Coronary Artery Disease
Nursing Care Plans
Acute Pain
Coronary
artery disease (CAD) is caused by a narrowing of the arteries that supply
the heart muscle with blood. When the arteries narrow, blood flow is
reduced. The reduced blood flow causes the heart muscle to receive less
oxygen than it needs to function properly. When ischemia occurs patients
typically develop angina or chest pain originating from the heart. It has
been described as chest pain or discomfort that has a squeezing or
pressure-like quality, usually felt behind the breastbone (sternum), but
sometimes felt in the shoulders, arms, neck, jaws, or back.
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Objective data:
The pt. May manifest:
ü restlessness
ü pain scale of 9/10
ü chest pain
ü irritability
ü (+) guarded behavior
ü (+) facial grimaces
ü crying
ü v/s change
ü diaphoresis
ü sleep disturbance
ü increase RR and pulse
Objectives:
Short Term:
o
After 3 hours of nursing Interventions (ni),
the pt. Will verbalize understanding of pt’s condition and health teachings
given to provide comfort and relieve of pain.
Long term
o
After 2 days of ni, the pt. Will demonstrate behavior of being
relieved from pain and will be free from the complications of the condition.
NURSING
INTERVENTIONS: with rationales
v
Assess pt.’s condition.
o
to have baseline data.
v
Monitor and record v/s.
o
to have baseline data and this are usually altered in the
condition.
v
Assess pains location and intensity/severity arising with.
o
to have baseline data for planning and interventions.
v
Provide comfort measures like stretching of linens and assisting
in position.
o
to provide non-pharmacological Pain management.
v
Provide diversional activities like having conversation w/ the
pt.
o
to divert pt.’s attention.
v
Stress to pt the importance of providing adequate rest period to
the pt.
o
to prevent fatigue.
v
Administer meds as ordered.
o
to reduce pain
Expected outcome
Ø The
pt.’s so will verbalize understanding of pt’s condition and health teachings
given to provide comfort and relieve of pain and pt.
Ø
Will demonstrate behavior of being relieved from pain and will
be free from the complications of the condition.
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