Nursing Care Plan

Nursing Diagnosis
Ineffective tissue perfusion related to decreased cardiac output. Cues/Data with pale conjunctiva, nail beds and buccal mucosa (+)chest pain (+) DOB Generalized weakness Abnormal pulse rate and rhythm Altered BP readings.

Analysis
Due to decreased cardiac output, there is decreased preload and stroke volume thus there is decreased blood pumped out from the blood. Decrease in stroke volume decreases perfusion throughout the body Reference:

Goal
After 8 hours of nursing intervention, the patient will be able to: verbalize relief of pain as evidence by decrease pain scale rating

Nursing Interventions
Independent: Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.

Rationale

Evaluation
After 8 hours of nursing intervention, the patient will be able to: verbalize relief of pain as evidence by decrease pain scale rating Yes_ No_ Why? know other technique of relaxation Yes_ No_ Why? prevent further complication Yes_ No_ Why?

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Assess cardiac and circulatory status.

know other technique of relaxation

prevent further complication

Establish a quiet environment.

Teach patient relaxation techniques and how to use them to reduce stress.

To identify intensity, precipitating factors and location to assist in accurate diagnosis. Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion. A quiet environment reduces the energy demands on the patient. Anginal pain is often precipitated by emotional stress that can be relieved nonpharmacologic

Elevate head of bed.

Reposition the patient every 2 hours Instruct patient on eating a small frequent feedings Assess the response to medications every 5 minutes.

al measures such as relaxation. Elevation improves chest expansion and oxygenation. To prevent bed sores To prevent heartburn and acid indigestion Assessing response determines effectiveness of medication and whether further interventions are required.

Collaborative: Administer or assist with selfadministration of vasodilators, as ordered. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart,

decreasing preload which in turn decreases the workload of the heart. Give beta blockers as ordered. Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.