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  • Nursing Care Plan: Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

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    CLEMENT, EUGENE CHAD
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    1) The patient, I.G.A., is a 45-year-old male admitted to the ward with a diagnosis of myocardial infarction who was experiencing acute chest pain. 2) The nursing care plan identified acute pain as the primary nursing diagnosis and included interventions such as assessing vital signs and pain levels, keeping the patient at rest, and teaching deep breathing exercises to help ease the pain. 3) After 4 hours of nursing interventions, the goal of reduced pain was partially met as the patient reported their pain was "okay" and facial grimacing was slightly noted, with stabilized vital signs within the target range.

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    1) The patient, I.G.A., is a 45-year-old male admitted to the ward with a diagnosis of myocardial infarction who was experiencing acute chest pain. 2) The nursing care plan identified acute pain as the primary nursing diagnosis and included interventions such as assessing vital signs and pain levels, keeping the patient at rest, and teaching deep breathing exercises to help ease the pain. 3) After 4 hours of nursing interventions, the goal of reduced pain was partially met as the patient reported their pain was "okay" and facial grimacing was slightly noted, with stabilized vital signs within the target range.

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    88 views2 pages

    Nursing Care Plan: Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

    Uploaded by

    CLEMENT, EUGENE CHAD
    1) The patient, I.G.A., is a 45-year-old male admitted to the ward with a diagnosis of myocardial infarction who was experiencing acute chest pain. 2) The nursing care plan identified acute pain as the primary nursing diagnosis and included interventions such as assessing vital signs and pain levels, keeping the patient at rest, and teaching deep breathing exercises to help ease the pain. 3) After 4 hours of nursing interventions, the goal of reduced pain was partially met as the patient reported their pain was "okay" and facial grimacing was slightly noted, with stabilized vital signs within the target range.

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    of 2

    NURSING CARE PLAN

    Name of Patient: I.G.A. Attending Physician: _Dr. A_ Age: _45 years old Ward/Bed Number: __
    Impression / Diagnosis: _Myocardial Infarction_
    Nursing
    Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Rationale Evaluation
    Interventions
    11/15/20 Acute pain r/t Acute pain is defined After 2-3 hours of 1. Assess vital signs 1. To obtain baseline 11/15/20
    1:00 PM myocardial infarction as an unpleasant nursing intervention, data. 5:00 PM
    sensory and emotional the patient must be 2. Assess pain before
    experience arising and after
    - “Gasakit gid ang able to: 2. To monitor the After 4 hours of
    from actual or interventions, noting
    akon nga dughan kag potential tissue damage location, effectiveness of the nursing intervention:
    indi gid ko kahulag or described in terms characteristics, medications prescribed
    sang mayo.” As of such damage severity (0–10 scale). and the process of GOAL PARTIALLY
    verbalized (International wound healing. MET as evidenced by:
    Association for the
    -Patient positions Study of Pain); sudden 3. Keep at rest in a 1. client verbalized
    or slow onset of any Semi-Fowler’s
    himself to ease pain 1. verbatim of 3. Semi-Fowler’s “okay naman
    intensity from mild to position.
    severe with an decreased pain position promotes pamatyagan ko ah,
    anticipated or comfort and eases the manug discharge
    -refused other predictable end and a pain. naman ko gani subong
    assessments due to duration of less than 4. Instruct to do deep nga adlaw”
    pain six months (source: breathing exercises 4. Deep breathing
    Doenges, et al., when pain is felt, and exercises promotes 2. facial grimacing is
    Nurse’s Pocket Guide
    2. no facial grimacing also teach the circulation of oxygen in slightly noted
    14th Edition, pg. 600).
    importance of the the body. Oxygen is also
    exercises. an essential factor in
    3. BP of 90/60 – wound healing and it 3. Blood Pressure of
    120/80 mmHg speeds up the healing 110/70 mmHg
    process. Deep breathing 4.patient discharged
    4. Participates actively
    in assessment
    procedures

    exercises also relieves


    anxiety and relaxes the around 5:30pm
    patient.

    Student Nurse: Clement, Eugene Chad A.


    Clinical Instructor: Liza Ramirez, RN, MAN

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