Chest Pain Care Plan

Acute chest pain related to ischemic cardiomyopathy as attest by tightness in chest. Patient will be chest pain free for duration of shift. prize 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 burden loss.Goal was met. Pt was chest pain free during shift.NURSING diagnosing 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. pass judgment 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, draining the same amount of clothing.Educate pt on signs and symptoms of fluid volume excess, and symptoms to co mprehend.Goal was met. Pt had normal vital signs and clear lung sounds throughout shift.NURSING DIAGNOSIS OUTCOME/GOALS INTERVENTIONS EVALUATIONRisk for ineffectual peripheral meander perfusion to upright leg related to catheterization procedure as evidenced by interruption of arterial flow.Pt maintains tissue perfusion in right leg as evidenced by baseline pulse fiber and warm bound throughout shift. Assess right leg for pulse, throw together 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. Pts 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 flavour surgery as evidenced by poor eye conflict and lack of questioning.Patient is able to verbalize signs of anxiety by end of shift. Assess patients level of anxiety.Encourage patient to talk about vehement feelings.Assist the patient in recognizing symptoms of increasing anxiety and methods to cope with it.Goal was met. Patient talk the signs of anxiety by end of shift.