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VISION
Governor Panotes Avenue,
“MABINI COLLEGES shall cultivate a CULTURE Daet, Camarines Norte
of EXCELLENCE in education.”
Tel. no. (054) 721-1281 local 109
Email: mabinicollege@hotmail.com
and extension service programs at all educational levels as
its monumental contribution to national and global growth
and development.
Specifically, it transforms students into:
1. God – fearing;
2. Nation – loving;
3. Law abiding;
4. Earth caring;
5. Productive; and
6.Locally and Globally competitive persons

NURSING CARE PLAN

Submitted by:
MORENO, HAROLD ANGELO C.
BSN III – A
Group 3

BYMR
Name: Eden Medino Age: 62 y/o Sex: Female

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Acute pain Goal: Independent: The goal was met.
related to Verbalize - Monitor and - Variation of
“Sumasakit po ang dibdib ko tissue ischemia relief/control of chest document appearance and After 4 hours of nursing
at nahihilo po ako,” as as evidenced pain within characteristic of behavior of patients intervention the patient
verbalized by the patient. by facial appropriate time pain, noting verbal in pain may present a
was able to report of
grimace. frame for reports, nonverbal challenge in
decrease in her chest pain
Objective: administered cues (moaning, assessment. Most
 Diaphoretic, cold, medications. patients with an from 9/10 to 3/10.
crying, grimacing,
clammy skin restlessness, acute MI appear ill,
 Fatigue Short Term: diaphoresis, distracted, and
 Restlessness After 4 hours of clutching of chest) focused on pain.
 Facial girmace nursing interventions and BP or heart rate Verbal history and
 Vital signs taken as the patient will be changes. deeper investigation
follows: able to report of of precipitating
 BP= 140/100 mmHg decrease in chest factors should be
 PR= 80 bpm pain. postponed until pain
 RR= 33 cpm is relieved.
 O2 Sat = 90% Long Term: Respirations may be
 Temperature= 37⁰ After 5 days of increased as a result
 Pain Scale = 9/10 nursing of pain and
interventions, patient associated anxiety;
will be able to display release of stress-
a reduced tension, induced
relaxed manner, ease catecholamine
of movement. increases heart rate
and BP.

- Obtain full - Pain is a subjective

description of pain experience and must
from patient be described by

BYMR
 including location, patient. Provides
intensity (using scale baseline for
of 0–10), duration, comparison to aid in
characteristics (dull, determining
crushing, described effectiveness of
as “like an elephant therapy, resolution
in my chest”), and and progression of
radiation. Assist problem.
patient to quantify
pain by comparing it
to other
experiences.

- Review history of - Delay in reporting

previous angina, pain hinders pain
anginal equivalent, relief and may
or MI pain. Discuss require increased
family history if dosage of medication
pertinent. to achieve relief. In
addition, severe pain
may induce shock by
stimulating the
sympathetic nervous
system, thereby
creating further
damage and
interfering with
diagnostics and relief
of pain.
- Instruct patient to - Decreases external
report pain stimuli, which may
immediately. aggravate anxiety
Provide quiet and cardiac strain,
environment, calm limit coping abilities
activities, and and adjustment to
comfort measures. current situation.
Approach patient
calmly and
confidently.

- Instruct patient to - Helpful in decreasing

do relaxation perception and
techniques: deep response to pain.
and slow breathing, Provides a sense of
distraction having some control
behaviors, over the situation,
visualization, guided increase in positive
imagery. Assist as attitude.
needed.

- Check vital signs - Hypotension and

before and after respiratory
narcotic medication. depression can occur
as a result of narcotic
administration. These
problems may
increase myocardial
damage in presence
of ventricular
insufficiency.
 - Administer - Increases amount of
supplemental oxygen available for
oxygen by means of myocardial uptake
nasal cannula or and thereby may
face mask, as relieve discomfort
indicated. associated with
tissue ischemia.

Collaborative:
Administer medications as
indicated:

- Nitrates are useful for

- Antianginals: pain control by
nitroglycerin (Nitro- coronary vasodilating
Bid, Nitrostat, Nitro- effects, which
Dur), isosorbide increase coronary
dinitrate (Isordil), blood flow and
mononitrate (Imdur) myocardial
perfusion. Peripheral
vasodilation effects
reduce the volume of
blood returning to
the heart (preload),
thereby decreasing
myocardial workload
and oxygen demand.

- Beta-blockers: - Important second-

atenolol (Tenormin), line agents for pain
pindolol(Visken), control through
 propranolol effect of blocking
(Inderal), nadolol sympathetic
(Corgard), stimulation, thereby
metoprolol reducing heart rate,
(Lopressor) systolic BP, and
myocardial oxygen
demand.May be
given alone or with
nitrates. Note: beta-
blockers may be
contraindicated if
myocardial
contractility is
severely impaired,
because negative
inotropic properties
can further reduce
contractility.

- Analgesics: - Although intravenous

morphine, (IV) morphine is the
meperidine usual drug of choice,
(Demerol) other injectable
narcotics may be
used in acute-phase
and/or recurrent
chest pain unrelieved
by nitroglycerin to
reduce severe pain,
provide sedation, and
decrease myocardial
workload. IM
injections should be
avoided, if possible,
because they can
alter the CPK
diagnostic indicator
and are not well
absorbed in
underperfused
tissue.
BYMR