NURSING CARE PLAN FOR: ACUTE PAIN

Assessment Subjective data: - The patient verbalized Pumunta ako ng hospital dahil sa paninikip at pananakit ng aking dibdib (chest pain). - The patient also verbalized Nahihirapan akong huminga tuwing naninikip at nanakit ang aking dibdib. - The patient is restless. Objective data: - Vital Signs on admission day: BP: Nursing Diagnosis ACUTE PAIN Related to: decreased myocardial blood flow Secondary to: Rationale Atherosclerosis is a slow disease in which your arteries become clogged and hardened. Fat, cholesterol, calcium, and other substances form plaque, which builds up in arteries. Because of the formation of plaque, the arteries are blocked resulting to decreased blood flow (oxygen supply). Planning GOAL: Within the 7 hours of the shift the patient would be able to: - be free from pain OBJECTIVES: Within the 7 hours of the shift the patient would be able to: - demonstrate the use of proper relaxation techniques and diversional activities as indicated - remain free from pain - modify lifestyle pattern according to his current condition - verbalize understanding of the nature of his condition or disease - show stable vital signs Implementation INDEPENDENT: 1. Monitor characteristics of pain through verbal and hemodynamic responses (crying, pain, grimacing, restlessness, respiratory rhythm, blood pressure and changes in heat rate). 2. Assess the description of pain experienced by patients include: place, intensity, duration, quality, and distribution. Rationale Evaluation GOALS: Goals are met. INTERVENTION: Interventions should be continued until the patient has fully recovered. EVALUATION Within the 7 hours of the shift the patient was able to: -be free from pain Within the 7 hours of the shift the patient was able to: - demonstrate the use of proper relaxation techniques and diversional activities as indicated - remain free from pain - modify lifestyle pattern according to his current condition - verbalize understanding of the nature of his condition or disease - show stable vital 1. Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

As evidenced by: Restlessness

2. Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other symptoms to obtain accurate data. 3. To be able to give immediate proper nursing intervention/s. 4. Helps reduce external stimuli that can add to the tranquility so patients

3. Instruct patient to notify nurse immediately when chest pain occurs. 4. Provide a comfortable environment, reduce the activity,

NURSING CARE PLAN FOR: ACUTE PAIN

130/70mmH g (High) PR: 86bpm (normal) RR: 18cpm (normal) (11/23/13) - X-ray reveals: Magnified cardiac size (enlarged or cardiomegaly ) - Troponin I:46.68 (high) - SGOT : 319 (high) - SGPT: 87.61 (high) - follow and take the prescribed medications - experience reduced pain - understand health teachings of the nonpharmacologica l methods on relieving pain and limit visitors. can rest in peace and signs the power of the heart - follow and take the is not too hard. prescribed medications 5. Helps relieve pain - experience reduced experienced by pain patients - understand health psychologically teachings of the which can distract the nonpharmacological patient that is not methods on relieving focused on the pain pain experienced. 6. To decrease oxygen demand.

5. Encourage diversional activities.

6. Remind patient to avoid strenuous activities, increase physical activities and overextension. 7. Provide light meals. Have patient rest for 1 hr after meals. 8. Monitor patients vital signs before and after giving the medication. DEPENDENT 9. Administer antianginal

7. Decreases myocardial workload associated with work of digestion, reducing risk of anginal attack. 8. This will relieve chest pain episodes.

9. Knowing the patient's progress,

NURSING CARE PLAN FOR: ACUTE PAIN

medication as ordered. 10. Monitor serial ECG changes. COLLABORATI VE: 11. Coordinate with the dietitian for the diet appropriate to the patient current condition. after being given the drug. 10. To have a baseline data and to monitor the patients progress. 11. It will help us determine the proper diet for the patient that may prevent worsening of the patients condition.