Group 4

SISON, Monira
SOLUREN. Judeson
SUAVERDEZ, Aleli
TABUENA, Bernadette
TAMORIA, Celine Angeli
TINALIGA, Ann Jessaneth
TORRES, Donna Marie
TUAZON, Mary Jude
VALENZUELA, Richiel Ross
VEA, Emily
VELASQUEZ, Nori Anne
 Problem No.3
 Mrs. Delos Santos, a 62 year old
housewife is admitted to the ER with
complaints of pain “under my left breast
that pushes to my back”. She rates the
pain as 9 on the pain scale of 1 to 10. Her
ECG shows an elevated ST segment. She is
placed on oxygen therapy and an IV line is
inserted. Cardiac serum markers are drawn
and sent to laboratory. Her vital signs are
T=36.9’c, HR= 110bpm, and BP=
110/70mmHg. The doctor ordered to give
Morphine through IV and a thrombolytic
agent thru IV.
Prioritized Nursing Diagnosis
 Ineffective cardiac tissue perfusion
related to reduced coronary blood
flow

 Acute pain related to increase oxygen
demand


 Activity intolerance related to cardiac

dysfunction
 1. Assessment
SUBJECTIVE CUE:
“pain under my left breast that pushes to

my back.” as verbalized by the client.



 OBJECTIVE CUE(s):
 ECG: elevated ST segment
 Vital Signs: T=36.9’c; HR= 110bpm;
BP= 110/70mmHg
 Diaphoresis

Diagnosis Planning
 Ineffective  After Four(4)
cardiac hours of nursing
intervention,
tissue client will have
perfusion an adequate
related to cardiac output
reduced as evidenced
coronary by: stable:
improving ECG,
blood flow Heart rate and
rhythm
Intervention Rationale
INDEPENDENT:


 Assess and monitor  Assessing provides
patient’s condition.  baseline data and
 compare and
determine the
 cause and effect of
 health treatment.
 Obtain ECG , as  ECG during symptom
prescribed to maybe useful in the
determine diagnosis of an
extension of extension of MI 
infarction 
  Administer oxygen  Oxygen therapy
therapy as increases the
necessary oxygen supply to

the myocardium if
actual oxygen

saturation is less
 than normal
 


 Physical rest
reduces
 Ensure physical rest, myocardial oxygen
backrest elevated consumption.
to promote
comfort
 DEPENDENT: 


 Administer  Thrombolytic drugs
thrombolytic drugs are used to clear
(e.g. blocked artery and
streptokinase) avoid permanent
damage to the
perfused tissue
 Evaluation

 AfterFour(4) hours of nursing

intervention, the goal was met,
patient appears to have an
adequate cardiac output as
evidence to have a stable ECG
and heart rate and rhythm
 2. Assessment
SUBJECTIVE CUE(s):
 “I feel pain under my left breast that
pushes to my back” as verbalized by the
client.
 She rates pain as nine(9) on the pain scale
of 1 to 10.
OBJECTIVE CUE(s):

 ECG: elevated ST segment

 Vital Signs: T=36.9’c; HR= 110bpm; BP=
110/70mmHg
Diagnosis Planning
 Acute Pain  AfterFour(4)
related to hours of
increase nursing
oxygen intervention
demand the client will
be relieved
from pain and
a scale score
from nine (9)
to zero (0).
Intervention Rationale
 INDEPENDENT: 
 the general  This helps in
condition of the determining
client. possibility of
 underlying
condition or organ

dysfunction
 requiring
 Monitor vital signs. treatment.

 Vital signs are
usually altered in
acute pain.
 Provide comfort  It promotes non-
measures such as pharmacological
cold or warm pain management.
compress. 
 
 Encourage deep-  This provides
breathing relaxation.
exercise.


 To distract attention
 Encourage and reduces
diversional tension.
activities such as
watching TV.
 COLLABORATIVE: 
 
 Administer narcotic  This maintains
analgesic (e.g. acceptable level of
Morphine Sulfate) pain for the client.
 
 Position the client:  To promote comfort.
backrest elevated
 Evaluation

 AfterFour(4) hours of nursing

intervention the client
verbalized relief/ control of
pain.
 3. Assessment
 OBJECTIVE CUE(s):
 Increase heart rate: 110 bpm
 Fatigue and weakness
 ECG: elevated ST segment
Diagnosis Planning
 Activity  WithinFive(5)
intolerance days of nursing
interventions,
related to the client will be
cardiac able to increase
dysfunction and achieve
and decrease desired activity
oxygen level,
progressively.
supply
Intervention Rationale
INDEPENDENT:
  Assessing provides
 Assess the client’s baseline data and
condition. compare and
determine the
 cause and effect of
 health treatment.
 
 Monitor client’s vital  Changes in v/s assist
signs. with monitoring
physiologic
responses to
increase activity.
 Identify causative  Alleviation of factors
factors leading to that are known to
intolerance of create intolerance
activity. of activity level.
 
 Turn client at least  This will improve
every two(2) respiratory
hours. function and
prevent skin

breakdown.
 
  To improve breathing
 Encourage client to and increase
do deep-breathing activity level.
exercise.
 DEPENDENT: 


 Assist the client with  To gradually increase
ambulation, as the body to
ordered, with compensate for
progressive as the increase in
client tolerance overload.
permits.
 Evaluation

 After Five(5) days of nursing

intervention, the goal was met
as the client increased and
achieved the desired activity
level.