Assessment Diagnosis Planning Intervention Rationale Evaluation

● HR: 112 Acute pain related to After nursing Use flow sheets to Timely intervention is After nursing intervention,
● BP: 160/120 increase cardiac workload intervention, the document pain, more likely to be the patient:
● (+) dob patient will be able therapeutic successful in
● Noted persistent to: interventions, alleviating pain. Verbalized satisfactory pain
chest discomfort response , and length control at a level of 3 on a
radiating to the Describe satisfactory of time before pain rating scale of 0 to 10.
back. pain control at a level occurs. Instruct the
less than 2 to 3 on a client to report pain RR of 18 bpm.
rating scale of 0 to as soon as it begins.
10. HR of 80 bpm.
Respond immediately Prompt responses to
RR ranges within 12- to reports of pain. reports of pain may Demonstrate uses
20 bpm. result in decreased pharmacological and non-
anxiety of the pharmacological pain-relief
HR ranges within 60- patient. techniques.
100 bpm.
Identify precipitating Helps differentiate
Demonstrate uses event, if any: this chest pain, and
pharmacological and frequency, duration, aids in evaluating
non-pharmacological intensity, and possible progression
pain-relief location of pain. to unstable angina.
techniques.
Place the patient at Reduces myocardial
complete rest during oxygen demand to
chest pain periods. minimize risk of
tissue injury.

Eliminate additional Patients may

stressors or sources experience an
of discomfort exaggeration in pain
whenever possible. or a decreased ability
to tolerate painful
stimuli if
environmental or
intrapersonal factors
are further stressing
them.

Provide or promote
nonpharmacological
pain management:
1. Comfort 1. Facilitates gas
measures (e.g exchange to
change of decrease
position, hypoxia and
elevating head resultant
shortness of
breath.
2. Use of relaxation 2. These
exercises (e.g techniques may
focused reduce tension
breathing, and
visualization, subsequently
guided imagery) reduce pain.

Administer analgesics To maintain

as indicated, to acceptable level g
maximum dosage, as pain.
needed.