Chest Pain Care Plan

Acute chest pain related to ischemic cardiomyopathy as evidenced by tightness in chest. Patient will be chest pain free for duration of shift.Assess for chest pain q 4 hours during shift.Monitor vital signs q 4 hours during shift.Educate patient on importance of lifestyle modifications such as weight loss.Goal was met. Pt was chest pain free during shift.NURSING DIAGNOSIS OUTCOME/GOALS INTERVENTIONS EVALUATIONExcess fluid volume related to CHF as evidenced by patient weight gain of 2kg since hospitalization and +2 edema in lower extremities.Pt maintains adequate fluid volume and electrolyte balance as evidenced by vital signs within normal limits, and clear lung sounds throughout shift. Assess for crackles in lungs, changes in respiratory pattern, shortness in breath and orthopnea.Monitor weight daily and consistently with the same scale, at the same time of day, wearing the same amount of clothing.Educate pt on signs and symptoms of fluid volume excess, and symptoms to report.Goal w as met. Pt had normal vital signs and clear lung sounds throughout shift.NURSING DIAGNOSIS OUTCOME/GOALS INTERVENTIONS EVALUATIONRisk for ineffective peripheral tissue perfusion to right leg related to catheterization procedure as evidenced by interruption of arterial flow.Pt maintains tissue perfusion in right leg as evidenced by baseline pulse quality and warm extremity throughout shift. Assess right leg for pulse, skin color, temperature and sensation.Monitor cannulation site for swelling, bruits and hematoma.Educate patient on signs of reduced tissue perfusion and to report these signs. Goal was met. Pt’s right leg maintained tissue perfusion as evidenced by pulse quality and warm extremity throughout shift.NURSING DIAGNOSIS OUTCOME/GOALS INTERVENTIONS EVALUATIONRisk for anxiety related to impending heart surgery as evidenced by poor eye contact and lack of questioning.Patient is able to verbalize signs of anxiety by end of shift. Assess patient’s level of anxiety. Encourage patient to talk about anxious feelings.Assist the patient in recognizing symptoms of increasing anxiety and methods to cope with it.Goal was met. Patient verbalized the signs of anxiety by end of shift.