Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Higher Education ‫وزارة التعليم العالي‬

University of Tabuk ‫جامعة تبوك‬
Faculty of Applied Medical Sciences ‫كلية العلوم الطبية التطبيقية‬
Department of Nursing ‫قسم التمريض‬

UNIVERSITY OF TABUK
FACULTY OF APPLIED MEDICAL SCIENCE
DEPARTMENT OF NURSING

NURSING CARE PLAN

Name of Student: _______Abdullah soleiman Alomrani _______ Student Number: __391000578____

Name of Patient: _____WALEED ALHOUITEY ____ Age: ____37__ Medical Diagnosis: ___acute chest pain _____
Ward/Unit: ___surgical ward ___ Room/ Bed No.: __1824__ Date of Assessment: ___11/2/2021__
Assessment Nursing Diagnosis Goal Interventions Rationale Evaluation
Subjective Cues: Goal Statement: Independent: Fully Met:
Pt stated that " I fell 1-Variation of appearance
pain in my chest". Pt will be free from pain 1- Monitor and document and behavior of patients Pt will be free from any
Acute pain related after intervention and characteristic of pain, noting in pain may present, pain after 24hr of
to reduced coronary have a knowledge about verbal reports, nonverbal Respirations may be intervention, also with
blood flow. his condition and BP or heart rate increased as a result of knowledge about his
changes. pain and associated condition.
anxiety; release of stress-
Objective Cues: 2- Check vital signs before induced catecholamines
and after narcotic increases heart rate and .
Difficulty of breathing. medication. BP.
Fatigue.
Pain scale 7 of 10 Objectives: 2- Hypotension and Partially Met:
Vs: Long Term Objectives: 3-Teaching client about his respiratory depression
Rr: 21 condition. can occur as a result of
Bp: 128/78 Pt after 24 hours he will narcotic administration.
Pm: 80 be free from any pain
T: 37 With knowledge how to 3- help to decrease
reduce or decrease the anxious and promoting
pain. healing process.

Unmet:

Revised summer 2016

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Higher Education ‫وزارة التعليم العالي‬
University of Tabuk ‫جامعة تبوك‬
Faculty of Applied Medical Sciences ‫كلية العلوم الطبية التطبيقية‬
Department of Nursing ‫قسم التمريض‬

4-increases amount of
Dependent: oxygen available for
myocardial uptake and
4-Administer thereby may relieve
Short Term Objectives supplemental oxygen. discomfort associated
with tissue ischemia.
5- administer morphine.
Decrease pain scale 7 to 5- administered when the
3 in 2 hrs.. pain unrelieved by
nitroglycerin to reduce
sever pain.

Collaborative:
6- assesses blood flow to
the heart muscle when it
6-radioactive tracer is stressed.

Date Submitted: __________________________ Faculty Name & Signature: _________________________

Revised summer 2016