Introduction:

For the purpose of privacy and confidentiality, the real name of the patient in this Case Study is
withheld and she will referred to as Patient X
Patient X is a 98 years old female who was currently residing at San Miguel, Tarlac City. Patient
X was admitted at the Central Luzon Doctors Hospital last July 6, 2014 at 10:40pm with a chief
complaint of difficulty of breathing.

Background Knowledge
Congestive Heart Failure describes the inability or failure of the heart to adequately meet the
needs of organs and tissues for oxygen and nutrients. This decrease in cardiac output, the amount of blood
that the heart pumps, is not adequate to circulate the blood returning to the heart from the body and lungs,
causing fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may
include shortness of breath, weakness, and swelling.

What Causes Congestive Heart Failure?
There may be many potential reasons for a patient to develop heart failure. It may be due to
structural damage to the heart, inability of the heart to squeeze properly, medications or drugs that affect
heart function, lung disease, and other underlying medical diseases. More than one cause may be present
at the same time.

Risk Factors
Congestive heart failure is often a consequence of atherosclerotic heart disease and therefore the
risk factors are the same: poorly controlled high blood pressure, high cholesterol, diabetes,smoking, and
family history. Heart valve disease becomes a risk factor as the patient ages. (ww.medicinenet.com)

Congestive Heart Failure Symptoms
The hallmark symptom of left heart failure is shortness of breath or dyspnea (dys=abnormal +
pnea= breathing). This may occur while at rest, with activity or exertion, while lying flat (orthopnea), or
may awaken a patient from sleep (paroxysmal nocturnal dyspnea). The shortness of breath may be due to
fluid (water, mainly) accumulation in the lungs or the inability of the heart to be efficient enough to pump
blood to the organs of the body when called upon in times of exertion or stress. Chest pain or angina may
be associated, especially if the underlying cause of the failure is atherosclerotic heart disease.
(www.medicinenet.com)

When to Call the Doctor
The Doctor should be called if there are signs and symptoms of congestive heart failure and any of
these situations:

Symptoms of sudden heart failure, such as:
o Severe shortness of breath (trouble getting a breath even when resting).
o Suddenly getting an irregular heartbeat that lasts for a while, or getting a very fast
heartbeat along with dizziness, nausea, or fainting.
o Foamy, pink mucus with a cough and shortness of breath.
o Chest pain or pressure, or a strange feeling in the chest.
o Sweating.
o Shortness of breath.
o Nausea or vomiting.
o Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one
or both shoulders or arms.
o Lightheadedness or sudden weakness.
o A fast or irregular heartbeat.


Medical treatment











Objectives
1. To be able to know the meaning of congestive heart failure, its etiology and also its
factors.
2. To know the different nursing intervention and management of congestive heart failure
3. Establish rapport to the patient and SO in order to gather essential information about the
case.
4. To be able to understand the case.
5. Pan the appropriate nursing intervention to address the patients health needs. The
intervention should address not only the physical well being but also with her emotional,
social, and mental welfare.




















Nursing Process
A. Nursing health history
A. Demographic Data

Name: Patient X
Address: San Miguel, Tarlac, City
Gender: Female
Age: 98 yrs. Old
Birthdate: August 9, 1915
Religion: Catholic
Date of admission: July 6, 2014 / 10:40pm
Attending Doctor: Conrado R. Genilo III MD
Admitting Doctor: Maricis C. Lopez MD

B. Chief complaint

Patient X was brought to the hospital and seek medical attention due to the chief
complaint of difficulty of breathing, easily fatigability and

C. History of present illness

1 day prior to admission the patient manifest difficulty of breathing and easy fatigability
with edema at both lower extremities.

Hospitalization

According to her daughter in law, patient X was brought to the hospital for 3 days
admission because of constipation and she was managing though enema last 2012. On the
year of 2013 she also brought to the hospital for check up because of her lumbar fracture
due to fall and the patient advice to wear body brace for management. .


Injuries

Patient X has lumbar fracture last 2013 due to fall and the patient advice to wear
body brace for management. .

Transfusion
Patient X has no previous blood transfusion.

Medication
Her daughter in law says that patient x was taking Analgesic when she experience bone
fracture.

Allergies
Patient X has no Allergies.

Social and Personal History
Patient X has no work but her son says when they were young Patient X always
fishing in the pond to have their food. Her son also added that Patient X always clean
their house while he laundry their clothes. She usually speaks Ilocano when talking to her
son and daughter in law. She also experience living in San Diego California when her
daughter got married and stay there for almost 5 yrs.
Residence
Patient X is currently residing at San. Miguel, Tarlac, City. Their house is made
of concrete materials and it was adequate for them. She lives with her son and sometimes
she was visited by his/her child together with her grandchild.












Nursing Health History
General descriptions of the patient

Patient x is weak looking due to difficulty of breathing because of thick secretions she was
hooked to a venture mask. Sometimes patient is not responsive because of her condition but she
cooperates when needed.

Health perception, health management Pattern

Patient x recently diagnosed having CHF.

Nutritional metabolic Pattern

Patient X loves to eat vegetables and fish. She never add seasonings with MSG contents when
cooking their foods and sometimes she eat meat.

Activity Exercise Pattern

Before Patient X was admitted to the hospital she still doing house hold chores like washing
plates, cleaning their house and laundering their clothes.

Sleep rest Pattern

Patient X wakes up early and sleeps more than 8 hours. She sleep all the time with three to four
pillows and sometimes shes experiencing paroxysmal dyspnea when she lies flat on bed.




















Review of System

General Appearance

Weight loss Weight gain Anorexia *Fatigue
*Weakness Night sweats generalized jaundice

Note: the patient has weak in appearance

Skin

Itch Bruising Rash Bleeding
Lesions Blister Ecchymoses Burns Drainage

Note: No abnormalities in skin found

Ears
Pain Discharge Tinnitus
*Hearing loss

Note: the patient has slightly hearing loss due to aging

Nose

Obstruction Epistaxis Discharges

Note: no abnormalities in skin found

Throat & Mouth

Sore throat Bleeding gums Tooth Ache
Tooth Decay

Note: No abnormalities in throat and mouth

Chest

Cough Hemoptysis Wheeze Pain in Respiration
*Dyspnea *Sputum *Rales

Note: the patient is unable to expel sputum, suctioning performed. Dyspnea and rales is the symptoms of
CHF.

CVS

*Chest pain *Palpitation Dyspnea * Edema
Orthopnea Others__________

Note: Chest pain, Palpitation and Edema because of congestion

GIT

Intolerance Heartburn Nausea Jaundice
Vomiting Pain Bleeding Excessive Gas
Constipation Change in BM Melena

Note: no abnormalities in GIT found

Genito Urinary

Dysuria Nocturia Retension Polyuria
Dribbling Hematuria Flank Pain Tea colored urine
Oliguria

Note: patient experience Oliguria and tea colored urine due to concentration.

Neuro

Headaches Dizziness Memory Loss Fainting
Numbness Tingling Seizures
Paresis Paralysis
Others: ________________
Notes: patient has memory loss due to aging.






Anatomy and Physiology
To understand what occurs in heart failure, it is useful to be familiar with the anatomy of
the heart and how it works. The heart is composed of two independent pumping
systems, one on the right side, and the other on the left. Each has two chambers, an
atrium and a ventricle. The ventricles are the major pumps in the heart.

The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries
carry blood away from the heart while veins carry blood into the heart. The vessels colored blue
indicate the transport of blood with relatively low content of oxygen and high content of carbon
dioxide. The vessels colored red indicate the transport of blood with relatively high content of
oxygen and low content of carbon dioxide.
The Right Side of the Heart
The right system receives blood from the veins of the whole body. This is "used" blood,
which is poor in oxygen and rich in carbon dioxide.
The right atrium is the first chamber that receives blood.
The chamber expands as its muscles relax to fill with blood that has returned from the
body.
The blood enters a second muscular chamber called the right ventricle.
The right ventricle is one of the heart's two major pumps. Its function is to pump the
blood into the lungs.
The lungs restore oxygen to the blood and exchange it with carbon dioxide, which is
exhaled.

The Left Side of the Heart
The left system receives blood from the lungs. This blood is now oxygen rich.
The oxygen-rich blood returns through veins coming from the lungs (pulmonary veins) to
the heart.
It is received from the lungs in the left atrium, the first chamber on the left side.
Here, it moves to the left ventricle, a powerful muscular chamber that pumps the blood
back out to the body.
The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to
perform contractions powerful enough to force the blood to all parts of the body.
This strong contraction produces systolic blood pressure (the first and higher number in
blood pressure measurement). The lower number (diastolic blood pressure) is measured
when the left ventricle relaxes to refill with blood between beats.
Blood leaves the heart through the ascending aorta, the major artery that feeds blood to
the entire body.
The Valves
Valves are muscular flaps that open and close so blood will flow in the right direction.
There are four valves in the heart:
The tricuspid regulates blood flow between the right atrium and the right ventricle.
The pulmonary valve opens to allow blood to flow from the right ventricle to the lungs.
The mitral valve regulates blood flow between the left atrium and the left ventricle.
The aortic valve allows blood to flow from the left ventricle to the ascending aorta.





Pathophysiology
Left Sided Congestive Heart Failure
Pathophysiology














Causes
o Myocardial Infarction
o Hypertension
o Aortic stenos is insufficiency
o Mitral stenos is insufficiency
Reduced myocardial contractility
Increases cardiac workload
Decreased diastolic filling
Obstructions of left atrial emptying
Left atrial pressure Left sided CHF Bloods dams back into
the pulmonary
capillary bed
Stroke volume decreases
Pressure at the
pulmonary capillary bed
Tissue perfusion
decreases
Cellular hypoxia Pulmonary edema
Bloods flow to the kidneys
RAAS stimulation
Vasoconstriction and
reabsorption of Na and water
ECF volume
S/S
Total blood volume
Systemic BP
DRUG STUDY

Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Clopidogre
1 bisulfate
Anti platelet
Drug
75mg
1 tab
OD
Inhibits platelet
aggregation by
inhibiting binding of
adenosipinediphosphate
to its platelet receptor
and subsequent ADP-
mediative activation of
glycoprotein complex
Lactation Active
pathological
bleeding such as
peptic ulcer or
intracranial
hemorrhage.
GI bleeding, purpura,
bruising,
hematoma,
epistaxis,
hematuria,
eye bleeding
(mainly conjunctiva),
intracranial bleeding,
GI disturbances,
diarrhea, rash,
pruritus
-Assess for any active
bleeding as with ulcers or
intracranial bleeding
-take exactly as directed,
may take without regard to
food. Food will lessen
chance of stomach upset
-report any unusual bruising
or bleeding; advise all
providers of prescribed
therapy





Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Lasix Loop diuretic 1 amp
IVP
q8

Inhibits sodium and
chloride
reabsorption at the
proximal tubules,
distal tubules and
ascending tubules
loop of henle
leading to excretion
of water together
with sodium,
chloride and
potassium diuretic,
antihypertensive.
Hypersensitivity
to sulfonylureas
anuria
Orthostatic
hypotension,
thrombophlebitis,
chronic aortitis,
vertigo,headache,
dizziness, paresthesia,
restlessness, fever
photosensitivity,
urticarial, pruritis
necrotizing angitis
-monitor the blood pressure,
fluid intake and output,
electrolytes: potassium,
sodium, calcium, magnesium,
glucose, uric acid and BUN
-monitor neurologic
manifestation of hypokalemia,
hypomagnesemia,
hyponatremia, hyperchloremia
-monitor intake and output
-assess patient for tinnitus,
hearing loss, ear pain






Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Ranitidine Histamine H2
Receptor
blocking drug
50mg
IV
q12
Competitively
inhibits gastric acid
secretion by
blocking the effect
of histamine H2
receptors both
daytime and
nocturnal basal
gastric acid
secretion, as well as
food and
pentagastrin
-simulated gastric
acid are inhibited
Hypersensitivity
History of acute
Porphyria
Long term therapy
Cardiac arrhythmias,
bradycardia, headache,
fatigue, dizziness,
hallucination,
depression, insomnia
-use caution in presence of
renal hepatic impairment
-assess potential for
interactions with other
pharmacological agents patient
may be taking
- assess knowledge/ teach
patient appropriate use,
possible side effects/
appropriate interventions, and
adverse symptoms to repot





Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Rosuvastatin
calcium
Anti-
hyperlipidemic
20 mg 1
tab OD
A fungal metabolite
that inhibits the
enzyme (HGM-
CoA) that catalyzes
the first step in the
cholesterol
synthesis pathway,
resulting in a
decrease
In serum
cholesterol, serum
LDLs (associated
with increased risk
of coronary artery
disease) and either
an increase or no
change in serum
HDLs (associated
with decreased)

hypersensitivity,
impaired hepatic
function,
alcoholism, renal
impairment,
advanced age,
hypothyroidism
Nausea, dyspepsia,
diarrhea, constipation,
vomiting, rhinitis,
sinusitis, cough,
dyspnea, pneumonia
-Arrange for proper
consultation about need for
diet and exercise changes
-Administer drug at bed time
-Monitor patient closely for
signs of muscle injury,
especially higher doses
-Provide comfort measures to
deal with headache, muscle
cramps, or nausea
-Offer support and
encouragement to deal with
disease, diet, drug therapy, and
follow-up care.



Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Kaliumdurule

electrolytic
and water
balance agent
1 tab
TID
Principal
intracellular cation;
essential for
maintenance of
intracellular
isotonicity,
transmission of
nerve impulses,
contraction of
cardiac, skeletal,
and smooth
muscles,
maintenance of
normal kidney
function, and for
enzyme activity.
Plays a prominent
role in both
formation and
correction of
imbalances in
acidbase
metabolism.

Severe renal
impairment; severe
hemolytic
reactions; untreated
Addisons disease;
crush syndrome;
early postoperative
oliguria (except
during GI
drainage);
adynamic ileus;
acute dehydration;
heat cramps,
hyperkalemia,
patients receiving
potassium-sparing
diuretics, digitalis
intoxication with
AV conduction
disturbance.

Nausea, vomiting,
diarrhea, abdominal
distension.
Pain, mental confusion,
irritability, listlessness,
paresthesias of
extremities, muscle
weaknessand heaviness
of limbs, difficulty in
swallowing, flaccid
paralysis.
Oliguria,
anuria.Hyperkalemia


-Monitor I&O ratio and
pattern in patients receiving
the parenteral drug. If oliguria
occurs, stop infusion promptly
and notify physician.
-Monitor for and report signs
of GI ulceration (esophageal
or epigastric pain or
hematemesis).
-Monitor patients receiving
parenteral potassium closely
with cardiac monitor. Irregular
heartbeat is usually the earliest
clinical indication of
hyperkalemia.
-Be alert for potassium
intoxication (hyperkalemia,
see S&S, Appendix F); may
result from any therapeutic
dosage, and the patient may be
asymptomatic.



Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Cordarone

Anti-
arrhythmics

200mg
1 tab
TID
Effects result from
blockade of
potassium
chloride leading to
a prolongation
potential duration.

-Contraindicated
In patients
hypersensitivity
to drug or iodine.
-Those with
cardiogenic shock,
second or third
degree AV block,
severe SA node
disease resulting
in bradycardia
unless an artificial
pacemaker is
present, and in
those for whom
bradycardia has
caused syncope.

CNS : fatigue, malaise,
tremor, peripheral
neuropathy, ataxia,
paresthesia, insomnia,
sleep disturnbances,
headache.
CV: hypotension,
bradycardia,
arrhythmias, heart
failure, heart block,
sinus arrest, edema.
EENT: visual
disturbances, optic
neuropathy, or
neuritis resulting in
visual impairment,
abnormal smell.
GI : Nausea, vomiting,
abnormal taste,
anorexia,
constipation,
abdominal pain.
Hematologic :
coagulation
abnormalities
Hepatic : hepatic
-Monitor blood pressure and
heart rate and rhythm
frequently.
-Perform continuous ECG
monitoring when starting or
changing doses. Notify
prescriber or significant
change in assessment result.
-Watch carefully for
pulmonary toxicity.
-Watch for evidence of
pneumonitis, exertional
dyspnea, non productive
cough, and pleuritic chest
pain.

failure , hepatic
dysfunction
Metabolic :
hypothyroidism,
hyperthyroidism.
Respiratory : acute
respiratory isease
distress syndrome,
SEVERE PULMONARY
TOXICITY.
SKIN :
photosensitivity, solar
dermatitis, blue gray
skin.








Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Lactulose

Contraindicated
in patients on a
low galactose
diet.

1tbsp
HS
Produces an
osmotic effect in
colon ; resulting
distention
promotes
peristalsis. Also
decrease
ammonia,
probably as a
result of bacterial
degradation,
which lowers the
pH of colon
contents.
Contraindicated in
patients on a low
galactose diet.

Abdominal cramps,
belching, diarrhea,
flatulence, gaseous
distension. Nausea,
vomiting.
-To minimize sweet taste,
dilute with water or fruit
juice or give with food.
-Prepare enema by adding
200g (300ml) to 700 ml of
water or normal saline
solution.
-Monitor mental status
-Replace fluid intake.
-Inform patient about
adverse reactions and tell
him to notify prescriber if
reactions become
bothersome or if diarrhea
occurs.






ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:



Objective:Patient
manifested:
Generalized
weakness
(+) DOB


Easy fatigability After nursing
intervention the
patient will able to
show strength and
energy
1. Assess vital
signs.
2. Determine
presence or
degree of
sleep
disturbances.
3. Obtain client
descriptions
of fatigue.
4. Ask client to
rate fatigue.
5. Plan
interventions
to allow
individually
adequate rest
periods.
6.
Assist with
self-care
needs and
ambulation.
7. Avoid
exposure to
temperature
and humidity
extremes
8. Instruct client
in ways to
monitor
responses to
1. To evaluate
fluid status
and
cardiopulmo
nary
response to
activity.
2. Fatigue can
be a
consequence
of sleep
deprivation.
3. To assist in
evaluating
impact on
clients life.
4. To
determine
degree of
fatigability.

5. To maximize
participation.
6. To conserve
energy for
other tasks.
7. Has negative
impact on
energy level.
8. Indicate the
need to alter
activity level
9. To promote
For further
management
activity and
significant
signs or
symptoms.
9. Promote
overall health
measures
10. Provide
supplemental
oxygen, as
indicated.
11. Assist client
to identify
appropriate
coping
behaviors.


energy
10. Presence of
hypoxemia
reduces
oxygen
available for
cellular
uptakes and
contributes
to fatigue.
11. Promote
sense of
control and
improves
self-esteem.


Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:

Objective:Patient
manifested:
productive
cough
yellowish in
color
presence of
rales upon
auscultation
(+) DOB


Impaired Gas
exchange

After nursing
intervention the
will able to breath
w/o oxygen
therapy, and
decrease secretion
production.
1. Monitor and
record vital
signs
2. Observe color
of skin,
mucous
membranes
and nail beds,
noting
presence of
peripheral
cyanosis.
3. Elevate head
of bed and
encourage
frequent
position
changes.
4. Keep back dry.
5. Promote
adequate rest
periods
6. Change
position q 2
hrs.
7. Keep
environment
allergen free
8. Suction
secretions
PRN
9. Administer
oxygen
therapy as
ordered.

1. To obtain
baseline data
2. Cyanosis of
nail beds
may
represent
vasoconstric
tion or the
bodys
response to
fever/ chills
3. To promote
maximal
inspiration,
enhance
expectoratio
n of
secretions in
order to
improve
ventilation
4. To avoid
coughing
5. Rest will
prevent
fatigue and
decrease
oxygen
demands for
metabolic
demands
6. To promote
drainage of
secretions
7. To reduce
irritant
effects on
airways
8. To clear
For further
evaluation and
management













airway when
secretions
are blocking
the airway.
9. O2 therapy is
indicated to
increase
oxygen
saturation

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:(none)

Objective:Patient
manifested:
Edema on
extremities(
6mm)
DOB

Excess Fluid
Volume

-After nursing
intervention the
patient will be able
to decrease
difficulty of
breathing.
-patientsedema
will decrease from
(6mm) to 0.
-
1. Establish rapport
2. Monitor and record
VS
3. Assess patients
general condition
4. Monitor I&O every 4
hours
5. Assess for presence
of peripheral edema.
Do not elevate legs if
the client is dyspnic.
6. Follow low-sodium
diet and/or fluid
restriction
7. Encourage or
provide oral care q2
8. Monitor for
distended neck veins
and ascites
9. Evaluate urine
output in response
to diuretic therapy.
10. Assess the need for
an indwelling
urinary catheter.
11. Institute/instruct
patient regarding
fluid restrictions as
appropriate.

1. To gain
patients trust
and
cooperation
2. To obtain
baseline data
3. To determine
what
approach to
use in
treatment
4. I&O balance
reflects fluid
status
5. Decreased
systemic
blood
pressure to
stimulation of
aldosterone,
which causes
increased
renal tubular
absorption of
sodium Low-
sodium diet
helps prevent
increased
sodium
retention,
which
decreases
water
retention.
For further
management and
evaluation
Fluid
restriction
may be used
to decrease
fluid intake,
hence
decreasing
fluid volume
excess.
6. The client
senses thirst
because the
body senses
dehydration.
Oral care can
alleviate the
sensation
without an
increase in
fluid intake.
7. Heart failure
causes venous
congestion,
resulting in
increased
capillary
pressure.
When
hydrostatis
pressure
exceeds
interstitial
pressure,
fluids leak out
of
htecpaillaries
and present
as edema in
the legs, and
sacrum.
Elevation of
legs increases
venous return
to the heart.
8. Inidicates
fluid overload
9. Focus is on
monitoring
the response
to the
diuretics,
rather than
the actual
amount
voided
10. Treatment
focuses on
diuresis of
excess fluid.
11. This helps
reduce
extracellular
volume.





Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:(none)

Objective:Patient
manifested:
Edema on
extremities
(grade 6)
DOB

Excess Fluid
Volume

-After nursing
intervention the
patient will be
able to decrease
difficulty of
breathing.
-patientsedema
will decrease from
( grade 6) to 0.
-
12. Establish rapport
13. Monitor and record
VS
14. Assess patients
general condition
15. Monitor I&O every 4
hours
16. Assess for presence
of peripheral edema.
Do not elevate legs if
the client is dyspnic.
17. Follow low-sodium
diet and/or fluid
restriction
18. Encourage or
provide oral care q2
19. Monitor for
distended neck veins
and ascites
20. Evaluate urine
output in response
to diuretic therapy.
21. Assess the need for
an indwelling
urinary catheter.
22. Institute/instruct
patient regarding
fluid restrictions as
appropriate.

12. To gain
patients trust
and
cooperation
13. To obtain
baseline data
14. To determine
what
approach to
use in
treatment
15. I&O balance
reflects fluid
status
16. Decreased
systemic
blood
pressure to
stimulation of
aldosterone,
which causes
increased
renal tubular
absorption of
sodium Low-
sodium diet
helps prevent
increased
sodium
retention,
which
decreases
water
retention.
For further
management and
evaluation
Fluid
restriction
may be used
to decrease
fluid intake,
hence
decreasing
fluid volume
excess.
17. The client
senses thirst
because the
body senses
dehydration.
Oral care can
alleviate the
sensation
without an
increase in
fluid intake.
18. Heart failure
causes venous
congestion,
resulting in
increased
capillary
pressure.
When
hydrostatis
pressure
exceeds
interstitial
pressure,
fluids leak out
of
htecpaillaries



and present
as edema in
the legs, and
sacrum.
Elevation of
legs increases
venous return
to the heart.
19. Inidicates
fluid overload
20. Focus is on
monitoring
the response
to the
diuretics,
rather than
the actual
amount
voided
21. Treatment
focuses on
diuresis of
excess fluid.
22. This helps
reduce
extracellular
volume.

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:


PainObjective:Patient
manifested:
(+) DOB
with a rate of
6 out of 10
with
complaints of
chest pain
unprovoked

Acute Pain

The patient will
verbalize decrease
of pain.
1. Assess
patient pain
for intensity
using a pain
rating scale,
for location
and for
precipitating
factors.
2. Provide
comfort
measures.
3. Establish a
quiet
environment
.
4. Elevate head
of bed.
5. Monitor vital
signs,
especially
pulse and
blood
pressure,
every 5
minutes until
pain
subsides.
6. Teach
patient
relaxation
techniques
and how to
use them to
1. To identify
intensity,
precipitating
factors and
location to
assist in
accurate
diagnosis.
2. To provide
nonpharmacolo
gical pain
management.
3. A quiet
environment
reduces the
energy demands
on the patient.
4. Elevation
improves chest
expansion and
oxygenation.
5. Tachycardia and
elevated blood
pressure usually
occur with
angina and
reflect
compensatory
mechanisms
secondary to
sympathetic
nervous system
stimulation.
6. Anginal pain is
For further
management and
evaluation.
reduce
stress.

often
precipitated by
emotional stress
that can be
relieved non-
pharmacological
measures such
as relaxation.