Words: 382
X Nursing Care Plan |Assessment |Diagnosis |Planning |Intervention |Rationale |Evaluation | | | | | | | | |Subjective: “nahihirapan siyang |Activity intolerance related to |Within the shift, monitor the |Instruct the patient for bed |To comfort the patient. STG: | |huminga as verbalized by the |cardiac dysfunction, changes in |ECG and vital signs every hour |rest with comfort position. | |Within 2hrs of nursing | |patients companion” |oxygen supply and consumption as|to determine abnormalities. | | |intervention, the client | | |evidenced by shortness of | |Instructed the patient in |To improve breathing pattern. tolerated activity without | |Objective: |breath. |Comfort the patient to normalize|isometric and breathing | |difficulty of breathing and had | | | |activity level of respiratory |exercise. | |been able to utilize breathing | |-increase heart rate | |distress. |To lessen fatigue and weakness. |techniques. | |-increase blood pressure | | |Assist patient with ambulation | | | |-pallor | | |as ordered. |LTG: | |-fatigue and weakness | | | |For patients chest pain and |Within 3 day of nursing | |-decrease oxygen | | |Give medication as per doctor’s |shortness of breath. |intervention, the client | |saturation | | |order. |increased and achieved desired | | | | | | |activity level, progressive | |V/S | | | | |without intolerance symptoms | | | | | | |noted such as respiratory | |BP:140/80 | | | | |compromise. | |PR:80 | | | | |Goal met. |RR:27 | | | | | | |Temp:37? c | | | | | | | | | | | | | | | | | | | | Assessment |Diagnosis |Planning |Intervention |Rationale |Evaluation | | | | | | | | |Subjective: “naninikip ang aking|Alteration in comfort as |After 8 hrs of nursing |Assess chest pain of 7/10. |To determine the intensity of |After the 2 days of nursing | |dibdib as verbalize by the |evidence by the above signs and |intervention the client will | |pain. intervention the client have | |patient” |symptoms related to mycocardial |have improved comfort in the |Encourage the patient to | |improved comfort in chest and is| | |ischemia resulting from coronary|chest by giving medications, |maintain bed rest during pain |To reduce respiratory distress |able to rest, displays reduced | |Objective: |artery occlusion with loss/ |monitoring vital signs, checking|with position of comfort to | |tension and sleeps comfortable. | |-restlessness |restriction blood flow to an |the ECG and proper positioning |promote calmness. | | | |-facial grimacing |area of the myocardium and; |of the patient. | | | | |-fatigue |necrosis of the myocardium. |Administer analgesics as | | | |-shortness of breath | | |ordered, such as morphine | | | | | | |sulfate, beta blockers, and |Morphine is a drug of choice to | | | | | |calcium channel blockers. control MI pain | | |V/S as taken: | | | | | | |BP:140/80 | | | |To block the sympathetic | | |PR:80 | | | |stimulation, reduce heart rate | | |RR:27 | | | |and lowers myocardial demands. | | |Temp:37? | | | | | | | | | | |To increase coronary blood flow | | | | | | |and collateral circulation which| | | | | | |can decrease pain due to | | | | | | |ischemia. | | | | | | | | |