NRS-C007-09-1

LORMA MEDICAL CENTER

Carlatan, San Fernando City, La Union
NURSING CARE PLAN
Name of Patient: LARDIZABAL, WEVELYN Physician: DR. JOSEFINA ZALES
Age: 55
Date of Admission: 10/23/2017 Surgery: NA Date of Surgery: NA
DIAGNOSIS: CC: CHEST PAIN
ASSESSMENT NURSING PLAN NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: 1 Identify precipitating event, if 1. Helps differentiate this Goal met.
Masakit itong dibdib Acute Pain related to At the end any; frequency, duration, chest pain, and aids in
ko, as verbalized by decreased of the shift, intensity, and location of pain. evaluating possible The patient
the patient. myocardial the patient progression to unstable verbalizes relief
blood flow and shall angina. from pain.
Increased verbalize 2. Place patient at complete 2. Reduces myocardial
OBJECTIVE: cardiac relief from rest during anginal episodes. oxygen demand to
workload/oxyge pain. minimize risk of tissue
Restless
n consumption 3. Elevate head of bed if patient injury/necrosis.
Admitting
is short of breath. 3. Facilitates gas exchange
BP: 140/90 to decrease hypoxia and
CR: 70 4. Monitor heart rate/rhythm. resultant shortness of
O2SAT: 98 breath.
T: 36.3C 4. Patients with unstable
RR: 19 angina have an increased
risk of acute life-threatening
dysrhythmias, which occur
5. Stay with patient who is in response to ischemic
experiencing pain or appears changes and/or stress.
anxious. 5. Presence of nurse can
6. Maintain quiet, comfortable reduce feelings of fear and
environment; restrict visitors as helplessness.
necessary. 6. Mental/emotional stress
7. Provide light meals. Have increases myocardial
patient rest for 1 hr after workload.
meals. 7. Decreases myocardial
workload associated with
work of digestion, reducing
8. Provide supplemental risk of anginal attack.
oxygen as indicated. 8. Increases oxygen
available for myocardial
9. Administer antianginal and uptake/reversal of ischemia.
pain medication(s) promptly as 9. provides pharmacologic
indicated support to angina
prevention and
management