Nursing Diagnoses Nursing Intervention Client Goals - Care Plan

Nursing Diagnoses Nursing Intervention Client Goals

Pain R/T tissue ischemia 1. Assess CP for location, duration, intensity, & radiation; use a scale of 0-10

2. Instruct pt to rest during pain

3. Medicate as ordered

4. Remain with pt until CP relieved

5. Assess BP, P, RR, & SpO2 1. Pt reports absence of dyspnea & CP

2. Pt will report decrease in CP using pain scale

3. V/S remain within normal limits (BP 90/60-140/90, P 60/100BPM, RR 12-20RPM, Sp02 90-100%)

Nursing Diagnoses Nursing Intervention Client Goals

Decreased cardiac output R/T altered myocardial contractility 1. Instruct pt to report chest pain

2. Administer O2 as ordered

3. Monitor LOC, peripheral pulses, capillary refill, peripheral edema

4. Assess lung sounds q shift & prn

5. Obtain EKG as ordered

6. Monitor color of mucous membrane/skin, skin temperature, & diaphoresis

1. Pt will report onset of CP & use pain scale to describe intensity of pain

2. No alteration in LOC is observed, peripheral pulses present & equal bilaterally, capillary refill <3 seconds, no peripheral edema is observed.

3. Mucous membranes pink and moist, skin warm and dry to touch

Nursing Diagnoses Nursing Intervention Client Goals

Anxiety R/T threat to or change in health status 1. Encourage pt to verbalize fears