Assessment Diagnosis Planning Intervention Rationale Evaluation

GG, 59-year-old Decreased cardiac Short term goal: Independent: Independent: After 2-4 hours of
female output related to After 2-4 hours of 1. Place patient 1. Upright nursing care, the
myocardial nursing care, the in High position client was able to
Client appears ischemia as client will Fowler’s promotes demonstrate
distressed, pale evidenced by demonstrate position. greater lung improved cardiac
and sweaty. delayed capillary improved cardiac 2. Encourage expansion, output as
refill (4 seconds), output, as relaxation thereby evidenced by
BP - 94/54 mmHg distressed evidenced by techniques reducing stable BP higher
HR - 115 appearance, stable BP higher such as deep workload of than 90/60 mmHg
beats/min pallor, diaphoresis, than 90/60 mmHg breathing heart. but not more than
RR - 26 hypotension (BP but not more than exercises. 2. Deep 120/80 mmHg, HR
breaths/min 94/54 mmHg), and 120/80 mmHg, HR 3. Monitor vital breathing between 60-100
T - 36.2 deg C increased heart between 60-100 signs every helps lower bpm, RR within
SpO2 - 96% with rate and bpm,RR within 15-30 heart rate 12-20 bpm, CRT
no supplemental respiratory rate 12-20 bpm, CRT minutes. and decrease of less than 2
oxygen above normal of less than 2 myocardial seconds, and
Capillary refill range (tachycardia seconds, and Dependent: oxygen improved skin
delayed at 4 and tachypnea). improved skin 1. Administer demand. color.
seconds color. supplemental 3. Continuous
O2 via face monitoring After
History: Long term goal: mask at 3 L provides hospitalization, the
Angina, After per minute as critical data to patient was able to
hypertension, hospitalization, the ordered by detect demonstrate
hypercholesterola patient will the physician. changes in understanding and
emia, type 2 demonstrate 2. Administer patient’s implementation of
diabetes mellitus understanding and medications condition and lifestyle
(T2DM) and acute implementation of as ordered by evaluate modifications to
myocardial lifestyle the physician. effectiveness support
infarction 12 modifications to of cardiovascular
months ago. support interventions. health, as
cardiovascular evidenced by
health, as Dependent: consistent
evidenced by 1. Supplemental adherence to
consistent oxygen prescribed
adherence to supports medications,
prescribed tissue dietary changes,
medications, oxygenation and regular
dietary changes, and reduces exercise.
and regular cardiac
exercise. workload.
2. Medications
will increase
myocardial
contractility
and cardiac
output.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

GG, 59-year-old Acute pain related Short term goal: Independent: Independent: After 2-4 hours of
female to myocardial After 2-4 hours of 1. Monitor vital 1. Continuous nursing care, the
ischemia as nursing care, the signs every monitoring client was able to
Squeezing chest evidenced by pain client will verbalize 15-30 provides verblize relief of
pain. scale of 2 out of relief of chest pain minutes. critical data chest pain as
Patient’s chest is 10, increased as evidenced by 0 2. Encourage to detect evidence by 0 out
tender to heart rate out of 10 pain relaxation changes in of 10 pain pain
palpation, with an (tachycardia) and scale, HR between techniques patient’s scale, HR between
area of maximal increased 60-100 bpm, RR such as deep condition and 60-100 bpm, RR
tenderness on left respiratory rate within 12-20 bpm, breathing evaluate within 12-20 bpm,
side. Pain is (tachypnea), with and absence of exercises. effectiveness and absence of
radiating across to distressed pallor and 3. Provide a of pallor and
the right, up to the appearance, pallor diaphoresis. quiet and interventions. diaphoresis.
neck and down the and diaphoresis. comfortable 2. Deep
right arm. Long term goal: environment breathing After
Client appears After during helps lower hospitalization, the
distressed, pale hospitalization, the hospitalization heart rate patient was able to
and sweaty. patient will . and demonstrate
demonstrate decrease understanding and
Pain scale - 2/10 understanding and Dependent: myocardial implementation of
BP - 94/54 mmHg implementation of 1. Administer oxygen lifestyle
HR - 115 lifestyle medications demand. modifications to
beats/min modifications to as ordered by 3. A quiet and support
RR - 26 support the physician. comfortable cardiovascular
breaths/min cardiovascular environment health, as
T - 36.2 deg C health, as helps reduce evidenced by
SpO2 - 96% with evidenced by sensory input consistent
no supplemental consistent that could adherence to
oxygen adherence to amplify pain prescribed
prescribed signals, medications,
History: medications, thereby dietary changes,
Angina, dietary changes, promoting a and regular
hypertension, and regular more exercise.
hypercholesterola exercise. tolerable
emia, type 2 experience
diabetes mellitus for the
(T2DM) and acute patient.
myocardial
infarction 12 Dependent:.
months ago. 1. Medications
will increase
myocardial
contractility
and cardiac
output.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

GG, 59-year-old Risk for anxiety Short term goal: Independent: Independent: The patient was
female related to acute The patient will 1. Monitor vital 1. Continuous able to exhibit
myocardial exhibit relaxation signs every monitoring relaxation within 8
Client appears ischemia as within 8 hours of one hour. provides hours of nursing
distressed, pale evidenced by nursing care as 2. Encourage critical data to care as evidenced
and sweaty. distressed evidenced by HR the patient to detect by HR between
appearance, between 60-100 use changes in 60-100 bpm, RR
HR - 115 pallor, diaphoresis, bpm, RR within relaxation patient’s within 12-20 bpm,
beats/min heart rate and 12-20 bpm, and techniques condition and and absence of
RR - 26 respiratory rate absence of such as deep evaluate distressed
breaths/min above normal distressed breathing effectiveness appearance, pallor
T - 36.2 deg C range (tachycardia appearance, pallor exercises of and diaphoresis.
and tachypnea). and diaphoresis. 3. Within one interventions.
hour of 2. Deep The patient was
Long term goal: hospitalizatio breathing able to
The patient will n, explain the helps lower demonstrate
demonstrate procedures heart rate effective coping
effective coping and the and decrease mechanisms as
mechanisms as situation to anxiety. evidenced by a
evidenced by a client and 3. Explaining positive attitude
positive attitude family. the about recovery
about recovery 4. Encourage procedures and motivation to
and motivation to the patient to and situation adhere to
adhere to express helps build prescribed
prescribed feelings and rapport and medications,
medications, concerns aids in dietary changes,
dietary changes, verbally calming the and regular
and regular during each patient. exercise.
exercise. nurse-patient 4. Verbal
interaction for expression
the entire allows
duration of patients to
hospital release
stay... pent-up
5. During the emotions,
8-hour reducing
nursing internal
intervention, stress and
encourage anxiety.
family to 5. When
support patients feel
emotionally supported,
and spiritually stress levels
by providing decrease and
daily sense of
affirmations. security and
well-being
increase.