MERLYN E.

TOLENTINO 4TH YR 401- 4A

ASSESSMENT NURSING DIAGNOSIS Acute pain related to tissue ischemia ANALYSIS OBJECTIVE OF CARE After 1 hour of nursing intervention the client will verbalize relief/ control of chest pain NURSING INTERVENTION INDEPENDENT Monitor/ document characteristics of pain, noting verbal reports, nonverbal cues and hemodynamic response. Obtain full description of pain from client including location, intensity, duration, characteristics and radiation. Assist client to quantify pain by comparing it to other experiences Variation of appearance and behavior of clients in pain may present a challenge in assessment Pain is a subjective experienced and must be described by client. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution/ progression of problem. May differentiate current pain from preexisting patterns, as well as identify complications such as extension of infarction, pulmonary emobulos, or pericarditis. Delay in reporting pain hinders pain/ relief may necessitate increased dosage of medication to achieve relief. RATIONALE EVALUATION

SUBJECTIVE : sumasakit ang dibdib ko . OBJECTIVE Chest pain Facial grimacing Restlessness Changes in LOC

PATHOPHYSIOLOGY BELOW

Was the client able to verbalize relief/ control of chest pain ?

VS T emp: 36.5 C Pulse: 89 bpm Resp: 23 cpm BP: 130/100 mmHg

Review history of previous angina, angina equivalent, or MI pain. Discuss family history if pertinent.

Instruct client to report pain immediately

Provide quiet environment, calm activities, and comfort measures. Approach client calmly and confidently

Decreased external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation. Helpful in decreasing perception of response to pain. Hypotension/respiratory depression can occur as a result of narcotic administration

Assist/ instruct relaxation techniques

Check vital signs before and after administration of narcotic medication

PATHOPHYSIOLOGY OF MYOCARDIAL INFARCTION