Name: I.J.P.

Age: 36 years old Chief complain: Chest pain Diagnosis: Angina Pectoris
ASSESSMENT NURSING OUTCOME NURSING RATIONALE EVALUATION DISCHARGE
DIAGNOSI CRITERIA INTERVENTION PLANNING
S
Subjective: Acute pain Short term goal:  Instruct -Unbearable pain Met. The M- Instruct
“kasakit gid sang related to After 8hrs of shift, patient to may cause patient was the client
akon dughan kag decreased the patient will be notify nurse vasovagal able to regarding
nabudlayan myocardial able to: immediately response, demonstrate prescribed
gawa ako mag blood flow when chest decreasing BP and relief of pain medications
ginhawa.” As as  Demonstrate pain occurs. heart rate. as evidenced and to take
verbalized by evidenced relief of pain by stable vital them
the patient. by reports as evidenced  Assess and -Provides signs, absence according to
of pain. by stable vital document information about of muscle frequency.
signs, patient disease tension and
Objective: absence of response to progression. Aids restlessness E-Patient
T-36.50C muscle medication. in evaluating should stay
P-114 tension and effectiveness of Met. The in a quiet and
R-18 restlessness interventions, and patient has peaceful
BP-130/90 mmHg may indicate need anginal place.
O2 Sat-96% for change in episodes
Long term goal: therapeutic decreased in T-Instruct the
-restlessness After 24hrs, the regimen. frequency, client
-delayed patient will be: duration, and regarding the
capillary refill severity. purpose of
-cool peripheries  Reports  Observe for -Decreased cardiac diagnostic
-thready pulse anginal associated output stimulates medical and
episodes symptoms: sympathetic and surgical
decreased in dyspnea, parasympathetic procedures
frequency, nausea and nervous system, and the pre-
duration, and vomiting, causing a variety of procedure
severity. dizziness, vague sensations and post-
palpitations, that patient may procedure
desire to not identify as expectations.
micturate. related to anginal
episode. H-Teach
patient
regarding
health on
 Evaluate -Cardiac pain may what are the
reports of radiate. Pain is do’s and
pain in jaw, often referred to don’ts to
neck, more superficial avoid
shoulder, sites served by the anything bad
arm, or hand same spinal cord to occur.
(typically on nerve level.
left side). O-Instruct
the client to
 Place patient -Reduces seek medical
at complete myocardial oxygen attention if
rest during demand to pain persists
anginal minimize risk of and return to
episodes. tissue injury. the physician
as soon as
 Elevate head -Facilitates gas symptoms
of bed if exchange to reoccur.
patient is decrease hypoxia
short of and resultant
breath. shortness of
Name: I.J.P. Age: 36 years old Chief complain: Chest pain Diagnosis: Angina Pectoris
breath. D-tell patient
to follow
doctor’s
order
-Patients with regarding
 Monitor unstable angina diet on what
heart rate have an increased to eat. And
and rhythm. risk of acute life- eat healthy
threatening food to have
dysrhythmias, proper
which occur in nutrition.
response to
ischemic changes S- tell family
and/or stress. members to
guide and be
with the
-Blood pressure patient
 Monitor vital may initially rise always to
signs every 5 because of reduce stress
min during sympathetic and anxiety
initial anginal stimulation, then regarding
attack. fall if cardiac health
output is condition.
compromised.
S- prayer is
-Anxiety releases powerful
 Stay with catecholamines,
patient who which increase
is myocardial
experiencing workload and can
pain or escalate and/or
appears prolong ischemic
anxious. pain. Presence of
nurse can reduce
feelings of fear and
helplessness.

-Mental/emotional
 Maintain stress increases
quiet, myocardial
comfortable workload.
environment.
Restrict
visitors as
necessary.