ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Acute pain r/t Short term: At the end ● Monitor and ● Variation of At the end of 3
“Sakit akong dughan myocardial of 3 hours of nursing document appearance minutes, the client:
ma’am, murag ischemia interventions, the characteristic of and behavior
ginakumot akong client will be able to: ● Decreased
pain, noting of patients in
dughan tapos pain scale
mudagan sa li-og, sa ● Decrease pain verbal reports, pain may from 9/10 to
sa panga dayon sa scale from 9/10 nonverbal cues present a 6/10
abaga ma’am” as to 6/10 (moaning, crying, challenge in
verbalized by the grimacing, assessment.
patient Long term: At the end restlessness, Most patients
of 8 hours of nursing diaphoresis, with an acute At the end of 8
Objective: interventions, the hours, the client:
clutching of MI appear ill,
● Pain scale of client will be able to: ● Verbalized
● Verbalize relief chest) and BP or distracted,
9/10 relief or
heart rate and focused
● Facial or control control
of chest changes. on pain.
grimacing of chest
pain within Verbal history
● Restlessnes pain within
s appropriate and deeper
appropriate
time frame for investigation
time frame
administered ● Obtain full of precipitating
for
medications. description of pain factors should
administere
from patient be postponed
d
including location, until pain is
medications
intensity (using relieved.
.
scale of 0–10), Respirations
duration, may be
characteristics increased as a
(dull, crushing, result of pain
described as “like and
an elephant in my associated an
chest”), and xiety; release
radiation. Assist of stress-
patient to quantify induced
 pain by comparing catecholamine
it to other s increases
experiences. heart rate and
● Instruct patient to BP.
report pain ● Pain is a
immediately. subjective
Provide quiet experience
environment, calm and must be
activities, and described by
comfort patient.
measures. Provides
Approach patient baseline for
calmly and comparison to
confidently. aid in
determining
● Administer effectiveness
supplemental of therapy,
oxygen by means resolution and
of nasal cannula progression of
or face mask, as problem.
indicated. ● Decreases
external
● Administer stimuli, which
medications ( may
analgesics, beta aggravate
blockers and etc.) anxiety and
cardiac strain,
limit coping
abilities and
adjustment to
current
situation.
● To comply
physician’s
order.