NCP for Acute Coronary Syndrome Assessment Background Diagnosis Knowledge Subjective: atherosclerosis Acute pain Sumasakit related

to ang dibdib myocardial ko , as ischemia ischemia verbalized as by the evidenced patient. angina by severe pectoris chest pain. Objective: Severe chest pain Pain scale 10/10

Planning Within 2 hours of nursing intervention the patient will experience decrease level of pain.

Interventions -Evaluate chest pain (ex. intensity, location, radiation, duration, and precipitating and alleviating factors) in order to accurately evaluate, treat, and prevent further ischemia. -Monitor effectiveness of oxygen therapy to increase oxygenation of myocardial tissue and prevent further ischemia. -Administer medications to relieve/prevent pain and ischemia to decrease anxiety and cardiac workload. -Obtain 12lead ECG during pain episode to help differentiate angina from extension of

Evaluations After 2 hours of nursing intervention the patient experienced a decreased level of pain.

MI or pericarditis. -Monitor cardiac rhythm and rate and trends in blood pressure and hemodynamic parameters (e.g., central venous pressure and pulmonary artery wedge pressure) to monitor for hypotension and bradycardia, which may lead to hypoperfusion. Assessment Subjective: Nahihilo ako, as verbalized by the patient. Objective: PR - 85 RR - 30 BP 160/100 Background Diagnosis Knowledge Atherosclerosis Ineffective tissue oerfussion ischemia (cardiac) related to potential angina pectoris pulmonary congestion as decrease manifested blood flow by dyspnea. Planning Within 8 hours of nursing intervention the patient will be able to maintain stable vital signs. Intervention -Monitor vital signs frequently to determine baseline and ongoing changes. -Monitor for cardiac dysrhythmias, including disturbances of both rhythm and conduction, to identify and treat signi cant dysrhythmias. -Monitor respiratory evaluation After 8 hours of nursing intervention the patient had maintain stable vital signs.

status for symptoms of heart failure to maintain appropriate levels of oxygenation and observe for signs of pulmonary edema. -Monitor uid balance (e.g., intake/output, daily weight) to monitor renal perfusion and observe for uid retention. -Arrange exercise and rest periods to avoid fatigue and decrease the oxygen demand on myocardium. -instruct patient to eat low fat and low salt diet.