S

NURSING CARE PLANS

Name :
Age :
DIAGNOSIS OUTCOME INTERVENTION
Acute Pain related to Physical agent (tissue After nursing care 2 x 24 hours of pain in Pain Management
ischemia) patients can be reduced. with criteria: 1. Monitor and document characteristics of
Pain Control pain, noting verbal reports, nonverbal cues,
Possibly Evidenced By Indicator B A for example, moaning, crying, restlessness,
- Verbal/coded reports of pain Recognizes pain onset 2 5 diaphoresis, clutching chest, rapid breathing,
- Facial mask (grimacing) Describes casual factor 2 5 and hemodynamic response (BP and heart
- Restlessness Report uncontrolled symptoms to 2 5 rate changes).
- Changes in heart rate, blood pressure health profesional 2. Obtain full description of pain from client
Use preventive measures 2 5 including location, intensity (using 0 to 10 or
Subjective 1. Never Domonstrated similar scale), duration, characteristics (dull
1. Patients complained pain between the 2. Rarely Domonstrated or crushing), and radiation. Assist client to
chest and neck 3. Sometimes Domonstrated quantify pain by comparing it to other
2. Patients complained sharp pain 4. Often Domonstrated experiences
5. Consistenly Domonstrated 3. Instruct client to report pain immediately
Objective 4. Assist or instruct in relaxation techniques,
1. HR : 140/100 mmHg Pain Level such as deep, slow breathing and distraction.
2. Pulse : 98 x/m Indicator B A 5. Collaboration (Administer medications)
3. RR : 25 x/m 6. Check vital signs before and after
4. Facial grimacing Respiratory rate 2 5 administration of medication.
Blood Pressure 2 5
Radial pulse rate 2 5
1. Servere deviation from normal range
2. Subtantial deviation from normal range
3. Moderate deviation from normal range
4. Mild deviation from normal range
5. No deviation from normal range

Decreased Cardiac Output related to Reduced Hemodynamic Regulation

preload 1. Auscultate apical pulse; assess heart rate,
rhythm, and document dysrhythmia if
Possibly Evidenced By telemetry available.
- Tachycardia 2. Palpate peripheral pulses.
- ECG changes 3. Monitor Blood Presure.
- Fatigue 4. Administer medications, as indicated
5. Monitor serial ECG and chest x-ray changes.
Subjective 6. Measure cardiac output and other functional
1. Patients complained he is tired and weak parameters, as indicated.
2. Patients complained

Objective
1. HR : 140/100 mmHg
2. Pulse : 98 x/m
3. RR : 25 x/m