with other pain relief measures.
d) Provide the person optimal pain relief
with prescribed analgesics.
e) Institute and modify pain control
measures on the basis of the patient’s response
f) Monitor patient satisfaction with pain
management at specified intervals
that he develops an aching in his chest
and slight, regular palpitations. The ache
is still present when he goes to bed, when
he wakes several times during the night,
and when he gets up in the morning,
seven hours after retiring. Thus, at the
hospital, Patient A complaints of chest
pain accompanied by diaphoresis, slight
shortness of breath, and nausea. Which
therefore shows that Patient A
consistently demonstrated recognition of
pain onset.
[160501] Describes causal
Factors
Patient A described that he experienced
unstable angina and also drinks some
soda water, but when the aching does not
improve, he decides to go to the
emergency department. Moreover, during
health history taking he also stated that
he has a history of hypertension that has
not been treated and even mentioned that
he’s father died due to MI at 55 years of
age.
[160503] Uses preventive measures
2-Rarely demonstrated
Patient A rarely demonstrated preventive
measures as on the onset of experiencing
unstable angina he aggravated the
symptoms by drinking a soda water.
Additionally, he left his hypertension
untreated for 15 years. However, his
discharge planning includes The medical
plan is to continue treatment of his
hypertension with propranolol and he
plans to return to driving his cab, but for
fewer hours per week.
[160504] Uses non-analgesic relief
measures
1-Never demonstrated
During the course of his hospitalization,
Patient a never demonstrated usage of
non-analgesic relief measures as his chest
pain was treated with IV morphine
sulfate.
[160505] Uses analgesics as
recommended
5-Consistently demonstrated
In the event of experiencing chest pain,
with the use of IV morphine sulfate, the
patient is given pain relief.
[160509] Recognizes associated
symptoms of pain
5-Consistently demonstrated
Patient A consistently recognizes
associated symptoms of pain felt. Hence,
at the hospital Patient A complaints of
chest pain accompanied by diaphoresis,
slight shortness of breath, and nausea.
[160511] Reports pain
Controlled
5-Consistently demonstrated
Patient A claimed that he has no longer
experienced chest pain on the fourth day
of his hospitalization, but he continues to
feel nauseous after eating meals. Thus,
he was discharged on the seventh day of
his hospitalization.