Assessment Diagnosis Goal Intervention Evaluation

Subjective Acute pain Short term goal:  Monitor and document characteristic of pain, noting Short term goal
“masakit related to After 30 mins of verbal reports, nonverbal cues (moaning, crying, met: After 30 mins
ang dibdib myocardial nursing grimacing, restlessness, diaphoresis, clutching of chest) of nursing
ko” as ischemia intervention the and BP or heart rate changes. intervention the
verbalized patient will  Review history of previous angina, anginal equivalent, or patient verbalize
by patient. verbalize MI pain. Discuss family history if pertinent. relief/control of
Pain scale relief/control of  Instruct patient to report pain immediately. Provide quiet chest pain within
of 8/10. chest pain within environment, calm activities, and comfort measures. appropriate time
Objective appropriate time Approach patient calmly and confidently. frame for
Facial frame for  Instruct patient to do relaxation techniques: deep and administered
grimace administered slow breathing, distraction behaviors, visualization, medications.
restlessness medications. guided imagery. Assist as needed. Pain scale reprted
HR 125 Long term goal:  Check vital signs before and after narcotic medication. as 2/10.
After 2-3 days of  Instruct patient to follow diet as indicated (low salt, low Long term goal:
rendering care fat). goal partially met
and  Instruct on medication effects, contraindications and After 2-3 days of
interventions, the symptoms to report. rendering care
patient will be and interventions,
able to have an Administer medications as indicated: the patient is able
improved feeling  Antianginals: nitroglycerin (Nitro-Bid, Nitrostat, Nitro- to have an
of control and Dur), isosorbide dinitrate (Isordil), mononitrate (Imdur) improved feeling
comfort.  Beta-blockers: atenolol (Tenormin), pindolol(Visken), of control and
Vital signs within propranolol (Inderal), nadolol (Corgard), metoprolol comfort.
normal range. (Lopressor) Vital signs within
 Analgesics: morphine, meperidine (Demerol) normal range
Assessment Diagnosis Goal Intervention Evaluation
Subjective: Activity Short Term Goal: 1. Establish rapport both to Short Term Goal:
- “Mabilis akong mapagod at Intolerance After 5-8 hours shift duty patient and S.O.
manghina, simpleng Gawain lng related to of 2.Monitor vital signs, before Goal Met: Patient
nakakramdam na ako ng hirap Imbalance rendering care and and after doing such activities. was able to
sa paghinga” as verbalized by between oxygen interventions, the patient 3. Encourage patient to verbalized
the patient Supply and will be able to verbalized verbalize her feelings and understanding
Objective: Demand understanding about her concerns regarding her about her
Weak in appearance secondary to condition. present condition and condition
Pallor Myocardial Long term Goal: limitations. Long term Goal:
Experience shortness of Infarction After 1 to 2 weeks 4. Maintain stressful activity Goal Met, Patient
breathing of intervention, the restrictions and assist patient showed
Needs assistance in doing patient will report with self care activities as measurable
minimal activities measurable increase in needed. increase in
Easy fatigability activity tolerance. 5. Provide frequent rest activity tolerance.
With Oxygen inhalation at 2-4 Perform ADL’s without periods, especially after meals.
Lpm the need of assistance 6. Encourage rest periods
Vital signs taken as: and able to do it between care activities.
BP=130/90 comfortably
PR=90 bpm Collaborative:
RR= 20 cpm 1.Administer beta-blockers
Temp= 37.8 such as metoprolol, as
Functional Level Classification: ordered.
Level III – means, walk no more
than 50 ft on level without
stopping; unable to climb one
flight of stairs without stopping.
Assessment Diagnosis Goal Intervention Evaluation
Subjective: Short Term Goal: 1. Establish rapport both to patient Short Term Goal:
“ Mabuti naman na Risk for After 8 hours shift of and to the S.O Goal Met: Patient
pakiramdam ko, hindi na Decrease cardiac duty and rendering 2. Monitor patient’s vital signs, verbalized
sumasakit ang dibdib output related to patient care and nursing noting blood pressure changes. understanding
ko,minsan minsan na interventions, the patient 3. Provide a calm and restful about his risk for
lang pero hindi na increase vascular will verbalized decrease cardiac
surroundings
kagaya noon” as resistance as understanding about his 4. Maintain activity restrictions and output and able to
verbalized by the evidenced by risk for decrease cardiac assisted patient with self care promote
patient. narrowing of output and promote activities as needed. appropriate
Objective: coronary arteries appropriate actions to 5. Provided comfort measures (ex. actions to promote
 Experience easy promote patient’s Back massage and elevation of patient’s
secondary to condition. condition
fatigability head)
 Experience Myocardial Long term Goal: 6. Encouraged to do relaxation Long term Goal:
dizziness and Infarction After 3-5 days of techniques such as distraction Goal partially
shortness of breath rendering patient care 7. Maintain head elevated Met: Patient
upon doing and interventions, the approximately 30 degrees. reported feeling of
minimal activities ( patient will report feeling 8. Instruct patient to avoid activities comfort and
Standing) of comfort and lessen the that create a Valsalva response (e.g. lessen signs and
 Experiences chest possible signs and straining to have a bowel movement, symptoms being
pain, nausea and symptoms of being in holding breath while moving up in felt and observed
vomiting, and risk for decrease cardiac bed) through the proper
epigastric pain. output through the proper 9. Maintain on bed rest or semi management and
 Restlessness management and fowlers position. participation to
 With an Oxygen participation to Collaborative: intervention and
inhalation at 2-4 intervention and 1. Administer Administer beta- medication
Lpm medication regimens. blockers such as metoprolol, as regimens .
 Vital signs taken ordered.
as: 2. Administer supplemental oxygen
BP=150/90 as needed.
PR=109 bpm 3. Perform surgical intervention
RR= 26 cpm such as PTCA as needed.
Temp= 35.0