assessment SUBJECTIVE: The patient may report: Chest pain, heaviness, or pressure that may radiate to the shoulders,

, arms, neck, jaw, or upper abdomen.

diagnosis Acute pain related to decreased myocardial blood flow.

planning After 8 hours of nursing intervention the patient will: Remain free from pain Maintain stable vital signs. Maintain relaxed body posture.

OBJECTIVE: Tachycardia Elevated blood pressure Jugular vein distention Cool, clammy skin

intervention Assess for vital signs and symptoms of pain such as facial grimacing, rubbing of neck or jaw, reluctance to move, increased blood pressure, and tachycardia. Note onset, duration, location, and pattern of pain. Use a pain rating scale to assess the patients perception of the pains severity. Administer sublingual nitroglycerin as ordered. Instruct the patient to notify a nurse immediately when experiencing pain. Have the patient stop current activity, and place him on bed rest in a semi- to high Fowlers position. Administer oxygen as ordered. Obtain a 12-lead ECG immediately during acute chest pain. Stay with the patient during chest pain episodes.

evaluation After 8 hours of nursing intervention the patient was free from pain, maintains stable vital signs, and relaxed body posture.

Angina pectoris