BSN IV-I

Name: Arnold Age:27 Diagnosis: PTB

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

SUBJECTIVE: Short Term Independent:
“Sumasakit ang -Pain r/t tissue Objective: -Pain is a subjective Short Term Objective:
dibdib ko” (I’ve ischemia -Obtain full experience and must
been experiencing -After 8 hours of description of pain be described by -After 8 hours of
(coronaryartery occlusion) nursing Nursing intervention the patient able to
chest pains) as from patient patient
verbalized by the intervention the verbalize relief/control of chest pain
Pathophysiology: including location,
patient patient will
intensity (0–10),
OBJECTIVE: Verbalize Long term Objective:
Occlusion of duration, characteristics
·Restlessness relief/control of
(dull/crushing), and
·Facial chest pain.
radiation. Assist patient to -After 1 week of
grimace quantify pain by comparing it to
coronary artery Nursing intervention, the patient will
·Pain scale of Long Term Objective: other experiences
slightly relieve from chest pain within
9 out of 10 Decrease blood appropriate time frame for administered
·V/S taken as flow to the -After 1 week of Instruct patient to medications.
follows myocardium nursing report pain
T: 37.6 ˚C intervention, the immediately.
P: 112 Delay in reporting -Goal Partially met
patient will pain hinders pain
BP: 140/ 100 Decrease Verbalize relief/may require
oxygen supply free from increased dosage of
(ischemia) chest pain within medication to
appropriate time achieve relief
Anaerobic frame for
metabolism administered Provide quiet Decreases external
medications. environment, calm stimuli, which may
activities, and aggravate anxiety
Lactic acid comfort measures and cardiac strain,
formation limit coping abilities
and adjustment to
current situation
-Assist/instruct in
Pain relaxation -Helpful in decreasing
techniques, e.g., perception of/
deep/slow response to pain.
breathing, Provides a sense of
distraction having some control
behaviors, over the situation,
visualization, guided increase in positive
imagery attitude.

Collaborative

Administer
supplemental Increases amount of
oxygen by means of oxygen available for
nasal cannula or myocardial uptake
face mask, as and thereby may
indicated relieve discomfort
Administer medications associated with
as indicated: tissue ischemia

Antianginals, e.g.,
nitroglycerin,
isosorbide dinitrate Nitrates are useful for
(Isordil) pain control by
coronary vasodilating
effects, which
increase coronary
blood flow and
myocardial perfusion.

Analgesics, e.g., Although intravenous

morphine, (IV) morphine is the
meperidine usual drug of choice,
(Demerol) other injectable
narcotics may be
used in
acutephase/recurrent
chest pain unrelieved
by nitroglycerin to
reduce severe pain,
provide sedation, and
decrease myocardial
workload
 Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation
Subjective: Short Term Independent:
-Sleep disturbances Objective: -Provide a - Reduces stress and Short Term Objective:
“Hindi ako related to retained mucus quiet excess stimulation,
makatulog secretion secondary to -After 4 hours environment promoting rest. After 4 hours of nursing
dahil sa ubo pulmonary tuberculosis of nursing and limit visitors during interventions, the patient
ko” as interventions, the acute phase. was able to demonstrate
verbalized patient will a measurable increase in
by Pathophysiology: demonstrate - Elevate head - These Measures tolerance inactivity with
the patient. a measurable and encourage promotes maximal absence of dyspnea and
Pathogen invades the body increase in frequent position inspiration, enhance excessive fatigue.
tolerance in changes, deep expectoration of
Objective: activity with breathing and secretions to improve Long term Objective:
Fatigue. Defense mechanism fails, the absence of effective coughing. ventilation.
pathogen invades the lungs dyspnea and After 7 days
Dyspnea. excessive of nursing
Yellowish fatigue. - Encourage adequate - Facilitates healing interventions, the patient
Cough rest balanced with process and enhances will demonstrate
It will irritate the lining of the Long Term moderate activity. natural resistance.
noted free from intolerance in
lungs and increase the Objective: promote adequate activity with absence of
production of mucus nutritional intake. dyspnea and excessive
V/S taken
as follows: -After 7 days fatigue.
T: 37.7 of nursing -Force fluids to -Fluids especially warm
P: 90
Decrease oxygen is delivered in interventions, the at least 3000 ml liquids aid in -Goal partially met
R: 22 the body patient will per day and offer mobilization
BP: 110/80 demonstrate warm, rather than cold and expectoration of
free from fluids. secretions.
Increased in RR, metabolism intolerance in
and disturbs the sleeping cycle activity with Collaborative:
absence of - Administer -Aids in
dyspnea and medications as reduction of
Restlessness excessive prescribe: bronchospasm and
fatigue. mucolytics or mobilization of
expectorants. secretions.