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