This is a Do-It-Yourself Nursing Care Plan on Chest Pain.
All you have to do is put a check in the blank for the appropriate conditions/ situation for the nursing care plan. Customize and add details. Presto! An instant NCP!
ASSESSMENT: CHEST PAIN
NURSING DIAGNOSIS:
Related To:
___Myocardial Infarction
___Unstable Angina
___Coronary Artery Disease
___Chest Trauma
___Stress Anxiety
___Musculoskeletal Disorders
___Pulmonary, Myocardial contusion
___Other:_____________________________
As evidenced by:
Major: (Must be present)
___Person reports or demonstrates a discomfort.
Minor: (May be present)
___Increased BP
___Diaphoresis
___Dilated pupils
___Restlessness
___Facial mask of pain
___Crying/moaning
___Short of breath
___Anxiety
NURSING ANALYSIS: Analyze the probable cause of the problem
______________________________
DESIRED GOAL/ PLAN AND OUTCOME:
The patient will:
___Verbalize relief/control of pain.
___Verbalize causative factors associated with chest pain.
___Other: _____________________________
NURSING INTERVENTIONS:
___Assess for causative factors associated:
* Activity
* Stress
* Eating
* Bowel elimination
* Previous angina attack
* Other: ____________________________
___Assess characterizing of chest pain.
* Location
* Intensity (Scale 1-10)
* Duration
* Quality
* Radiation
___Review history of previous pain experienced by patient and compare to current experience.
___Instruct patient to report pain immediately.
___Continuous EKG monitoring; note and record pattern during pain. Obtain STAT 12-lead EKG per policy for acute changes noted on continuous monitor.
___Provide a quiet, restful environment.
___As per physician order, administer IV analgesics in small increments until pain is relieved or maximum dose is achieved. Monitor BP during administration of pain meds. Assess pt. response to pain medication and notify physician if pain is not controlled or pt. experiences adverse reaction (decreased BP, HA, distress).
___Administer nitroglycerine as ordered by physician. Monitor as stated above.
___Titrate IV Nitro to achieve pain relief as ordered by physician. Monitor hemodynamic response to medication (BP, urine output).
___Administer supplemental oxygen as ordered by physician.
___Assist with ADL's to reduce cardiac stressors.
___Assist in eliminating causative factors as identified by patient assessment.
___Other:______________________________
RATIONALE explains in detail why such nursing intervention is needed
______________________________________
EVALUATION:
___Goal met: __________________________
___Goal partially met: ___________________
