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

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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