NURSING CARE PLAN

Pt: 56y/o Male with chief complaint of chest pain

Admission time: 04/06/25 (3:57 PM)
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Acute pain r/t gastric acid SHORT- TERM GOALS: INDEPENDENT: INDEPENDENT: SHORT-TERM GOALS:
 “ Masakit ang kaliwang irritation, secondary to  Relieve pt difficulty of  Assess pain q4h using  Pt shows proper and
tyan tapos umaakyat suspected angina pectoris breathing within 8 hrs of PQRST • Providing baseline data can normal breathing
yung sakit sa dibdib, 4 aeb verbal reports of shift  Encourage rest and immediately detect indications pattern
days na rin na hindi stomach pain radiating  Within 4 hrs of limit physical activity of abnormalities  Pt appeared more
natatae” verbalized by toward the chest and intervention, the pt will  Provide calm and relaxed and
• To reduce oxygen demand
the pt difficulty of breathing. verbalize a reduction in quiet environment comfortable after
 “ Dati lasingero ako chest pain and appear  Educate on proper • Calm surroundings help interventions
pero matagal na yon more relaxed and less deep breathing decrease sympathetic  Pt is well educated
mga 20 years ago” the restless. technique stimulation, helps in lowering on identifying and
pt stated  Pt will know to recognize  Monitor VS closely reporting early s/sx
oxygen demand
s/sx of abnormalities and  Position pt on Semi- of severe
OBJECTIVE: severe complications fowler’s position • Proper breathing techniques complications
 Facial grimace  Educate pt on early reduces tension and may lessen
 Difficulty of Breathing LONG-TERM GOALS: reporting of any pain LONG-TERM GOALS:
pain
 Pale looking  Pt demonstrate coping or discomfort  Pt demonstrated
 Restless and strategies pain and • Monitoring VS helps in strategies of pain
uncomfortable discomforts DEPENDENT: detecting worsening s/sx management and
 Vital signs  Pt will remain free from  Administer discomforts
- BP: 140/80 complications r/t chest prescribed • Positioning pt on Semi-  No recurrence of
- HR: 76 bpm pain and GERD medications folwer’s helps to relieve chest chest pain, pt
- RR: 24  Pt VS will be maintained (Nitroglycerin, pain and provide enough space verbalized
- Spo2: 99% on normal baseline data morphine, aspirin) for lung expansion understanding of
Hx:  Administer care
 (+) HPN for 5 years with prescribed O2 •Educating pt encourages him  VS is maintained on
 maintenance of therapy to identify early s/sx which can normal parameters
amlodipine &  Monitor IV Fluids reduces risks for severe and continuously
telmisartan therapy complications monitored
 (+) GERD
(Gastroesophageal COLLABORATIVE:
Reflux Disease)  Coordinate with
DEPENDENT:
physician for any
diagnostic test order • Prescribed medications helps
 Collaborate with to reduce angina and relieve
other healthcare pain
team for other
symptoms • O2 therapy increase supply of
management O2 in myocardium and relieve
DOB

COLLABORATIVE:
 Coordinating with
physician helps in
identifying the
underlying cause of pain
 Collaboration with other
healthcare team helps
to determine possible
causes of pain and
prevent any
complications