NCP v2.0
Content
Nursing Diagnosis
27 1300H Jan 16
Acute Pain related to
coronary tissue ischemia
“Sobrang sakit ng dibdib
ko na parang may
nakadagan at kumakalat
sa kaliwang braso”
Nursing Objectives
Within 20 minutes of
nursing interventions, Mr R
will be able to
demonstrate relief of chest
pain as evidenced by:
Nursing Intervention
1.
Mr R verbalization of pain
relief with pain scale from
10/10 to 4-0/10.
Pain Scale of 10/10
(+) Levine’s Sign
(+) Facial Grimacing
(+) Restlessness
(+) Shortness of breath
(+) Diaphoresis
(+) cold clammy skin
(+) sinus tachycardia with
occasional arrhythmia (ST
segment elevation and T
wave inversion)noted on
ECG monitor
V/S
CR: 145 bpm
RR: 31 cpm
BP: 160/90 mmHg
O2 sat: 89%
(-) Levine’s Sign
(-) Facial Grimacing
(-) Restlessness
(-) Shortness of breath
(-) Diaphoresis
(-) cold clammy skin
normal sinus rhythm noted
on ECG monitor
V/S
CR: 60-100 bpm
RR: 16-20 bpm
BP: 110-130/80-90 mmHg
O2 sat: 95%-99%
2.
3.
4.
5.
6.
7.
Evaluation
Goals met.
Assessed and
After 20 minutes of
monitored
nursing interventions, Mr R
characteristic of pain was able to relieve of
(P-Q-R-S-T) and
chest pain as evidenced
noting verbal
by:
reports, nonverbal
cues (moaning,
“Hindi na masyadong
crying, grimacing,
masakit ang dibdib ko.”
restlessness,
diaphoresis,
Pain Scale of 2/10
clutching of chest)
and BP or heart rate (-) Levine’s Sign
changes.
(-) Facial Grimacing
Placed Mr R on
(-) Restlessness
Semi-fowler’s
(-) Shortness of breath
position, with side
(-) Diaphoresis
rails up and locked.
(-) cold clammy skin
Demonstrated and
normal sinus rhythm noted
instructed relaxation on ECG monitor
technique such as
V/S
Pursed Lipped
CR: 89 bpm
Breathing
RR: 20 bpm
Provided with calm,
BP: 120/90 mmHg
non-stressful and
O2 sat: 95%
quiet environment
Instructed to be on
complete bed rest
without bathroom
privileges for 3 days
as ordered.
Assisted in activities
of daily living e.g.
self-care.
Emphasized
adherence on Low
cholesterol low salt
low fat diet
8. Obtained a 12-lead
ECG during the
symptomatic event
as ordered
9. Administered O2 via
face mask @ 5L/min
as ordered
10.
Administered
medications:
Morphine 2.5mg
slow IV push as
ordered
11.
Administered
acetylsalicylic acid
162 mg PO as
ordered
27 1300H Jan 16
Acute Pain related to
coronary tissue ischemia
“Sobrang sakit ng dibdib
ko na parang may
nakadagan at kumakalat
sa kaliwang braso”
Nursing Objectives
Within 20 minutes of
nursing interventions, Mr R
will be able to
demonstrate relief of chest
pain as evidenced by:
Nursing Intervention
1.
Mr R verbalization of pain
relief with pain scale from
10/10 to 4-0/10.
Pain Scale of 10/10
(+) Levine’s Sign
(+) Facial Grimacing
(+) Restlessness
(+) Shortness of breath
(+) Diaphoresis
(+) cold clammy skin
(+) sinus tachycardia with
occasional arrhythmia (ST
segment elevation and T
wave inversion)noted on
ECG monitor
V/S
CR: 145 bpm
RR: 31 cpm
BP: 160/90 mmHg
O2 sat: 89%
(-) Levine’s Sign
(-) Facial Grimacing
(-) Restlessness
(-) Shortness of breath
(-) Diaphoresis
(-) cold clammy skin
normal sinus rhythm noted
on ECG monitor
V/S
CR: 60-100 bpm
RR: 16-20 bpm
BP: 110-130/80-90 mmHg
O2 sat: 95%-99%
2.
3.
4.
5.
6.
7.
Evaluation
Goals met.
Assessed and
After 20 minutes of
monitored
nursing interventions, Mr R
characteristic of pain was able to relieve of
(P-Q-R-S-T) and
chest pain as evidenced
noting verbal
by:
reports, nonverbal
cues (moaning,
“Hindi na masyadong
crying, grimacing,
masakit ang dibdib ko.”
restlessness,
diaphoresis,
Pain Scale of 2/10
clutching of chest)
and BP or heart rate (-) Levine’s Sign
changes.
(-) Facial Grimacing
Placed Mr R on
(-) Restlessness
Semi-fowler’s
(-) Shortness of breath
position, with side
(-) Diaphoresis
rails up and locked.
(-) cold clammy skin
Demonstrated and
normal sinus rhythm noted
instructed relaxation on ECG monitor
technique such as
V/S
Pursed Lipped
CR: 89 bpm
Breathing
RR: 20 bpm
Provided with calm,
BP: 120/90 mmHg
non-stressful and
O2 sat: 95%
quiet environment
Instructed to be on
complete bed rest
without bathroom
privileges for 3 days
as ordered.
Assisted in activities
of daily living e.g.
self-care.
Emphasized
adherence on Low
cholesterol low salt
low fat diet
8. Obtained a 12-lead
ECG during the
symptomatic event
as ordered
9. Administered O2 via
face mask @ 5L/min
as ordered
10.
Administered
medications:
Morphine 2.5mg
slow IV push as
ordered
11.
Administered
acetylsalicylic acid
162 mg PO as
ordered
