NURSING CARE PLAN NO.

1
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Decreased Cardiac Short Term: Independent: Short Term:
Patient complaining of 2 Output related to Altered Within 4 hours of nursing  Establish rapport  To gain trust. After 4 hours of nursing
hours of severe chest Stroke Volume intervention, the patient  Monitor patient vital  Served as baseline intervention, the patient
pain radiating to his left will participate in sign data was able to participate in
arm associating with activities that decrease the  Monitor ECG for  Decrease in cardiac activities that decrease
Diaphoresis and Nausea. workload of the heart such dysrhythmias, output may result in the workload of the
as stress management or conduction defects, changes in cardiac heart such as stress
Objective: therapeutic medication and for heart rate perfusion causing management or
 Diaphoretic regimen program. dysrhythmias. therapeutic medication
 Nausea  Position the patient  Promotes improve regimen program.
 Fatigability in semi- Fowler’s alveolar gas
Long Term: position. exchange. Long Term:
Within 4 days of nursing  Encourage patient to  Caffeine is cardiac After 4 days of nursing
interventions, the patient decrease intake of stimulant and may interventions, the patient
will be able to display caffeine, cola, and adversely affect was able to display
hemodynamic stability chocolates. cardiac function. hemodynamic stability
with normalization of  Observe the  Peripheral with normalization of
ECG tracing blood patient’s skin color, vasoconstriction ECG tracing blood
pressure readings. capillary refill time, may result in pale, pressure readings.
and diaphoresis. cool, clammy skin,
with prolonged -Goal Partially Met.
capillary refill time
due to cardiac
dysfunction and
decreased cardiac
output.
 Monitor intake and  To maintain
output and calculate adequate nutrition
24hrs fluid balance. and fluid balance.
 Instruct the patient  Restrictions can
and SO on fluid diet assist with decrease
 and diet in fluid retention,
requirements and thereby improving
restrictions of cardiac output.
sodium.

Dependent:
 Administer  To provide for
supplemental adequate
oxygen as ordered oxygenation.
 Administer medicine  To promote
as prescribed by the wellness.
physician.

NURSING CARE PLAN NO. 2

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Acute pain related to Within 2 hours of nursing Independent: After 2 hours of nursing
Patient complaining of 2 obstructed blood flow to intervention the patient  Monitor and document  Variation of intervention the patient
hours of severe chest the heart muscle as will experience decrease characteristic of pain, appearance and was able to experience a
pain radiating to his left evidenced by reports of level of pain. noting verbal reports, behavior of patients in decreased level of pain
arm associating with chest pain radiating to nonverbal cues pain may present a from 9/10 to 5/10.
Diaphoresis and Nausea. the left arm. (moaning, crying, challenge in
grimacing, restlessness, assessment. Most
Objective: diaphoresis, clutching patients with an acute
 Diaphoretic of chest) and BP or MI appear ill,
 Nausea heart rate changes. distracted, and focused
 Pain scale: 9/10 on pain. Verbal history
 ECG result: inferior and deeper
and posterior ST investigation of
segment elevations precipitating factors
 CARDIAC should be postponed
TROPONIN result: until pain is relieved.
0.30 ng/ml Respirations may be
increased as a result of
pain and
associated anxiety;
release of stress-
induced catecholamines
increases heart rate and
BP.
 Obtain full  Pain is a subjective
description of pain experience and must be
from patient described by patient.
including location, Provides baseline for
intensity (using scale comparison to aid in
of 0–10), duration, determining
characteristics effectiveness of
(dull, crushing, therapy, resolution and
described as “like an progression of problem.
elephant in my
chest”), and
 radiation. Assist
patient to quantify
pain by comparing it
to other experiences.
 Instruct patient to  Decreases external
report pain stimuli, which may
immediately. aggravate anxiety
Provide quiet and cardiac strain,
environment, calm limit coping abilities
activities, and and adjustment to
comfort measures. current situation.
Approach patient
calmly and
confidently
 Instruct patient to do  Helpful in
relaxation decreasing
techniques: deep and perception and
slow breathing, response to pain.
distraction Provides a sense of
behaviors, having some control
visualization, guided over the situation,
imagery. Assist as increase in positive
needed. attitude.
 Administer  Increases amount of
supplemental oxygen available for
oxygen by means of myocardial uptake
nasal cannula or face and thereby may
mask, as indicated. relieve discomfort
associated with
tissue ischemia.
 Dependent:  Short-term use of
 Administer antianginals,
medications such as anticoagulant, beta
Aspirin, Metoprolol, blockers and
Atorvastatin, analgesics
Nitroglycerin, medications (e.g.,
Ticagrelor and aspirin,
Heparin. nitroglycerin,
metoprolol, heparin)
provide relief from
the pain and
facilitate client’s
cooperation with
therapy.

NURSING CARE PLAN NO. 3

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective Peripheral Short Term: Independent: Short Term:
Patient complained lower Tissue Perfusion related Within 8-10hrs of nursing  Monitor oxygen  To detect changes in After 10hrs of nursing
extremity edema. to Diabetes Mellitus and interventions, the patient saturation and pulse oxygenation. interventions, the patient
 Hypertension as will be able to: rate by using pulse was able to:
Objective: evidenced by lower leg  Demonstrate oximeter.  Demonstrate
 Diaphoretic edema increased  Check Hgb levels.  Low levels reduce increased
 Nausea perfusion as the uptake of oxygen perfusion as
 Pitting edema 2+ evidenced by at the alveolar- evidenced by
noted on both legs, absence of edema. capillary. absence of
feet, and ankles  Verbalize  Instruct the patient  To reduce swelling. edema.
understanding of to elevate legs.  Verbalize
risk factors or understanding of
condition, therapy risk factors or
regimens, side  Check for pallor,  Peripheral condition,
effects of cyanosis, mottling, vasoconstriction therapy
medication, and cool or clammy skin. may result in pale, regimens, side
when to contact cool, clammy skin, effects of
healthcare with prolonged medication, and
provider. capillary refill time when to contact
due to cardiac healthcare
Long Term: dysfunction and provider.
Within 72hrs of nursing decreased cardiac
interventions, the patient output. Long Term:
will be able to:  Note urine output.  Ensures adequate After 72hrs of nursing
 Demonstrate perfusion of vital interventions, the patient
behaviors and organs. was able to:
lifestyle changes  Educate patient  Malnutrition  Demonstrate
to improve about nutritional contributes to behaviors and
circulation. status and the anemia, which lifestyle changes
importance of further compounds to improve
paying special the lack of circulation.
attention to obesity, oxygenation to
hyperlipidemia, and tissues. Obese
malnutrition. patients encounter
poor circulation in
adipose tissue,
 which can create
increased hypoxia in
tissues.
Dependent: Dependent:
 Check for optimal  Sufficient fluid
fluid balance. intake maintains
Administer IV fluids adequate filling
as ordered. pressures and
optimizes cardiac
output needed for
tissue perfusion.
Collaborative: Collaborative:
 Submit patient to  A variety of test are
diagnostic testing as available depending
indicated. on the cause of the
impaired tissue
perfusion.
Angiograms,
Doppler flow
studies, segmental
limb pressure
measurement such
as ankle-brachial
index (ABI), and
vascular stress
testing are examples
of these tests.
SOAPIE NO. 1

Subjective:

Patient complaining of 2 hours of severe chest pain radiating to his left arm associating
with Diaphoresis and Nausea.

Objective:

 Diaphoretic
 Nausea
 Fatigability
Assessment

Decreased Cardiac Output related to Altered Stroke Volume

Planning

Short Term:
Within 4 hours of nursing intervention, the patient will participate in activities that decrease the
workload of the heart such as stress management or therapeutic medication regimen program.

Long Term:
Within 4 days of nursing interventions, the patient will be able to display hemodynamic stability
with normalization of ECG tracing blood pressure readings.

Intervention

Independent:
 Establish rapport
 Monitor patient vital sign
 Monitor ECG for dysrhythmias, conduction defects, and for heart rate
 Position the patient in semi- Fowler’s position.
 Encourage patient to decrease intake of caffeine, cola, and chocolates.
 Observe the patient’s skin color, capillary refill time, and diaphoresis.
 Monitor intake and output and calculate 24hrs fluid balance.
 Instruct the patient and SO on fluid diet and diet requirements and restrictions of sodium.
Dependent:
 Administer supplemental oxygen as ordered
 Administer medicine as prescribed by the physician.
Evaluation

Short Term:
After 4 hours of nursing intervention, the patient was able to participate in activities that decrease
the workload of the heart such as stress management or therapeutic medication regimen program.

Long Term:
After 4 days of nursing interventions, the patient was able to display hemodynamic stability with
normalization of ECG tracing blood pressure readings.

-Goal Partially Met.

SOAPIE NO. 2

Subjective:

Patient complaining of 2 hours of severe chest pain radiating to his left arm associating
with Diaphoresis and Nausea.

Objective:

 Diaphoretic
 Nausea
 Pain scale: 9/10
 ECG result: inferior and posterior ST segment elevations
 CARDIAC TROPONIN result: 0.30 ng/ml
Assessment

Acute pain related to obstructed blood flow to the heart muscle as evidenced by reports of
chest pain radiating to the left arm.

Planning

Within 2 hours of nursing intervention the patient will experience decrease level of pain.

Intervention

Independent:
 Monitor and document characteristic of pain, noting verbal reports, nonverbal cues
(moaning, crying, grimacing, restlessness, diaphoresis, clutching of chest) and BP or
heart rate changes.
 Obtain full description of pain from patient including location, intensity (using scale of
0–10), duration, characteristics (dull, crushing, described as “like an elephant in my
chest”), and radiation. Assist patient to quantify pain by comparing it to other
experiences.
 Instruct patient to report pain immediately. Provide quiet environment, calm activities,
and comfort measures. Approach patient calmly and confidently
 Instruct patient to do relaxation techniques: deep and slow breathing, distraction
behaviors, visualization, guided imagery. Assist as needed.
 Administer supplemental oxygen by means of nasal cannula or face mask, as indicated.

Dependent:
 Administer medications such as Aspirin, Metoprolol, Atorvastatin, Nitroglycerin,
Ticagrelor and Heparin.
Evaluation

After 2 hours of nursing intervention the patient was able to experience a decreased level
of pain from 9/10 to 5/10.
SOAPIE NO. 3

Subjective:

Patient complained lower extremity edema.

Objective:

 Diaphoretic
 Nausea
 Pitting edema 2+ noted on both legs, feet, and ankles

Assessment

Ineffective Peripheral Tissue Perfusion related to Diabetes Mellitus and Hypertension as

evidenced by lower leg edema
Planning

Short Term:
Within 8-10hrs of nursing interventions, the patient will be able to:
 Demonstrate increased perfusion as evidenced by absence of edema.
 Verbalize understanding of risk factors or condition, therapy regimens, side effects of
medication, and when to contact healthcare provider.
Long Term:
Within 72hrs of nursing interventions, the patient will be able to:
Demonstrate behaviors and lifestyle changes to improve circulation.

Intervention

Independent:
 Monitor oxygen saturation and pulse rate by using pulse oximeter.
 Check Hgb levels.
 Instruct the patient to elevate legs.
 Check for pallor, cyanosis, mottling, cool or clammy skin.
 Note urine output.
 Educate patient about nutritional status and the importance of paying special attention to
obesity, hyperlipidemia, and malnutrition.
Dependent:
 Check for optimal fluid balance. Administer IV fluids as ordered.
Collaborative:
 Submit patient to diagnostic testing as indicated.

Evaluation

Short Term:
After 10hrs of nursing interventions, the patient was able to:
 Demonstrate increased perfusion as evidenced by absence of edema.
 Verbalize understanding of risk factors or condition, therapy regimens, side effects of
medication, and when to contact healthcare provider.
Long Term:
After 72hrs of nursing interventions, the patient was able to:
Demonstrate behaviors and lifestyle changes to improve circulation.