Assessment Diagnosis Scientific Goal Intervention Rationale Expected

Explanation Outcome

SUBJECTIVE: Alteration in Obstruction in Short Term: INDEPENDENT: Short Term:

comfort(Acute the coronary
“ Nahihirapan pain) related to arteries After 15 to 30 • Provide comfortable quiet •Psychological rest help After 15 to 30
akong huminga lactic acid minutes of environment limiting reduce emotional stress, minutes of
parang may decreased nursing stimuli. which can produce nursing
formation myocardial
nakadagang secondary to intervention vasoconstriction, intervention
contractility
kamay sa dibdib the patient elevating BP and the patient
ko”—as As evidenced decreased will be relief increasing heart rate or experienced a
verbalized by by: cardiac output from having work. relief from
the patient. difficulty of having
SUBJECTIVE insufficient breathing and •Promotes lung expansion difficulty of
“mga nasa 8 delivery of •Provide bed rest with head and decreases venous
“ Nahihirapan from having breathing and
yung sakit”-as oxygenated elevated 30-60 degrees return.
akong huminga chest pain. from having
verbalized by blood
parang may chest pain.
the patient. Long Term:
nakadangang Anaerobic Long Term:
•Perform deep breathing •Improves breathing and
kamay sa metabolism After 1-2
exercises. oxygen intake.
dibdib ko”—as hours of After 1-2
OBJECTIVE: verbalized by Increased Lactic nursing hours of
acid formation
•Cool, pale and the patient. interventions nursing
clammy skin. Chest pain the client will •Reduces pressure on interventions
As manifested display vital diaphragm and enhances the client will
• Body malaise by: signs near to chest expansion. display vital
OBJECTIVE: normal and signs near to
• Tachycardia
lessen the normal and
(RR=105) •Cool, pale and DEPENDENT:
symptoms of lessen the
• Tachypnea clammy skin. failure. symptoms of
•Administer oygen via nasal
(RR=22bpm) • Increases available
• Cold • Body malaise cannula regulated @ 4 oxygen for myocardial failure.
extremities liters/min as prescribed. uptake to combat effects
• Tachycardia of hypoxia or ischemia Goal met.
• pain scale of (RR=105)
8/10
• Tachypnea •Administer Fladene Flash
•Pursed lip (RR=22bpm) 80mg •to decrease the pain .
breathing
• Cold
•Use of extremities
accessory
• pain scale of
muscle \REFERENCE:
8/10
•Facial grimace Nurses’ Pocket Guide by
•Pursed lip
Doenges et al. 11th edition
•Guarding breathing
pp. 223
behavior
•Use of
accessory
muscle

•Facial grimace

•Guarding
behavior