Care Plan for coronary artery disease PDF

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Summary

care plan...

Description

Nursing Diagnosis (ND): Acute Chest Pain Related to (R/T): Coronary Artery Occlusion

As Evidenced By (AEB): Myocardial Infarction

Desired Patient Outcomes(Goals)

Nursing Interventions

Rationales:

Evaluation

Make sure the goals are measurable, realistic, specific, attainable, and have a time frame stated.

Assess Characteristics of chest pain.

To determine what appropriate interventions will be going to apply for better implementation of care.

Patient verbalized decreased pain

Obtain history of previous cardiac pain and family history of cardiac problems.

It provides information that may help to differentiate current pain from previous problems and complications.

Assess for respirations, BP and heart rate with each episodes of chest pain

STG:

1. After 15-30 minutes patient will be able to verbalize relieved pain.

pain is indication of MI. assisting the client in quantifying pain may differentiate preexisting and current pain patterns as well as identify complications.

2. Within 1-hour patient feeling of fatigue will decreased.

Decrease energy and feeling fatigue delay patient’s ability to feel better

3. Patient breathing will improve, and vital signs will be within normal range by 7:00 pm

Facilitates gas exchange to decrease hypoxia and resultant shortness of breath.

Patient will:

LTG: Patient will:

An increase in vital signs happens as the body compensate to pain, which can lead to other serious complications.

4.

Demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension and restlessness after 48hrs

Patients with unstable angina have an

Obtained all the information necessary to evaluate patient cardiac problems

Breathing and vital sings improved

Goals met by decreasing pain

Goals met by patient reporting feeling more energetic

Goals met by improving patient breathing and keeping vital signs within normal limits

in frequency and severity after a week of nursing interventions

increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and/or stress.

6. Pt will maintain Normal Sinus Rhythm

Reduce myocardial oxygen demand to minimize risk of tissue injury.

5. Pt will report anginal episodes decreased

Goals met by patient reporting anginal episodes decreased.

during hospitalization.

Nursing Diagnosis (ND): Activity Intolerance Related to (R/T): Cardiac Dysfunction, changes in oxygen supply Desired Patient Outcomes(Goals) Make sure the goals are measurable, realistic, specific, attainable, and have a time frame stated.

STG:

Nursing Interventions monitor heart rate, rhythm, respirations and blood pressure for abnormalities. Notify physician of significant changes in VS.

As Evidenced By (AEB): Shortness of Breath Rationales

Evaluation

Changes in VS assist with monitoring physiologic responses to increase in activity

Pt demonstrated increased tolerance to activity. Pt was able to ambulate to the room door and back to the bed without any abnormal changes in vitals. Pt chest pain decreased, patient skin intact.

Assist with active or passive ROM exercises at least QID

To maintain join mobility and muscle tone

Turn patient at least every 2 hours or prn.

To improve respiratory functions and prevent skin breakdown

1. Pt will increase gradually tolerance, starting 15 minutes the first time out of bed

Patient will: 2. Within 2 days patient will be able to utilize breathing techniques and energy conservation techniques effectively

3.Within 3 day of nursing interventions, the patient will be able to tolerate activity without excessive dyspnea.

Facilitates gas exchange to decrease hypoxia and resultant shortness of breath.

LTG: Patient will:

4.Within 7 days of nursing interventions, the client will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise

5.

6.

Nursing Diagnosis (ND): Deficient Knowledge Related to (R/T): New Diagnosis and lack of understanding of medical condition

As Evidenced By (AEB):

Desired Patient Outcomes(Goals)

Nursing Interventions

Rationales

Evaluation

Make sure the goals are measurable, realistic, specific, attainable, and have a time frame stated.

monitor patient’s readiness to learn and determine best methods to use for teaching.

To promote optima learning environment when patient shows willingness to learn

Pt verbalized understanding. Patient has gained full understanding of medication instructions

Provide time for individual interaction with patient

Stablish trust

Instruct patient in medication, dose, side effects and contraindications

STG:

1. be able to verbalize and demonstrate

Patient will:

understanding of information given regarding medication, condition and treatment regimen within 3 days of nursing interventions

To provide information to manage medication regimen and to ensure compliance

After 4 hours of my nursing intervention patient was able to understand the disease process and

2. Show motivation to learn in 30 minutes

treatment regimen.

3.Exhibits ability to deal with health situation and remain in control of life in the next 12 hours

LTG: Patient will:

4.be able to correctly perform all tasks prior to discharge 5. Exhibits ability to deal with health situation and remain in control of life after discharge 6. Demonstrates how to incorporate new health regimen into lifestyle.

The client had been able to correctly perform all tasks prior to discharge goal met....