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II. NURSING CARE PLAN No.

1
Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:


Objective:
Sharp and
radiating chest pain
Facial Grimace
Guarding
behaviour
sleep disturbances
restlessness

PR=
TEMPERATURE
=
RR=
BP=
Chronic pain
related to
blockages in the
coronary artery.
Short term goal:
After 30 minutes of
nursing
intervention, the
client will be
able to verbalize
understanding of
her condition
and health
teachings given
to provide
comfort and
relieve pain.

Long term goal:
Within 8 hours, the
client will be
able to report
that pain is
relieved/controll
ed

Within 8 hours, the
client will be
able to follow
prescribed
pharmacological
Independent
Assess pain location
and intensity/severity
arising with.

Provide comfort
measures like stretching
of linens and assisting in
positions.


Provide diversional
activities like having
conversations with the
client.

Stress the importance
of having adequate rest
periods.

Dependent

Take medicines as
prescribed



To provide baseline data for
planning and intervention.


to provide non-phamacological pain
management.




to divert patients attention.




to prevent fatigue.





to reduce pain
Short term goal:
After 30 minutes of
nursing intervention,
the client will be able
to verbalize
understanding of her
condition and health
teachings given to
provide comfort and
relieve pain.
GOAL MET

Long term goal:

Within 8 hours, the
client will be able:

to report the pain is
relieved

will be able to
follow prescribed
pharmacological
regimen.
























regimen.


Within 8 hours, the
client will be
able to
demonstrate
ways on how to
manage pain.


demonstrate ways
on how to manage
pain.

GOAL MET
NURSING CARE PLAN No. 2


Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:
none

Objective:
shortness of breath.
pallor
decreased pulse
decreased urine
output
Edema on upper
and lower
extremeties
chest pain

Ineffective tissue
perfusion
related to
decreased
cardiac output.
Short term goal:
After 30 minutes of
nursing intervention,
the client and
significant others
will be able to
demonstrate
behaviours on how
to have effective
airways.

Long term goal:
Within 8 hours, the
client will be free
from shortness of
breath.
Independent
assess the patients
condition

Monitor v/s.


Note the color and
temperature of skin.

Monitor urine output.


Monitor peripheral
pulse.


Provide a warm
environment.


Dependent
Admister O2 inhalation.

Take medicines as
prescribed

To serve as a baseline data


To serve as baseline data and this
are usually altered in the condition.

cool, pale skin is indicative of
decreased peripheral tissue perfusion.

Decreased tissue perfusion to the
kidneys may result to oliguria.

Decreased pulse is indicative of
decreased tissue perfusion from
vasoconstriction of the vessels.

A warm environment promotes
vasodilation which decreases preload
and promotes tissue perfusion.


To normalize breathing.

To increase urine output and lessen
edema.
Short term goal:
After 30 minutes
of nursing
intervention, the
client and
significant others
will be able to
demonstrate
behaviours on how
to have effective
airways.
GOAL MET

Long term goal:
Within 8 hours,
the client will be
free from shortness
of breath.
GOAL MET


NURSING CARE PLAN No. 3
Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:
Nanghihina ako
,as verbalized by
the client.

Objective:
Weakness
Verbalization of
overwhelming lack
of energy.
Drowsiness
Disinterest in
surroundings.
Activity intolerance
due to fatigue.
Short term goal:
After 30 minutes of
nursing
intervention, the
client will be
able to verbalize
understanding of
condition and
causative factors.


Long term goal:
Within 8 hours, the
client will be
able to come up
with plans and
ways to perform
ADLs and
desired
activities/level of
activity.
.


Independent
Monitor vital signs.


Determine ability to
participate in activities or
level of mobility.

Establish realistic activity
goals with client.


Provide a conducive
environment.



Dependent
Give medications as
ordered.



To provide baseline
information.

to enhance commitment to
promoting optimal outcomes.


To maximize participation.



To maintain/increase
strength and muscle tone and
to enhance sense of well being.



To lessen fatigue.

Long term goal:
After 30 minutes
of nursing
intervention, the
client will be able
to verbalize
understanding of
condition and
causative factors.
GOAL MET



Short term goal:
Within 8 hours,
the client will be
able to come up
with plans and
ways to perform
ADLs and desired
activities/level of
activity.
GOAL MET