Nursing Care Plan Clinical Judgment Model PDF

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Nursing Care Plan Student Initials__L.R___________________________________________________________________________________________________  Occupation__Businessperson____________________________________ Religion/Culture___Jewish________ ALLERGIES__N/A_____________________________________________________________________________________________________ Medical Diagnoses__Acute Myocardial Infarction_________________ Surgery (if applicable) __N/A__________ Assessment Recognition of Cues

Nursing Diagnosis (NANDA Diagnostic Statement) Analysis of Cues

Goals & Expected Outcomes (S-M-A-R-T) Prioritize the Hypothesis & Generate Solutions

Nursing Interventions (Strategies/Actions) Take Actions

Rationale for Interventions (Include Source and Page Numbers)

Evaluation (Client’s Response to Actions/Progress toward Achieving Outcome Goals) Evaluate the Outcomes

Subjective:

Patient complains of chest pain, diaphoresis and shortness of breath.

Objective: Patient has 6/10 chest pain. His Vital signs: Temperature: 99 F BP:132/84 HR:98 RR:24 O2:97(nasal Cannula)

Risk for Acute chest pain related to Coronary Artery occlusion as evidenced by Changes in pulse, BP.

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

Assess Characteristics of chest pain.

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

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

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

Assess for respirations, BP and heart rate with each episodes of chest pain Administering medication on time to prevent any pain and discomfort. Administer supplemental oxygen by means of nasal cannula or face mask, as indicated.

To determine what appropriate interventions will be going to apply for better implementation of care. It provides information that may help to differentiate current pain from previous problems and complications. An increase in vital signs happens as the body compensate to pain, which can lead to other serious complications. Medications will stop the chest pain and decrease the discomfort. Increases the amount of oxygen available for myocardial uptake and thereby may relieve

Patient verbalized decreased pain. Obtained all the information necessary to evaluate patient cardiac problems. Breathing and vital signs improve and no complaints of chest pain from the patient.

discomfort associated with tissue ischemia.

Assessment Recognition of Cues

Nursing Diagnosis (NANDA Diagnostic Statement) Analysis of Cues

Goals & Expected Outcomes (S-M-A-R-T) Prioritize the Hypothesis & Generate Solutions

Nursing Interventions (Strategies/Actions) Take Actions

Rationale for Interventions (Include Source and Page Numbers)

Evaluation (Client’s Response to Actions/Progress toward Achieving Outcome Goals) Evaluate the Outcomes

Subjective: The patient complained of being tired, and restlessness.

Risk for decrease Activity intolerance related to Presence of ischemic/necrotic myocardial tissues as evidenced by alterations in heart rate and BP with activity and development of dysrhythmias.

1.

Objective: 2. The patient is tired and he doesn’t have enough energy for ADLs.

Demonstrate measurable/progressi ve increase in tolerance for activity with heart rate/rhythm and BP within patient’s normal limits and skin warm, pink, dry during my shift. Report absence of angina with activity in 12 hours shift.

Document heart rate and rhythm and changes in BP before, during, and after activity. Correlate with reports of chest pain or shortness of breath.

Encourage rest initially. Thereafter, limit activity on the basis of pain and/or adverse cardiac response. Provide non stress diversional activities.

Instruct patient to avoid increasing abdominal pressure (straining during defecation). Refer to the cardiac rehabilitation program. Review signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician.

Trends determine the patient's response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level and/or return to bedrest, changes in medication regimen, or use of supplemental oxygen. Reduces myocardial workload and oxygen consumption, reducing risk of complications. Activities that require holding the breath and bearing down (Valsalva maneuver) can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP. Provides continued support and/or additional supervision and participation in the recovery and wellness process. Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication.

Increase in tolerance for activity with heart rate/rhythm and BP within patient’s normal limits.

Skin in not cyanotic and it’s warm, pink, dry.

Assessment Recognition of Cues

Subjective: Patient concern about his condition and he has fear of death and not able to go back to his normal life.

Objective: He has excessive sweating which can be associated with stress and his condition. while he was talking about his condition his BP, heart rate, and respiration rate went up. Vital signs: BP:144/108 HR:106 RR:24

Nursing Diagnosis (NANDA Diagnostic Statement) Analysis of Cues

Fear/Anxiety M  ay be related to threat to or change in health and socioeconomic status and Threat of loss/death as evidenced by Fearful attitude apprehension, increased tension, restlessness, facial tension, and uncertainty, feelings of inadequacy

Goals & Expected Outcomes (S-M-A-R-T) Prioritize the Hypothesis & Generate Solutions

Identify causes, contributing factors and recognize feelings.

Verbalize reduction of anxiety/fear.

Demonstrate positive problem-solving skills.

Nursing Interventions (Strategies/Actions) Take Actions

Rationale for Interventions (Include Source and Page Numbers)

Identify and acknowledge patient’s perception of threat and situation. Encourage expressions of, and do not deny feelings of, anger, grief, sadness, fear.

Coping with the pain and emotional trauma of an MI is difficult. Patient may fear death and/or be anxious about the immediate environment. Ongoing anxiety (related to concerns about impact of heart attack on future lifestyle, matters left unattended or unresolved, and effects of illness on family) may be present in varying degrees for some time and may be manifested by symptoms of depression.

Observe for verbal and nonverbal signs of anxiety (restlessness, changes in vital signs), and stay with patient. Intervene if the patient displays destructive behavior.

Orient patient and/or SO to routine procedures and expected activities. Promote participation when possible. Encourage independence, self-care, and decision making within accepted treatment plan. Support normality of grieving process, including time necessary for resolution.

Patient may not express concern directly, but words and actions may convey a sense of agitation, aggression, and hostility. Intervention can help patient regain control of his own behavior. Predictability and information can decrease anxiety for patient. Increased independence from staff promotes self-confidence and reduces

Evaluation (Client’s Response to Actions/Progress toward Achieving Outcome Goals) Evaluate the Outcomes

The patient can identify/use resources appropriately.

Patient can Recognize his feelings and can control them.

He can identify causes of his anxiety.

He can verbalize reduction of anxiety/fear.

feelings of abandonment that can accompany transfer from the coronary unit and/or discharge from hospital. Can provide reassurance that feelings are normal responses to situations and/or perceived changes....