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    Nursing Care Plan

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    April Kate Banagodos
    The nursing care plan summarizes Joseph Saycon, a 91-year-old male admitted with vomiting and chest pain. Over 3 days of nursing intervention, the goals were partially met as the patient was free from pain, maintained stable vital signs, and had a relaxed body posture. The nursing diagnosis was acute pain related to decreased myocardial blood flow. Objectives included remaining pain-free, maintaining stable vital signs and relaxed posture. Interventions included instructing to notify nurse of chest pain, observing for associated symptoms, placing at rest, elevating head of bed if short of breath, and monitoring heart rate/rhythm.

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    Nursing Care Plan

    Uploaded by

    April Kate Banagodos
    40 views2 pages
    The nursing care plan summarizes Joseph Saycon, a 91-year-old male admitted with vomiting and chest pain. Over 3 days of nursing intervention, the goals were partially met as the patient was free from pain, maintained stable vital signs, and had a relaxed body posture. The nursing diagnosis was acute pain related to decreased myocardial blood flow. Objectives included remaining pain-free, maintaining stable vital signs and relaxed posture. Interventions included instructing to notify nurse of chest pain, observing for associated symptoms, placing at rest, elevating head of bed if short of breath, and monitoring heart rate/rhythm.

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    NURSING-CARE-PLAN

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    The nursing care plan summarizes Joseph Saycon, a 91-year-old male admitted with vomiting and chest pain. Over 3 days of nursing intervention, the goals were partially met as the patient was free from pain, maintained stable vital signs, and had a relaxed body posture. The nursing diagnosis was acute pain related to decreased myocardial blood flow. Objectives included remaining pain-free, maintaining stable vital signs and relaxed posture. Interventions included instructing to notify nurse of chest pain, observing for associated symptoms, placing at rest, elevating head of bed if short of breath, and monitoring heart rate/rhythm.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    40 views2 pages

    Nursing Care Plan

    Uploaded by

    April Kate Banagodos
    The nursing care plan summarizes Joseph Saycon, a 91-year-old male admitted with vomiting and chest pain. Over 3 days of nursing intervention, the goals were partially met as the patient was free from pain, maintained stable vital signs, and had a relaxed body posture. The nursing diagnosis was acute pain related to decreased myocardial blood flow. Objectives included remaining pain-free, maintaining stable vital signs and relaxed posture. Interventions included instructing to notify nurse of chest pain, observing for associated symptoms, placing at rest, elevating head of bed if short of breath, and monitoring heart rate/rhythm.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    NURSING CARE PLAN

    Patient’s Name: Saycon, Joseph Age: 91 Sex: Male Admitting Diagnosis: Vomiting; Chest Pain Date: Dec. 5-7, 2022
    Assessment Nursing Diagnosis Objectives/Planning Intervention Rationale Evaluation
    Independent Independent
    Subjective After 3 days of my Goals are partially
    Acute pain related to nursing intervention, Instruct client to notify Pain and decreased cardiac output met
    “Pag admit niya maam decreased the patient will be able nurse immediately when may stimulate the sympathetic
    kay ga chest pain sha myocardial blood to increased blood flow chest pain occurs nervous system to release After 3 days of
    dayng ga suka. Ga lain flow as evidenced by: excessive amounts of nursing
    jod iyang paminaw” as norepinephrine, which increases interventions, my
    verbalized by patients  Remain free platelet aggregation and release of patient was free
    SO form pain thromboxane A2. from pain, maintains
    stable vital signs,
    Objectives  Maintain stable Observe for associated Decreased cardiac output and relaxed
    vital signs symptoms; dyspnea, stimulates sympathetic/ bodyposture.
     Elevated Blood nausea/vomiting, parasympathetic nervous system,
    Pressure  Absence of dizziness, palpitations causing a variety of vague Able to verbalize
    muscle tension sensations that client may not “Okay na akoang
     Cool, Clammy identify as related to anginal panimati maam, I
    skin  Maintain relaxed episodes. feel better, dili
    body posture pariha sauna.
     Jugular Vein Evaluation reports of
    pain in jaw, neck, Cardiac pain may radiate; pain is Salamat kaayo
    Distention often referred to more superficial maam”
    shoulder, arm or hand.
    sites served by the same spinal
     V/S take as cord nerve level.
    follows:
    BP: 180/120 mmHg Place client at complete
    rest during anginal Reduces myocardial oxygen
    SpO2: 98% demand to minimize risk tissue
    T: 36.7 C episodes.
    injury/necrosis.
    PR: 94 bpm
    Elevate head of bed if
    RR: 19 cpm Facilitates gas exchange to
    client is short of breath
    decrease hypoxia and resultant
    shortness of breath.
    Monitor heart
    rate/rhythm Clients with unstable angina have
    and increased risk of acute life-
    threatening dysthymias, which
    occur in response to ischemic
    changes and/or stress.
    Collaborative
    Collaborative
    O2 is administered by
    physician’s order. Increases oxygenation for
    myocardial uptake/ reversal of
    ischemia.

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