Western Mindanao State University

COLLEGE OF NURSING
Zamboanga City

Alternative Learning System

Related Learning Experience
HEART CLINIC

Submitted by:
DEMAYO, EDSON JOHN C.
BSN – 3A

Submitted to:

ELAINE MARIE E. SOQUEÑA, RN, MAN

Clinical Instructor
 NURSING CARE PLAN
ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE OF INTERVENTION RATIONALE
CARE
Subjective Acute pain Report pain is INDERPENDENT After applying
cue: related to relieved or Assess patient’s Patient’s perception and Assessed patient’s appropriate
“Sumasakit po myocardial controlled. perceptions of pain, along expression of pain are perceptions of pain, intervention,
ang dibdib ko.” ischemia as with behaviors and influenced by age, along with behaviors patient will be
As verbalized evidenced Demonstrate cultural expectations developmental stage, and cultural able to report
by the patient. by reports use of relaxation regarding pain. cognitive and behavioral expectations pain is relieved,
of chest skills. and sociocultural regarding pain. demonstrate
Objective pain factors. relaxation skills
cue: -Facial Verbalize sense and verbalize
expression of of control of Perform pain assessment Performed pain positive outlook in
pain response to each time pain occurs. To demonstrate assessment each the future.
-Weakness acute situation Document and improvements in status time pain occurs.
-Pain scale of and positive investigate changes from or to identify worsening Document and
7 over 10. outlook for the previous reports and of underlying investigate changes
future. evaluate results of pain condition/developing from previous
intervention. complications. reports and evaluate
results of pain
intervention.

Monitor skin color and

vital signs. Which are usually Monitored skin color
altered in acute pain. and vital signs.

Determine patient’s It can affect responses

factors in lifestyle. to analgesics and Determined
interventions for pain patient’s factors in
 management. lifestyle.

Encourage verbalization
of feelings about the pain, To evaluate coping Encouraged
such as concern about abilities and to identify verbalization of
tolerating pain. areas of additional feelings about the
concern. pain, such as
concern about
tolerating pain.
Encourage adequate rest
periods. To prevent fatigue that
can impair ability to Encouraged
manage or cope with adequate rest
pain. periods.
Instruct patient to do
relaxation techniques:
deep and slow breathing, Helpful in decreasing
distraction behaviors, perception and Instructed patient to
visualization, guided response to pain. do relaxation
imagery. Provides a sense of techniques: deep
having control over the and slow breathing,
situation, increase in distraction
positive attitude. behaviors,
visualization, guided
Discuss with SO ways in imagery.
which they can assist
patient with pain SOs may provide
management. assistance by Discussed with SO
transporting patient to ways in which they
prevent walking long can assist patient
distances or by taking with pain
on client’s strenuous management.
 chores, supporting
timely pain control,
encouraging eating
nutritious meals to
enhance wellness and
providing gentle
DEPENDENT massage to reduce
Administer analgesics, as muscle tension.
indicated.

Administered
analgesics, as
Administer antianginal, as To maintain acceptable indicated.
prescribed. level of pain. Notify
physician if regimen is
inadequate to meet pain
control goal. Administered
antianginal, as
prescribed.
INTERDEPENDENT Nitrates are useful for
Establish collaborative pain control by coronary
approach for pain vasodilating effects,
management based on which increase coronary
patient’s understanding blood flow and
about and acceptance of myocardial perfusion.
available treatment Established
options. collaborative
approach for pain
management based
Pain medications may on patient’s
include pills/liquids or understanding about
 suckers, injections, and acceptance of
based on client’s available treatment
symptomatology and options.
mechanism of pain as
well as tolerance for
pain and various
analgesics.

ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE
OF CARE
Subjective Activity Report INDEPENDENT After applying
cue: intolerance absence of Note patient reports of Symptoms may be a Noted patient appropriate
“Nanghihina po related to angina and weakness, fatigue, result of or contribute to reports of intervention,
ako at masakit presence of measurable pain, difficulty intolerance of activity. weakness, fatigue, patient will be
po ang dibdib ischemic/necrotic increase in accomplishing task. pain, difficulty able to report
ko.” As myocardial activity accomplishing task. absence of
verbalized by tissues as intolerance. angina and
the patient. evidenced by Document patient’s Trends determine Documented measurable
angina. heart rate and rhythm patient’s response to patient’s heart rate increase in
Objective changes in BP before, activity and may and rhythm changes activity
cue: during and after the indicate myocardial in BP before, during intolerance.
-Weakness activity. Correlates of oxygen deprivation that and after the
-Facial chest pain. may require decrease in activity. Correlates
grimace activity level or return to of chest pain.
-Pain scale of bed rest.
7 over 10
Determine the
patient’s current This provides a baseline Determined the
activity level and for comparison and an patient’s current
physical condition with opportunity to track activity level and
observation, exercise changes. physical condition
capacity testing or use with observation,
of functional-level exercise capacity
classification system. testing or use of
functional-level
classification
system.
Reduce intensity level To prevent overexertion.
or discontinue
activities that cause Reduced intensity
undesired level or discontinue
physiological changes. activities that cause
undesired
To reduce fatigue. physiological
changes.
Plan care to carefully
balance rest periods
with activities. Planned care to
carefully balance
This helps to minimize rest periods with
frustrations and activities.
Provide positive rechannel energy.
atmosphere while
acknowledging the Provided positive
difficulty of the atmosphere while
situation for the acknowledging the
patient. To enhance ability to difficulty of the
participate in activities. situation for the
patient.
Promote comfort
measures and provide
for relief for pain. Indicated need to alter Promoted comfort
activity level. measures and
provide for relief for
pain.
Instruct patient in
monitoring response
to activity and Many of these factors
recognizing signs and may be amenable to Instructed patient in
symptoms. modification, thus monitoring response
reducing risk factors to activity and
and promoting health. recognizing signs
Provide information and symptoms.
about the effect of
lifestyle on activity Provided
tolerance. To enhance sense of information about
well-being. the effect of lifestyle
on activity
tolerance.
Encourage patient to
maintain positive
attitude; suggest use
of relaxation To develop individually Encouraged patient
techniques. appropriate therapeutic to maintain positive
regimens. attitude; suggest
use of relaxation
INTERDEPENDENT techniques.
Provide referral to
psychological Provides continued
counseling, recreation support and additional Provided referral to
therapists as supervision and psychological
indicated. participation in recovery counseling,
 and wellness process. recreation therapists
as indicated.
Refer to cardiac
rehabilitation program.

Referred to cardiac
rehabilitation
program.

REFERENCE:
Doenges, Moorhouse, Murr (2019). Nurse’s Pocket Guide 15th Edition. Philadelphia, Pennsylvenia: F.A Davis Company