Nursing care plan 1 DATE : 19.10.2010 TIME : 1340hours NURSING DIAGNOSIS : Altered in comfort : chest pain related to myocardial infarction. SUPPORTING DATA : - patient verbalize of having chest pain on and off since 2 month - patient complain chest pain during lying prone GOAL : patient will feel comfortable and relax by reducing his chest pain within 2 hours after nursing intervention applied during hospitalization. NURSING INTERVENTION :
Transcript
Nursing care plan 1
DATE : 19.10.2010
TIME : 1340hours
NURSING DIAGNOSIS : Altered in comfort : chest pain related to myocardial infarction.
SUPPORTING DATA : - patient verbalize of having chest pain on and off since 2 month
- patient complain chest pain during lying prone
GOAL : patient will feel comfortable and relax by reducing his chest pain within 2 hours after
nursing intervention applied during hospitalization.
NURSING INTERVENTION :
1. Assess patient’s location , characteristic, quality, time onset, and duration.
As a baseline data for further intervention.
I :I ask Mr.N his wife about his chest pain pattern such as location,
characteristic, quality, time onset, and duration.
2. Monitor patient’s vital sign especially blood pressure and pulse
Increase in blood pressure indicate patient having pain.
I : Mr.N blood pressure is 145/107 mmHg and his pulse is 70 per minute
during admission.
3. Position patient’s in comfortable position or patient’s desire position.
Example : semi–fowlers position.
For better lung expansion and easier breathing so that can reduce pain and feel
more comfortable.
I : I suggest Mr.N to position in semi-fowlers position and help him to prop
up the bed.
4. Perform 12 lead electrocardiogram (ECG) to patient’s.
To evaluate patient’s heart rhythm.
I : I perform ECG after the interview. His result noted by staff nurse and
doctor.
5. Encourage patient to rest in bed (RIB) .
To reduce oxygen consumption and allow patient’s to relax.
I : I advise patient to rest in bed and placed the call bell near to the Mr. N
and asked him to call the nurses by pressing the call bell whenever help or
assistance needed.
6. Teach patient to do Deep Breathing Exercise (DBE).
To relax the muscles and help to divert the attention from pain. This also can
increase the oxygenation in our body.
I : I thought patient to do DBE. I told Mr.N to breath in through the nose and
hold as long as he can and then breath out through the mouth pursed lip. I
also tell patient’s can repeating the step whenever he felt nervous or pain.
7. Restrict the number of visitor by only allow them to visit during visiting
hour.
Patient will be able to rest more.It will reduce her activity and can prevent chest
pain occur.
I: I advice Mr.N family members do not stay long with patient and come on
visiting hours because patient’s need more rest. However, family member was
allow to stay with patient to support patient emotionally.
8. Inform to the doctor if patient’s chest pain still persist.
To plan for further treatment.
I: I did not inform doctor because patient’s pain has reduced and the chest
pain is tolerable. However, there is still pain on and off.
DATE : 19.10.2010
TIME : 1540hours
EVALUATION : patient’s chest pain reduced and patient able to tolerate the chest pain within
2 hours after nursing intervention given during hospitalization.
EVIDENCE -. Mr.N verbalized he feels more comfortable.
- Patient appears calm and comfortable.
Nursing care plan 2
DATE : 19.10.2010
TIME : 1600HOURS
NURSING DIAGNOSIS : Alteration in breathing pattern : shortness of breath related to
increase coronary oxygen demand.
SUPPORTING DATA : - patient complain having shortness of breath for 2 days.
- patient feel uncomfortable
GOAL : patient shortness of breath will reduce within 2 hours after nursing intervention given
during hospitalization.
NURSING INTERVENTION :
1. Assess patient’s general condition (level of consciousness, breathing pattern)
As baseline data for further intervention
I : I observed patient breathing pattern and noted that he is tachypnoea
I : Mr.N respiration rate is 24 per min, blood pressure 145/107, temperature
36.3, oxygen saturation 98%.
3. Encourage patient to completely rest in bed (CRIB).
To reduce oxygen demand
I : I advise Mr.N to completely rest in bed.
4. Position patient to semi-fowlers or fowlers position.
® To reduce the oxygen requirements.
I : I positioning Mr.N to semi-fowlers 45.
5. Teach patient Deep Breathing Exercise(DBE).
® To improve breathing pattern and help to increase oxygen level.
I : I teach patient to do Deep Breathing Exercise and also advise him to do every
morning
6. Monitor ECG immediately during pain .
® ST segment is depressed or downsloping and T wave may flatten indicate ischemia
I : I monitor ECG immediately during pain occur.
7. Report patient condition to the doctor if dyspnea and chest pain still persist.
® For further interventions.
I : I did not report patient condition to the doctor because patient had no shortness
of breath.
DATE : 19.10.2010
TIME : 1800hours
EVALUATION : patient’s had no shortness of breath and looks cheerful within 2 hours after
intervention given
EVIDENCE : - patient’s verbalize had no shortness of breath and looks comfortable
Nursing care plan 3
DATE: 20.10.2010
TIME: 0830hours
NURSING DIAGNOSIS: Knowledge deficit related to lack of information
about Ischemia Heart Disease (IHD).
SUPPORTING DATA: - Patient asked a lot of question of his disease.
- Patient look confuses.
GOAL: Patient will be understand about his disease and able to explain after 1 hour intervention given.
NURSING INTERVENTION:
1. Assess patient level of knowledge and understanding regarding his disease. As a baseline data and to plan further intervention.
I : I asked Mr. N what he understand about his disease and what he would like
to know regarding his disease.
2. Explain to the patient by using simple language and easy to understanding. To enhance patient knowledge and understand regarding his disease.
I : I explain to Mr. N by using the simple language and sentence. I also not using medical term.
3. Explain to the patient the definition, sign and symptoms of Ischemia Heart Disease. To make patient aware and understand about his disease.
I : I explain to the Mr. N about the clinical manifestation of Ischemia Heart Disease that he having.
4. Explain the important of medication, diet, hygiene and follow up. To prevent recurrent of his disease.
I : I explain to Mr. N about health education so that he can practice in his his activity daily living.
5. Encourage patient to ask more question regarding his disease. To avoid misunderstanding.
I : I encourage Mr. N to asked question if he not understand.
6. Encourage patient to explain back what he understand about his disease after explanation given.
To ensure patient more understand. I : After giving an explanation to the Mr.N, I asked him to explain back to me on his own words.
DATE: 20.10.2010
TIME: 0930hours
EVALUATION: Patient having a good understanding about his disease after 2 hours nursing
intervention given and during the hospitalization.
EVIDENCE: -patient able reexplain about his disease after the intervention given.
-patient not asking a lot of question regarding his disease.
Nursing care plan 4
DATE : 20.10.2010
TIME : 1015hours
NURSING DIAGNOSIS : Alteration in nutritional intake : imbalanced nutrition more than body
requirement.
SUPPORTING DATA : -patient lipid profile shows abnormalities where his total blood
cholesterol is 5.4 mmol/L ( <5.2 mmol/L)
GOAL : patient cholesterol level will be reduced within normal range after nursing
intervention given and maintain during hospitalization after health education given.
NURSING INTERVENTION :
1. Assess patient’s eating pattern and assessment of food intake. example : type of food intake.
As a baseline data for further intervention.I : During assessment I had ask my patient about his food intake and he like to eat meat and mutton.
2. Obtain patient’s Body Mass Index (BMI) and height to know the BMI level. The BMI level indicate patient’s in balance body weight or overweight.
I : I obtain Mr.N weight is 84 and his height is 168 and Mr.N BMI shows 28.9 which is overweight.
3. Provide guidance regarding specific food choices with healthy alternatives.
Specific diet information and suggestions help the patient’s to make better food choices. I : I recommend Mr.N to eat a lot of vegetables cereals, and less intake of cholesterol food.
4. Suggest pamphlets, and information on low-fat eating. To increase patient awareness and allows my patient’s to make conscious changes.
I : I gave him diet information and suggestion by providing him with healthy food pamphlets.
5. Encourage gradual but progressive dietary changes. Drastic changes in eating pattern may cause frustration and discourage the patient
from maintaining a healthy diet. I : I advise Mr.N to change his eating habits and pattern slowly but steady
. 6. Discourage use of high-fat, low-carbohydrate or other fat diets.
To reduced the cholesterol level and the risk for hyperlipidaemia.
I : I encourage patient to aware of high cholesterol food intake and better food choices.
7. Refer patient’s to dietician as doctor order To get better information about balance diet
I : I had call dietician to gave patient’s more information regarding balance diet and nutrition intake.
8. Inform doctor if patient cholesterol level is not reduced. I did not inform the doctor because my patient cholesterol level is reduced within
normal range on patient follow –up. I : I was at Dr.S clinic with Mr.N on his follow-up and ensure the cholesterol level within normal range with the staff at the clinic.
DATE : 3 .12.2010TIME : 0930hours
EVALUATION : patient’s cholesterol level is reduced within normal range after two weeks .
EVIDENCE : -Mr.N cholesterol level was normal range on his follow up
Nursing care plan 5
DATE : 21.10.2010
TIME : 1415hours
NURSING DIAGNOSIS : Knowledge deficit related to home management.
SUPPORTING DATA : - patient verbalize ‘ Nurse, how can I manage myself at home? ’
- patient ask how the chest pain occur
GOAL : patient and family will be able to gain better understanding of home management
after explanation given before discharge.
NURSING INTERVENTION :
1. Assess level of patient’s knowledge and understanding about the disease and selfcare at home As a baseline data and further intervention
I : I assess Mr.N knowledge through answer that he gave to me whether he understand on how the chest pain occur and how to manage him at home.
2. Develop teaching that include Anatomy and Physiology of the heart muscle, coronary arteries and atherosclerotic process that contribute to Ischemia Heart Disease by using simple word. To increase patient’s knowledge and understanding
I : I teach Mr.N little bit about Anatomy and Phsysiology of the heart muscle, coronary arteries and atherosclerotic process and how he get chest pain by using simple language and he comfortable with the language and liitle bit understand about his disease.
3. Provide patient’s information about home management at home include diet. To ensure patient take a good and balance diet to fatsen recovery regarding his diet.
I : I advise Mr.N to control his diet by take low salt diet, fat , and cholesterol and take more vegetable and fruit.
4. Encourage patient’s to do light exercise at home. To promote blood circulation.
I : I advise Mr.N to walk around his house for 15- 20 minutes.
5. Explain to patient regarding the importance of medications and the proper medication. - explain all the medication and the indication and side effect of each medication.
- follow 6R right medication, right dosage, right route, right time to prevent error
I : The staff nurse explained to Mr.N regarding the importance of medicines
during giving the To Take Away (TTA) drugs.
6. Encourage patient to ask any question regarding his home management. For clear and better understanding about home management.
I : I asked Mr.N whether he has any question .Mr.N so far don’t have any question and he understand his condition.
7. Inform Dr.S if pateint’s still not understand about his disease (IHD) For further explanation
I : I didn’t inform Dr.S because my patient understand about his disease.
DATE : 21.10.2010
TIME : 1445hours
EVALUATION : Mr.N and wife gain better understanding of Ischemia Heart Disease and
lifestyle changes after nursing intervention.
Nursing intervention 6
DATE :
TIME :
NURSING DIAGNOSIS: Activity intolerance related to shortness of breath
SUPPORTING DATA: - patient verbalize having shortness breath for 2 day
- patient cannot carry out Activity Daily Living without assistance.
GOAL: patient will able to perform ADL without assistant 24 hours after intervention given.
NURSING INTERVENTION:
1. Assess patient’s general condition(level of mobility, respiratory rate). To obtain baseline data for further intervention.
I: I had assessed Mr.N general condition and he was ambulating by his wife.
2. Monitor patient’s vital sign (blood pressure,pulse,respiration,spO2) As reference to indicate any abnormalities in patient’s vital sign.
I: I had monitored Mr.N vital sign .Mr.N 145/107 mmHg, 70 bpm, 20 min, 98%.
3. Position patient’s to semi fowler’s position or as patient’s desire position. To promote lung expansion and increase oxygenation.
I: I had position Mr.N to semi fowler’s and he comfortable with that position.
4. Teach patient’s deep breathing and coughing exercise. To promote lung expansion
I: I had taught Mr.N on how to perform deep breathing and coughing exercise.
5. Assist patient’s in active exercise if patient’s able to do so. To ensure patient compliance with his own tolerance
I: I had Mr.N during perform active exercise. Mr.N able to move and don need any assistant while he doing exercise.
6. Encourage patient to do light activity example: take a short walk . To avoid shortness of breath
I: I encourage Mr.N to take a short walk .
7. Advise patient’s to rest in bed (RIB). To preserve oxygen demand and increase oxygen needed.
I: I advice Mr.N to rest in bed .
8. Encourage patient’s family member to assist patient during carry out Activity Daily living. To ensure patient ambulating himself and as a moral support.
I: I encourage Mr.N wife to always assist Mr.N especially when he carry out Activity Daily Living.
9. Report patient condition in the nursing report. As a evidence to be compare
I: I had record patient condition in the nursing report
DATE :
TIME:
EVALUATION: Patient will able to perform ADL without any assistant after 24 hours intervention
given.
EVIDENCE: - Patient verbalize able to carry out activity daily living without any assistant.
-patient look tidy and cheerful
NURSING CARE PLAN 3
DATE :
TIME :
NURSING DIAGNOSIS : Alteration in sleeping pattern, insomnia related to new environment.
SUPPORTING DATA : 1. Patient verbalize that she unable to sleep well
2. Patient looked restless
GOAL : Patient will be able to sleep well at least 6-8 hours per day after nursing intervention given and during hospitalization
NURSING INTERVENTION:
1.Assess patient sleeping pattern as usual frequently
As baseline data and for further intervention
I : I ask Mr.N what time that he usually sleep at home and he said he sleep at 2100hours and at the hospital he sleep at 0001hours and cannot sleep at all.he even wake up at 3 o’clock.
2. Position my patient to semi fowlers position
To promote good lung expansion and easier to breath and to make patient comfortable
I: I prop up the head of the bed for Mr.N so that he can breath easily and comfortable.
3. Provide quite and conducive environment to the patient
To promote comfortable to the patient to get a well sleep
I:I ensure the ventilation on her room is good by set the room temperature as desired by Mr.N . I also draw her curtain and advice the other patients to control their voice.
4. Plan all nursing procedure properly such as vital sign (TPR)
To minimize disturbance to her when she sleep and to get a well sleep
I: I plan all my nursing procedure before I attend to Mr.N at do the procedure at the same time.
5. Restrict visitor except the patient wife & daughter
To ensure patient get adequate rest & relive her tension
I:I tried to explain to patient relatives that he need a lot of rest and do not disturb him if not necessary.
6. Advice patient not to take any drinks that contain caffeine before sleep time
To prevent patient from get difficulties to sleep
I: I told to Mr.N that drinks that contain caffeine can make her can’t sleep
7. Inform doctor if patient still can’t sleep
To plan a further treatment to her
I:I didn’t inform doctor because he able to sleep well than before
EVALUATION : Patient able to slept well in 6-8 hours per day after nursing intervention given
SUPPROTING DATA : 1. I saw Mr.N slept well when I’m doing a ward round
