ASSESSMENT DIAGNOSIS PLAN INTERVENTION EVALUATION

subjective Acute pain r/t Heart Verbatim and non- Perform a After 5-15 mins of
failure as e/b pt. report verbatim relief of pain comprehensive effective nursing
of pain after 5-15 mins of assessment. Assess intervention resident will
 “I’m having effective nursing location, state relief of pain and
Difficulty in intervention. characteristics, show no signs of pain.
onset, duration,
breathing”
frequency, quality
 “I have pain and severity of pain.
in my chest” -Assessment is the
first step in
 Restlessness managing pain. It
 SOB helps ensure that the
patient receives
effective pain relief.
Objective
BP 155/98 Observe for
P 110 nonverbal indicators
R 27 of pain: moaning,
T 36.9C guarding, crying,
facial grimace.
O2sat% 85% at RA
-Some patients may
Heart failure
deny the existence of
Leg edema, bilateral
pain. These
Crackles in the lung behaviors can help
bases with proper
evaluation of pain.
Shortness of breath
upon exertion
Use
Confusion nonpharmacological
pain relief methods
(relaxation exercises,
breathing exercises,
music therapy).
- Works by
increasing the
release of
endorphins, boosting
the therapeutic
effects of pain relief
medications.

Provide O2 therapy
-to support need of
oxygen in the body.

Provide optimal pain

relief by
administering
prescribed pain relief
medication.
- Various types of
pain requires
different analgesic
approaches. Some
responds well to non-
opioid pain relievers
while others demand
a combination of
non-opioid and low
dose opioid.
Fluid volume excess Decreased of edema to Limit sodium intake after 1-2 weeks of
related to decreased both legs after 1-2 weeks Salt may retain effective nursing
cardiac contractility of effective nursing interventions, decreased
as evidenced by interventions. Limit Fluid intake. of edema to both legs.
bilateral lower To prevent fluid retention
extremity edema and holding too much
fluid in the body

Elevate legs when in bed

To help improve blood
flow to heart.

Give water pill

(furosemide) as ordered.
To manage and get rid of
edema.