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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluations

The patient presented with acute chest pain and was diagnosed with acute pain related to tissue ischemia. The nursing plan was to monitor the patient for relief of chest pain within 8 hours through medication, relaxation techniques, and vital sign monitoring. Interventions included administering oxygen, medications, and teaching relaxation techniques to help decrease the patient's pain, anxiety, and cardiovascular strain. The nursing rationale was that early pain relief through various interventions could help prevent increased cardiac damage. The patient's pain level and vital signs would be reevaluated after 8 hours of nursing care.

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Ajay Supan
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1K views3 pages

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluations

The patient presented with acute chest pain and was diagnosed with acute pain related to tissue ischemia. The nursing plan was to monitor the patient for relief of chest pain within 8 hours through medication, relaxation techniques, and vital sign monitoring. Interventions included administering oxygen, medications, and teaching relaxation techniques to help decrease the patient's pain, anxiety, and cardiovascular strain. The nursing rationale was that early pain relief through various interventions could help prevent increased cardiac damage. The patient's pain level and vital signs would be reevaluated after 8 hours of nursing care.

Uploaded by

Ajay Supan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment Nursing Planning Interventions Rationale Evaluations

Diagnosis
SUBJECTIVE: Acute pain related to After 8 hours of Monitor and document Variation of appearance After 8 hours of
tissue ischemia as nursing intervention characteristic of pain, and behavior of patients nursing intervention
“My chest is in pain, evidenced by client will verbalize noting verbal reports, in pain may present a client have verbalize
and I feel weak” as changes in pulse and relief/control of chest nonverbal cues challenge in assessment. relief/control of chest
verbalized by the blood pressure and pain within (moaning, crying, Most patients with an pain within
patient report of chest pain. appropriate time grimacing, restlessness, acute MI appear ill, appropriate time
frame for administer diaphoresis, clutching distracted, and focused on frame for
OBJECTIVE: medications, display of chest) and BP or pain. Verbal history and administered
reduce tension, relax heart rate changes. deeper investigation of medications, display
 Tachycardia manner, ease of precipitating factors reduced tension,
 pressure or movement, and should be postponed until relaxed manner, ease
tightness in the demonstrate use of pain is relieved.  of movement, and
chest. relaxation demonstrated use of
 shortness of techniques. relaxation techniques.
breath.
 sweating.
 Discomfort Obtain full description Pain is a subjective
 Weakness of pain from patient experience and must be
 nausea. including location, described by patient.
 anxiety. intensity (using scale of Provides baseline for
0–10), duration, comparison to aid in
characteristics determining effectiveness
(dull, crushing, of therapy, resolution and
Vital Sign: described as “like an progression of problem.
TEMP: 36.0 c elephant in my chest”),
PR: 160 bpm and radiation. Assist
RR: 27 cpm patient to quantify pain
BP: 138/78 mmHg by comparing it to other
experiences.

Review history of Delay in reporting pain


previous angina, angina hinders pain relief and
equivalent, or MI pain. may require
Discuss family history increased dosage of
if pertinent. medication to achieve
relief. 

Provide quiet Decreases external


environment, calm stimuli, which may
activities, and comfort aggravate anxiety and
measures. Approach cardiac strain, limit
patient calmly and coping abilities and
confidently. adjustment to current
situation.

Instruct patient to do Helpful in decreasing


relaxation techniques: perception and response
deep and slow to pain. Provides a sense
breathing, distraction of having some control
behaviors, visualization, over the situation,
guided imagery. Assist increase in positive
as needed. attitude.

Check vital signs before Hypotension and


and after narcotic respiratory depression can
medication. occur as a result of
narcotic administration.
These problems may
increase myocardial
damage in presence of
ventricular insufficiency.

Administer
supplemental oxygen by Increases amount of
means of nasal cannula oxygen available for
or face mask, as myocardial uptake and
indicated. thereby may relieve
discomfort associated
with tissue ischemia.
Administer medication useful for pain control by
as indicated coronary vasodilation
antianginals, beta- effects, which increase
blockers, analgesics. coronary blood flow and
myocardial perfusion.

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