Nursing Care Plan (NCP) for a Patient with Acute Coronary Syndrome

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Acute pain Short-Term Independent: Short-Term Goal:
The patient reports related Goal:  Provided a quiet environment  To decrease external stimuli After 1 hour of
of the pain over the myocardial After 1 hour of and comfort measures such as which may aggravate proper nursing
left chest radiating ischemia. proper nursing change of position condition and to encourage interventions, the
to the right arm. interventions, the to adjust to current situation patient was able to
patient will be able report
P – Worsen upon to report  Instructed to do relaxation  To provide a sense of decreased/relieved
doing exertion decreased/relieved techniques such as deep and having some control over pain (chest and to
activities pain (chest and to slow breathing exercise the situation and to promote radiating area) as
Q – Pressure over radiating area). positive attitude evidenced by pulse
the left chest rate within normal
R – To the right Long-Term Goal:  Encouraged adequate rest  To prevent fatigue that can range (89 bpm).
arm After 2 days of impair ability to manage or
S – // proper nursing cope with pain Long-Term Goal:
T – started 45 mins interventions, the After 2 days of
prior to admission patient will be able  Encouraged verbalization of  To evaluate coping abilities proper nursing
to demonstrate feelings about pain such as interventions, the
Objective: improved feeling concern about tolerating pain patient was able to
 Elevated pulse of control over demonstrate
rate present situation. improved feeling
 EKG: Collaborative: of control as
Inverted T wave  Administered supplemental  To increase amount of evidenced by
1 mm ST oxygen via nasal cannula at 3 oxygen available for verbalizing a sense
depression in L per minute, as indicated myocardial uptake and of control over
leads II, III, thereby may relieve present situation
and aVf discomfort and also future
outcomes.
Vital signs:  Administered 1 tab  To control pain and
 PR = 110 bpm nitroglycerin, as indicated decrease myocardial Goal Met
 BP = 120/90 workload and oxygen
mmHg demand
 RR = 20 cpm
 Temp. = 37.2
℃
References:
Doanges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. (14 ed.). F. A. DAVIS COMPANY, Philadelphia, Pennsylvania
Vera, M. (2020). 7 Myocardial Infarction (Heart Attack) Nursing Care Plans. https://nurseslabs.com/7-myocardial-infarction-heart-
attack-nursing-care-plans/