Student Nurses’ Community

NURSING CARE PLAN ─ Angina pectoris

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE:
The patient may report:
 Chest pain, heaviness,
or pressure that may
radiate to the
shoulders, arms, neck,
jaw, or upper
abdomen.
OBJECTIVE:
 Tachycardia
 Elevated blood
pressure
 Jugular vein distention
 Cool, clammy skin
Acute pain related After 8 hours of nursing
to decreased intervention the patient will:
myocardial blood
flow.  Remain free from pain
 Maintain stable vital signs.
 Maintain relaxed body
posture.
 Assess for vital signs and After 8 hours of nursing
symptoms of pain such as intervention the patient was free
facial grimacing, rubbing of from pain, maintains stable vital
neck or jaw, reluctance to signs, and relaxed body posture.
move, increased blood
pressure, and tachycardia.
Note onset, duration,
location, and pattern of
pain.
 Use a pain rating scale to
assess the patient’s
perception of the pain’s
severity.
 Administer sublingual
nitroglycerin as ordered.
 Instruct the patient to notify
a nurse immediately when
experiencing pain. Have the
patient stop current activity,
and place him on bed rest in
a semi- to high Fowler’s
position.
 Administer oxygen as
ordered.
 Obtain a 12-lead ECG
immediately during acute
chest pain.
 Stay with the patient during
chest pain episodes.