Nursing

Cues Rationale Goals and Objectives Nursing Intervention Rationale Evaluation

Diagnosis
Acute Pain Coronary artery Independent:
Subjective: related to lumen narrows Short Term: After 2 hours of
Bastanatigdanaman la decrease with increase After 2 hourssof nursing 1. Monitored and 1. Variation of nurse and patient
pagsakit it akundughan, as myocardial plaque intervention the patient documented appearance and interaction the
verbalized by Ms. Fearless. blood flow formation, will be able to: characteristics of behavior of pt. was able to:
and ischemia resistance to pain noting patients in pain
Ubsahiya ma blood flow a) Verbalize verbal reports, may present a
ospitalnagkaadanaadtohiyahin increases and character,onset, nonverbal cues challenge in a) Verbalized
chest pain, as verbalized by myocardial location, and BP or heart assessment. Most radiating pain
patients daughter. muscle blood duration,severity,patt rate changes. patients with an from chest to
supply is ern, and associated acute MI appear left arm,
Objective: compromised. factors of pain. ill, distracted, and
Radiating pain from chest to Normal focused on pain.
left arm myocardial
Facial grimace noted muscle has 2. Obtained full 2. Pain is a
Restlessness insufficient description of subjective
Pain scale : 7/10 oxygen uptake. pain from experience and
LDL:4.10 mmol As the amount of patient including must be
CBG: 169 mg/dl blood flow location, described by
Weight: 59 kg through vessels intensity (using patient. Provides
BMI:26(overweight) decreases, scale of 010), baseline for
BP: 180/90 mm hg oxygen uptake duration, comparison to aid
cannot increase characteristicsan in determining
significantly, d radiation. effectiveness of
resulting in therapy, resolution
compromise of and progression of
O2 supply in problem.
tissue that results
to increase 3. Reviewed history 3. Delay in reporting
production of of previous pain hinders pain
lactic acid their angina, anginal relief and may
by causing tissue equivalent, or MI require increased
necrosis, pain. pain. Discuss dosage of
family history if medication to
(Focus on pertinent. achieve relief. In
Pathophysiology addition, severe
by Barbara L. pain may induce
Bullock and Reet shock by
L. Henze. stimulating the
sympathetic
nervous system,
thereby creating
further damage
and interfering
with diagnostics
and relief of pain.

b) Display reduced 4. Instructed 4. Decreases

tension, relaxed patient to report external stimuli,
manner, ease of pain which may
movement. immediately. aggravate
Provided quiet anxiety and b) Displayed
environment, cardiac strain, reduced
calm activities, limit coping tension,
and comfort abilities and relaxed
measures. adjustment to manner, ease
Approach current situation. of movement
c) Demonstrate use of patient calmly
relaxation and confidently.
techniques.
5. Instructed
patient to do 5. Helpful in
relaxation decreasing
techniques: perception and c) Demonstrated
deep and slow response to pain. use of
breathing, Provides a sense relaxation
distraction of having some techniques
behaviors, control over the
visualization, situation, increase
guided imagery. in positive
Assist as needed. attitude.

6. Checked vital 6. Hypotension and

signs before and respiratory
after narcotic depression can
d) Verbalize medication. occur as a result
relief/control of chest of narcotic
pain within administration.
appropriate time These problems
frame for may increase
administered myocardial
medications. damage in d) Verbalized
presence of relief/control
Collaborative ventricular of chest pain
insufficiency. within
7. Administered appropriate
supplemental O2 time frame for
by means of 7. Increase amount administered
nasal cannula or of O2 available medications.
face mask, as myocardial
indicated. uptake and
thereby may Goal Partially
relieve discomfort Met.
associated with
8. Administered tissue ischemia.
medications, as
indicated:

Antiplatelet: Aspirin

Giving aspirin as
soon as possible
(unless
contraindicated)
inhibits platelet
activity,
interrupting
platelet
aggregation at
Antianginals: the site of plaque
Nitroglycerin rupture-key
mechanism in
unfolding acute
MI.

Nitrates are useful

for pain control by
 coronary
vasodilating
effects, which
increase coronary
blood flow and
myocardial
Beta-blockers: perfusion.
Carvedilol Peripheral
vasodilation
effects reduce the
volume of blood
returning to the
heart (preload),
thereby
decreasing
myocardial
workload and
oxygen demand.

Important
second-line
agents for pain
control through
effect of blocking
sympathetic
stimulation,
thereby reducing
heart rate, systolic
BP, and
myocardial
oxygen
demand.May be
given alone or
(8 Ed.,Nursing Care with nitrates. Note:
Plans- Guidelines for beta-blockers
individualizing Client may be
Care Across the Life contraindicated if
Span by Marilyn e. myocardial
Doenges,Mary contractility is
Frances Moorhouse, severely impaired,
Alice C. Murr) because negative
inotropic
properties can
further reduce
contractility.

(8 Ed.,Nursing Care
Plans- Guidelines for
individualizing Client
Care Across the Life
Span by Marilyn e.
Doenges,Mary
Frances Moorhouse,
Alice C. Murr)
 Nursing
Cues Rationale Goals and Objectives Nursing Intervention Rationale Evaluation
Diagnosis
Short term: Independent After 1-2 weeks of
SUBJECTIVE: Impaired Coronary artery nursing intervention
Gas lumen narrows After 2 hours of 1. Assessed 1. Manifestation of the client will was
Nagsakit man an Exchange with increase nursing intervention respiratory rate, respiratory able:
iyadughanamonagkurihiyapaghinga. related to plaque the client will be able: depth, and distress are
Pagdad-a haiya ha hospital diretso chest pain formation, ease. dependent on
man dawhiyagintaganhin oxygen and resistance to a) Demonstrate and indicative
amongamaupaynla, dyspnea blood flow improved of the degree of a) Demonstrated
as verbalized by patients daughter. increases and ventilation and lung improved
myocardial oxygenation of involvement ventilation and
muscle blood tissues by ABGs and underlying oxygenation of
supply is within clients general health tissues by ABGs
Objective: compromised. acceptable 2. Observed color status. within clients
Normal range and of skin, mucous acceptable
Pain radiating from chest to left myocardial absence of membranes and 2. Cyanosis of range and
arms muscles has symptoms of nailbed, noting nailbedsmay absence of
Dizziness insufficient respiratory presence of represent symptoms of
Weakness oxygen uptake. distress. peripheral vasoconstriction respiratory
BP: 180/90 mmHg As the amount b) Participates in cyanosis or or the bodys distress.
PR: 63 BPM of blood flow actions to central cyanosis. response to
RR: 22 CPM through vessels maximize fever or chills; b) Actively
decreases, oxygenation. however, participated in
oxygen uptake cyanosis of actions to
cannot increae earlobes, maximize
significantly, mucous oxygenation.
resulting in membranes ,
compromise of and skin around
O2 supply in the mouth is Goal Partially Met.
tissue. 3. Monitored heart indicative of
As body exerts rate and rhythm. systemic.
movements it
need ample 3. Tachycardia is
amount of usually present
properly as a result of
nourished blood fever and
and high dehydration,
amount of O2. 4. Elevated head but may
Causing and positioned represent a
imbalance at MHBR. response of
supply and Encouraged hypoxia.
demand of O2. deep breathing
and effective 4. These measures
coughing. promote
(Focus on maximal
Pathophysiology inspiration and
by Barbara L. enhance
Bullock and Reet Collaborative expectoration
L. Henze) 5. Monitored ABGs of secretion to
and pulse improve
oximetry. ventilation.

5. Identifies
problems, such
as ventilator
failure; follows
progress of
disease process
or
improvement.
6. Administered
oxygen as 6. Increase
ordered; amount of
maintained oxygen
continuous available for
oximetry. myocardial
uptake;Oximetr
y measures
peripheral
oxygen-
saturation.
7. Prepared for
intubation and 7. With increasing
mechanical hypoxia,
ventilation if mechanical
hypoxia ventilation may
increases. be necessary to
 oxygenate the
(8 Ed.,Nursing Care client
Plans- Guidelines for adequately.
individualizing Client (8 Ed.,Nursing
Care Across the Life Care Plans-
Span by Marilyn e. Guidelines for
Doenges,Mary individualizing
Frances Moorhouse, Client Care
Alice C. Murr) Across the Life
Span by Marilyn
e.
Doenges,Mary
Frances
Moorhouse,
Alice C. Murr)
 GOALS AND
CUES NURSING RATIONALE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSI
S
Subjective: Activity Coronary Short Term: Independent:
Yana dire Intoleranc artery lumen
namangguditonhiyanagtatrabaho. e related narrows with After 1-2 weeks of 1. Documented heart 1. Trends After 1-2 weeks of
Naglalakast-lakat gad to increase nursing intervention rate and rhythm and determine nursing intervention the
hiyausahayperomadalashigdanganka Imbalanc plaque the patient will be changes in BP patients patient was able to:
turog la itonhiya, as verbalized by e formation, able to: before, during, and response
patients daughter. between resistance to after activity. to activity a) Demonstrated
oxygen blood flow a) Demonstrate Correlated with and may measurable/prog
Objective: supply increases and measurable reports of chest pain indicate ressive increase
and myocardial or or shortness of myocardi
in tolerance for
Dizziness demand muscle blood progressive breath. al oxygen
Chest pain after exhaustion supply is deprivatio activity with
increase in
compromised. tolerance for n that may heart
BP: 180/90 mm Hg Normal activity with require rate/rhythm and
PR: 63 BPM myocardial heart decrease BP within
RR: 22 CPM muscles has rate/rhythm in activity patients normal
TEMP: 36.0 C insufficient and BP within level limits and skin
oxygen patients and/or ret
warm, pink, dry.
uptake. As the normal limits urn to
amount of and skin bedrest, b) Reported
blood flow warm, pink, changes absence of
through dry. 2. Encouraged rest in angina with
vessels initially. Thereafter, medicatio activity.
decreases, limited activity on n regimen,
oxygen basis of pain and/or or use of
uptake b) Report adverse cardiac suppleme
cannot absence of response. ntal
increae angina with Providednonstressdiv oxygen.
significantly, activity. ersional activities.
resulting in 2. Reduces
compromise Long Term: 3. Instructed patient to myocardi
of O2 supply avoid increasing al
in tissue. After 3-6 months abdominal pressure workload
As body exerts of nursing (coughing or and
movements it intervention the straining during oxygen
need ample client will be defecation). consumpti
amount of able to easily on,
properly do ADLs reducing
nourished without any risk of
blood and complain of complicati
high amount weakness and ons.
of O2. chest pain.
Causing
imbalance
supply and 4. Explained pattern of
demand of graded increase of
O2. activity level: getting
(Focus on up to commode or 3. Activities
Pathophysiolo sitting in chair, that
gy by Barbara progressive require
L. Bullock and ambulation, and holding
Reet L. Henze) resting after meals. the breath
and
5. Reviewed signs and bearing
symptoms reflecting down
intolerance of (Valsalva
present activity level maneuver
or requiring ) can
notification of nurse result in
or physician. bradycard
ia
Collaborative: (temporaril
y reduced
6. Referred to cardiac cardiac
rehabilitation output)
program. and
rebound
tachycard
ia with
elevated
BP.
(8 Ed.,Nursing Care Plans-
Guidelines for 4. Progressiv
individualizing Client Care e activity
Across the Life Span by provides a
Marilyn e. Doenges,Mary controlled
Frances Moorhouse, Alice demand
C. Murr) on the
heart,
increasing
strength
and
preventing
overexerti
on.

5. Palpitation
s, pulse
irregularitie
s,
developm
ent of
chest
pain, or
dyspnea
may
indicate
need for
changes
in exercise
regimen or
medicatio
n.

6. Provides
continued
support
and/or
additional
supervision
and
participati
on in
recovery
 and
wellness
process.

(8 Ed.,Nursing
Care Plans-
Guidelines for
individualizing
Client Care
Across the Life
Span by
Marilyn e.
Doenges,Mary
Frances
Moorhouse,
Alice C. Murr)
 GOALS AND
CUES NURSING RATIONALE OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Independent Long Term:
Subjective: Readiness to Verbalization of Short Term: 1. Determined 1. Provides After 3-6 month
SigeMaammakumpisalako para enhance Spiritual feelings and After 1-2 weeks of clients religious baseline for the client be will
makapangaroakohinpasaylosaDiyos, Well Being concern about nursing or spiritual planning care able to
as verbalized by Ms. Fearless. current situation intervention the orientation, and accessing acknowledge self
and desire to client will be able: current appropriate -worth and
manage through involvement, resources. continue using
increase reliance a) Verbalize and presence religious beliefs
on religious beliefs feelings and of conflicts. and customs to
and/or concerns cope to lives
participate in about about 2. Established situation and
rituals of a his/her environment 2. Promotes grow more in their
particular faith condition, that promote awareness spiritual lives
tradition in meaning of free expression and
improving way of life, death and of feelings and identification Goal Partially Met.
life. belief system concerns. of feeling so
b) Discuss beliefs Provide calm, they can be
and values peaceful deal with.
about spiritual setting when
issues. possible.
c) Use resources
that can help 3. Listened to
client in clients and
enhancing SOs reports or
spiritual being expression of 3. Help
d) Verbalize anger, understand
acceptance concern, clients and
of self as being alienation from SOs point of
worthy. God, belief view and how
that situation is they are
Long Term: a punishment questioning
After 3-6 month of for wrong their faith in
nursing doing and so the face of
intervention the forth tragedy.
client be will able
to acknowledge 4. Noted sense of
self -worth and futility , feelings
continue using of hopeless
religious beliefs ness and 4. These thoughts
and customs to helplessness and feelings
cope to lives can result in
situation and grow the client
more in their feeling
spiritual lives paralyzed and
unable to
5. Determined move forward
support systems to resolve the
available to situation.
client and SOs.
5. Presence or
lack of support
6. Asked how you systems can
can be most affect clients
helpful. Convey recovery.
acceptance of
clients spiritual 6. Promote trust
belief and and comfort,
concerns. encouraging
clients to be
7. Used open about
therapeutic sensitive
communicatio matters.
n skillsof
reflection and
active listening 7. Helps client
find own
Collaborative solution to
8. Discussed use concerns.
of, and provide
opportunities
for client and
SO to
experience 8. Can help heal
meditation, past and
Prayer, and present pain.\
forgiveness.

Example:
 Refer
patient to
priest in
charge for
Confession
and
Sacrament
of Anointing
of the Sick.

9. Assisted client
to develop 9. Enhances
goals for commitment
dealing with life to goal,
situation.\ optimizing
10. Referred to outcomes and
resources that promoting
can be helpful sense of hope.
such as 10. Specific
pastoral or assistance to
parish nurse, resolve life
religious stressors such
counselors. as relationship
problems etc.
11. Encouraged are important
participation in to advance
support groups. recovery
process.
11. Discussing
concerns and
question with
others can
help client
resolve
feelings.