ASSESSMENT
Objective Data: >Restlessness >Anxious >BP:140/90mmHg >RR:31 breaths/min Subjective Data: >Natatakot naman ngani akong maglala pa ining hilang ko, pabalik balik naman bga sana kami digdi sa ospital, as verbalized by the client
NURSING DIAGNOSIS (RATIONALE) Anxiety related to cardiac event
PLAN >GOAL After 2 hrs. of nursing intervention, the client will be able to verbalized the comfort he feels.
INTERVENTION 1.Assess patients anxiety level and coping mechanisms. 2.Develop of trust and care relationship with the client by letting the patient express what does he feels and listening attentively to this things. 3.Provide environmental modifications that can reduce anxiety by: -Perform a calm manner to the client -Ensuring a quiet environment by always closing the door of the room -Regulating the room temperature -Changing
RATIONALE
EVALUATION
(Anxiety causes the >Reduce patient sympathetic stress anxiety response which can lead to increase sympathetic stimulation that increases the workload of the heart which could cause pain and other signs and symptoms of ischemia)
1. These data provide information about psychological well-being of the patient 2. To encourage the patient to acknowledge and to express his feelings 3. To provide comfort and makes his environment more relax which decreases sympathetic response of a client. 4. Diversional activities aim of promoting and improving the quality of life through ongoing support and development of
After 2 hrs. of nursing intervention, the client has able to verbalized the comfort . ___Met ___Partially met ___Unmet
patients bed linen 4. Providing diversional activities like playing card games or listening to music. 5. Collaboration for the administration of antianxiety drugs to reduce the symptoms of severe anxiety.
clients psychological, emotional, spiritual, social and physical needs and well being. 5. Anti-anxiety drugs, also known as tranquilizers, are medications that relieve anxiety by slowing down the central nervous system. Their relaxing and calming effects have made them very popular: antianxiety drugs are the most widely prescribed type of medication for anxiety.
ASSESSMENT
Objective Data: >Educational attainment: Elementary level Subjective Data: >Dai ko man kaya aram kung ano ang nasa diet na yan saka kung papano maiiwasan ang hilang sa puso ang aram ko lang sa pagkakan yan ning mga taba, as verbalized by the client.
NURSING DIAGNOSIS (RATIONALE) Deficient knowledge related to postMI self-care
PLAN >GOAL After 1 hrs. of nursing intervention, the client will be able to express learning regarding postMI self-care >Adheres to the home health care program and choose lifestyle consistent with heart-healthy recommendations
INTERVENTION
RATIONALE
EVALUATION
(ACS is an emergent situation characterized by an acute onset of myocardial ischemia that results in myocardial death if definitive interventions do not occur promptly)
1.Assess ability to learn or perform desired healthrelated care 2.Assess motivation and readiness of client 3.Assess the individual learning needs 4.Encourage patient to develop hearthealthy eating patterns 5.Engage in regimen of physical conditioning with a gradual increase in activity duration and then a gradual increase in activity
1. Cognitive impairments need to be identified so an appropriate teaching plan can be designed. 2. Some clients are ready to learn soon after they already know the final diagnosis of their physician 3. Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learners preferred style with the educational method facilitates success in mastery of knowledge. 4. The more calorie intake, the more weight gain. Being overweight can cause heart disease because fats that are not burn can become fatty plaque that occlude artery. 5. Physical conditioning can burn most of the LDL that causes plaque which can occlude artery and cause MI
After 1 hrs. of nursing intervention, the client will be able to express learning regarding postMI self-care
___Met ___Partially met ___Unmet
ASSESSMENT
Objective Data: > Restlessness >Anxious >BP:140/90mmHg >RR:31 breaths/min >Pain scale: 6/10 Subjective Data: >kasurusubago lang nagkulog na naman daghan ko nagpakua na ngani akong bulong, kakaisip garo kung papano kami makakabayad ata pati nagmamaray na kuta pagmati ko, as verbalized by the client
NURSING DIAGNOSIS (RATIONALE) Acute pain related to psychological factor
PLAN >GOAL After 4 hrs. of nursing intervention, the clients pain will be reduce from 6/10 to 4/10
INTERVENTION
RATIONALE
EVALUATION
(The sympathetic stress response >To reduced which can lead to patients anxiety increase sympathetic stimulation that increases the workload of the heart which could cause pain and other signs and symptoms of ischemia)
1. Assess level of anxiety by monitoring vital sign 2. Encourage SO to provide therapeutic touch such as light massage in the extremities or back rub. 3. Encourage patient to a bed rest (bed rest) with fowler position / semifowler position. 4. Provide environmental modifications that can reduce anxiety by: -Perform a calm manner to the client -Ensuring a quiet environment by always closing the door of the room -Regulating the room temperature
1. These can point the patients level of anxiety as to mild, moderate, severe or panic and identify physical responses associated with both medical and emotional conditions 2. It is a way to divert attention of the client from pein being felt. 3. Fowlers position promote venus return of the blood. 4.To provide comfort and makes his environment more relax which decreases sympathetic response of a client. 5.By administering Isordil, it relaxes vascular smooth
After 4 hrs. of nursing intervention, the clients pain has been reduced from 6/10 to 4/10
___Met ___Partially met ___Unmet
-Changing patients bed linen 5. Administerning Isordil as prescribe
muscle with a resultant decrease in venous return and decrease in arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption.
