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    1. The nursing care plan is for a 70-year-old patient named Azza diagnosed with decompensated heart failure who presents with sharp chest pain rated 5/10 that increases with activity and decreases with rest and medication. 2. The expected outcome is that after 8 hours of nursing interventions, Azza will demonstrate adequate cardiac output as evidenced by stable vital signs, no dysrhythmias, decreased episodes of dyspnea, and decreased pain to 1/10 or lower on the pain scale. 3. Nursing interventions include comfort measures, encouraging rest and sleep, instructing the patient in relaxation techniques and diversional activities, and administering aspirin, hydralazine, amlodipine

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    1. The nursing care plan is for a 70-year-old patient named Azza diagnosed with decompensated heart failure who presents with sharp chest pain rated 5/10 that increases with activity and decreases with rest and medication. 2. The expected outcome is that after 8 hours of nursing interventions, Azza will demonstrate adequate cardiac output as evidenced by stable vital signs, no dysrhythmias, decreased episodes of dyspnea, and decreased pain to 1/10 or lower on the pain scale. 3. Nursing interventions include comfort measures, encouraging rest and sleep, instructing the patient in relaxation techniques and diversional activities, and administering aspirin, hydralazine, amlodipine

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    9 views4 pages

    Care PLN

    Uploaded by

    reem
    1. The nursing care plan is for a 70-year-old patient named Azza diagnosed with decompensated heart failure who presents with sharp chest pain rated 5/10 that increases with activity and decreases with rest and medication. 2. The expected outcome is that after 8 hours of nursing interventions, Azza will demonstrate adequate cardiac output as evidenced by stable vital signs, no dysrhythmias, decreased episodes of dyspnea, and decreased pain to 1/10 or lower on the pain scale. 3. Nursing interventions include comfort measures, encouraging rest and sleep, instructing the patient in relaxation techniques and diversional activities, and administering aspirin, hydralazine, amlodipine

    Copyright:

    © All Rights Reserved
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    of 4

    1

    III. Evidence Based Nursing Care Plan (continued) Course Adult I Adult II Critical Care
    Required Care 1 2 3
    Plan(s)
    Nursing Diagnosis #1: Decreased cardiac output related to altered myocardial contractility/inotropic changes evidenced by chest pain.
    Relevant Assessment 19 Intervention / Implementation 24 25
    Expected Outcome Rationale Evaluation
    15 20 Subjective
    Subjective data: Health History after 8 hours of nursing Ongoing Assessment - To assess the
    interventions the pt. will effectiveness of the
    Azza is 70 Y pt., diagnosed with demonstrate adequte nursing interventions After 8 hours of
    decompensated heart failure. She has 8:00 12:00
    cardiac output as and obtain baseline for nursing
    sharp chest pain, 5/10 on pain scale,
    increase when doing any physical evidenced by vital signs HR 70 85 future comparison. interventions ,
    activity and decreased when resting within acceptable limits, goals met as
    and taking the medications. She
    dysrhythmias absent and Spo 93% 93% evidence of the
    received aspirin Tablet 100 mg. 2
    decresed episods of clients report of
    dyspnea , also patient decrease in pain ,
    BP 126/6 121/7
    should verbalize a from 5/10 to 1/10
    0 0
    decrease in pain scale in pain scale. The
    from 5/10 to 1/10 or RR 16 18 pt. didn’t experince
    lower. further
    T 36.5 36.5 complications
    16
    Objective data: Physical
    21
    Preventive Orders - To alleviate pain brought about be
    Assessment - Provide comfort by promoting decreased CO as
    measures such as non- evidenced by BP of
    - Pain is 5/10 feels sharp. Increase
    when moving or applying pressure repositioning or quiet pharmacological 121/70 mmHg,
    and decrease when taking medication environment, and pain warm dry skin,
    and resting. Intermittent pain encourge rest and sleep. management clear lung sounds
    - Vital signs: hear upon
    and reduce
    BP: 126/60 mmHg
    PO2: 93% cardiac ascultatation.
    HR: 70 bats/min workload and
    T: 36.5 C O2 demand.
    RR: 16 b/min

    2
    17 22 Objective
    Diagnostic Data Educative Orders to distract attention and
    - Instruct the patient to reduce tension Negative facial
    High fibrinogen: 4.4 use relaxation To reduce the pain grimace , pt.
    Normal INR: .94 techniques and appears
    Low thrombin time: 12.6 encourage diversional comfortable and
    Low Hb A2: 2.1 activity such as listening relaxed.
    High Troponin T: 43 to music and - Vital signs
    High cholesterol : 8.3 socialization with others - HR : 85
    High triglycerides: 3.7 beats/min
    chest XR was done : congested - BP: 121/70
    - Blood gas CO2: 49.2 mmHg
    - Blood gas O2: 38 - T: 36.5 C
    - RR: 18
    b/min
    - Po2: 93%

    18 23
    Treatment Data Prescriptive Orders To reduce pain , also
    Aspirin Tablet 100 mg / 1 tablet they relax the blood
    Aspirin Tablet 100 mg per day vessels to make the
    Hydralazine Tablet 25 mg Hydralazine Tablet 25 mg blood flow easily and
    Amlodipine Tablet 10 mg Amlodipine Tablet 10 mg some of them slow HR
    Bisoprolol Tablet 2.5 mg Bisoprolol Tablet 2.5 mg to to make it easier for
    the heart to pump
    blood to body.

    3
    4

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