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8/2/2019 Short Form Workin' Care Plan 2-27-12
1/5
NUR DX SRG NUR INTERVENTIONS RATIONALE EVALUATION
Altered
Tissue
Perfusion:
Myocardial
r/t chest pain
2r
Development
of CAD
Patient will have
improved tissue
perfusion during
clinical shift AEB:
p HR WNL (60-100 bpm)
p Demonstratingno signs or
symptoms of
chest pain
(angina)
p O2 saturationWNL (95-100%
on room air)
Assessment:
y Assess blood pressure/ apical heart rate/ respirations q shifty Assess O2 sat q shifty Assess Telemetry q hr/PRN if experiencing anginay Assess positioning of patient q shifty Assess activity tolerance q shifty Assess skin/extremities q shift noting:
- Edema- Temperature- Color
y Assess capillary refill q shifty Assess Labs q shift/ PRN per physician ordersy Assess patient history for risk factor both modifiable and non-modifiable upon admission/ q dayy Assess patients willingness to cooperate with medical treatments q shifty Assess patients ability to recognize signs and symptoms indicative of decline in health status q
shift
Monitor:
y Monitor for changes in blood pressure/ apical heart rate/ respirations q shifty Monitor O2 sat q shifty Monitor for changes in Telemetry q hr/PRN if experiencing anginay Monitor positioning of patient q shifty Monitor activity tolerance q shifty Monitor for changes in skin/extremities q shift noting:
- Edema- Temperature- Color
y Monitor capillary refill q shifty
Monitor for changes in labs q shift/ PRN per physician ordersy Monitor for patients willingness to cooperate with medical treatments q shifty Monitor the patients ability to recognize signs and symptoms indicative of decline in health status
q shift
Interventions:
y Auscultate apical HR q shifty Obtain BP q shifty Auscultate lungs noting RR/Rhythm/Abnormal Breath Soundsy Maintain continuous ECG monitoringy Place patient in comfortable position and administer oxygen, if prescribed, to enhance myocardial
oxygen supply
8/2/2019 Short Form Workin' Care Plan 2-27-12
2/5
y Identify specific activities patient may engage in that are below the level at which chest painoccurs
y Reinforce the importance of notifying nursing staff whenever angina pain is experiencedy Encourage supine position for dizziness caused by anti-anginalsy Explain to the patient the importance of anxiety reduction to assist to control anginay Teach the patient relaxation techniquesy Review specific factors that affect CAD development and progression; highlight those risk factors
that can be modified and controlled to reduce the risk
NUR DX SRG NUR INTERVENTIONS RATIONALE EVALUATION
Risk for
Decreased
CardiacOutput r/t
narrowing of
arteries 2r
Development
of CAD
Patient will
maintain adequate
cardiac outputduring clinical shift
AEB:
p HR WNL (60-100 bpm)
p O2 SAT WNL(95-100% on
room air)
p All extremitieswarm/ dry/
p palpable pulsesnoted
bilaterally
p Capillary refill