ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S: Decrease cardiac After 8 hours of Goal met

Mat was awakened output related to nursing intervention  Establish rapport After 8 hours of
due to shortness of disease process the patient will be  Encourage the patient to take nursing intervention
breath, noticed chest of coronary able to: medicine on time. the patient was able to
discomfort and artery disease  Report  Instruct patient to notify nurse
weakness in both (CAD) as anginal immediately when chest pain  report reduce
upper and lower evidenced by episodes occurs. the frequency
extremities, and general weakness decreased in  Assess and document patient and severity of
increase in blood and dizziness frequency, response to medication. angina
pressure. duration, and Provides information about  The patient
severity. disease progression. will be able to
O:  Demonstrate  Identify precipitating event, if verbalize
(2/8/11) relief of pain any: frequency, duration, understanding
BP 160/120 as evidenced intensity, and location of pain. of the disease
Cholesterol: 234 by stable vital Helps differentiate this chest process and
Triglyceride: 123 signs, absence pain, and aids in evaluating treatment
HDL: 26 of muscle possible progression to regimen.
LDL: 83.4 tension and unstable angina.
CHEST PAL: restlessness  Observe for associated
Negative for symptoms:
pneumohemothorax. dyspnea, nausea and vomiting,
Heart is not enlarged. dizziness, palpitations, desire
Atherosclerotic aorta. to micturate. Decreased
Bones are cardiac output stimulates
unremarkable sympathetic and
parasympathetic nervous
(2/19/11) system.
Troponin T: 0.03-0.1
 Evaluate reports of pain in
ECG CONCLUSION:
jaw, neck, shoulder, arm, or
 Thickened hand. Pain is often referred to
anterior mitral more superficial sites served
valve leaflet by the same spinal cord  nerve
 with trivial level.
mitral  Place patient at complete rest
regurgitation. during anginal episodes.
 Aortic Reduces myocardial oxygen
sclerosis with demand to minimize risk of
trivial aortic tissue injury.
regurgitation.  Elevate head of bed if patient
 Trivial is short of breath. Facilitates
tricuspid gas exchange to decrease
regurgitation hypoxia and resultant
CT SCAN REPORT: shortness of breath.
 Monitor heart rate and
Chronic small vessel rhythm. Patients with
ischemic changes unstable angina have an
increased risk of acute life-
threatening dysrhythmias.
 Monitor vital signs every 5
min during initial anginal
attack. Blood pressure may
initially rise because of
sympathetic stimulation.
 Maintain quiet, comfortable
environment. Restrict visitors
as necessary.
Mental/emotional stress
increases myocardial
workload.
 Provide light meals. Have
patient rest for 1 hr after
meals. Decreases myocardial
workload associated with
work of digestion, reducing
risk of anginal attack.
 Administer Prescribed
medications. Aspirin to
reduce ability of blood clot so
that the blood flows easier;
Nitrates to relax blood
vessels; Statis to reduce
deposit on the arterial walls;
Beta blockers to decrease
cardiac demand for oxygen
 Provide supplemental oxygen
as indicated. Increases oxygen
available for myocardial
uptake and reversal of
ischemia.