Date/ Cues Need Nursing Objective Nursing Nursing Theory Evaluation

Time Diagnosis of Care Interventions

August Subjective: S Anxiety related to At the of the 1.Assess the 1.Assessing first the GOAL MET
22 , E death threat as rotation, the patient’s vital signs, patient is aligned
2020 The patient L evidenced by client will be level of anxiety and with the theory of The patient
verbalized the F fearful attitude able: physical reactions to Faye Abdellah’s 21 was alert,
7 AM following - secondary to anxiety. Nursing Problems appears
-3 PM statement, “I am P suspected -to verbalize which is focused on relaxed, and
so worried. E atypical relief of R: Ongoing anxiety the disease- was able to
You've got to R myocardial feelings of (related to concerns centered approach verbalized
help me ”, “ C infarction. anxiety about impact of heart to a patient- relief from
What is E attack on future centered approach. anxiety by
happening to P Rationale: - appear lifestyle) may be Knowing the patient saying,
me? Am I T Myocardial relaxed and present in varying and their condition. “Thanks for
having a heart I infarction in worst report that degrees for some time being patient
attack?”, & O case scenario anxiety is and may be with me. I am
“Please, help N causes death if not reduced to a manifested by just so
me! I'm - treated well and manageable symptoms of nervous and
terrified!” S not prevented with level depression. worried.” The
E good lifestyle patient was
Objective: L practices. The - perform also able to
F patient is anxious ways in self- perform the
BP: 120/100 C because she’s managing 2. Established 2.Establishing effective
mm/Hg O afraid she might anxiety rapport, talk to the rapport is the goal of techniques in
RR: 32 cpm N die. patient and help Hildegard Peplau in managing
PR: 76 bpm C identify the cause of her Theory of anxiety.
Temperature: E anxiety. Interpersonal
37.4 P Nursing which
O2 Sat: 83 % T R: The client will give states that nurse-
more substantial client relationship as
P information if rapport is the foundation of
A built between the nursing practice.
T nurse and the client.
T
E
R
N
ALFREDO BAULA JR. BSN3A
 3. Use presence, 3. The use of touch
touch (with and sense of caring
permission), is in line with the
verbalization, and philosophy of caring
demeanor to remind by Jean Watson as
clients that they are it highlighted the
not alone and to humanistic aspects
encourage of nursing as they
expression or intertwine with
clarification of needs, scientific knowledge
concerns, unknowns, and nursing practice
and questions.

R: Being supportive
and approachable
encourages
communication to the
client will substantially
reduce their anxiety if
they get the answer
they are looking for.

4. Position the 4. Move and

patient in maintain a desirable
comfortable semi- position is one of
fowlers position. the goals of the
Need Theory by
R: Positioning the Virginia Henderson.
patient in a This theory states
comfortable position that nurse’s role as
with upper extremities assisting sick or
erect will promote healthy individuals.
good respiration and
flow of blood
ALFREDO BAULA JR. BSN3A
 circulation.

5. Give patient O2 via

nasal cannula as 5. Maintaining the
indicated and as oxygenation to the
prescribed by the cells is a part of the
doctor. 21 Nursing
Problems developed
R: The patient is by Faye Abdellah
hyperventilating that
causes to heighten the
anxiety that the patient
is experiencing.

6. Educate the
patient about ways of 6. Dorothea Orem’
coping up with theory of Self-care
anxiety: Defeciti also applies
Teach the patient with the social and
about deep breathing psychological needs
and panting exercise of a person not just
physical. Teaching
- Teach the patient the client how to
about distraction or self-manage her
diversion tactics. anxiety attacks is an
act of assisting
- Teach the patient to others in the
relax muscles. provision and
management of self-
- Teach the patient care to maintain or
about positive talking improve human
to self. functioning.

ALFREDO BAULA JR. BSN3A

 R: Offering the patient
ways to cope up with
anxiety will help the
patient self-manage
her anxiousness.

7. Provide the patient 7. Florence

with Privacy and nice Nightingale’s theory
ambiance. state that in order
for a patient to heal
R: Excessive noise fast, the
increases anxiety; environment must
involvement in a quiet be changed
activity can be accordingly by
soothing to the human which it promotes
mind. healing.

8. Provide the patient 8. Providing

with adequate resting adequate rest is
period. also included in
Faye Abdellah’s 21
R: Conserves energy nursing problems.
and enhances coping
abilities.

ALFREDO BAULA JR. BSN3A

 Date/ Cues Need Nursing Objective Nursing Nursing Theory Evaluation
Time Diagnosis of Care Interventions
August Subjective: C At the of 1.Assess the 1.Faye Abdellah’s GOAL MET
22 , O Acute pain the patient’s vital signs theory on 21 Nursing
2020 The patient G related to rotation, and characteristics Problem is focused The patient
verbalized, “I don't N myocardial the client of pain. on knowing the was able to
7 AM feel right again. My E ischemia will be patient and their perform
-3 PM chest really hurts. T secondary to able: R: Pain is a part of the condition that. To relaxation
It's crushing. It's 8 I suspected subjective experience recognize the techniques as
out of 10” V atypical -Verbalize of the patient. VS Pain physiologic taught by the
E myocardial relief of characteristics responses of the nurse. She
Objective: - infarction. chest pain. provides baseline for body to disease appears to be
- Pain Scale of P comparison to help in conditions— more relaxed
8/10 E Rationale: - Display crafting effective of pathologic, and less
- Chest Pain R reduced course of action. physiologic, and tensioned as
-Hyperventilation C The pain the tension, compensatory. compared to
- Diastolic E patient relaxed assessment
Hypertension P experiences is a manner, phase. She
T result of lack of ease of 2. Instruct patient to 2. Attending directly also reported
BP: 120/100 U oxygenation to the movement. report pain to the needs of the relief in chest
mm/Hg A tissues of the immediately. patient is achieved and mid back
RR: 32 cpm L heart. The tissue - perform when there is an pain by
PR: 76 bpm cannot work the use R: Additional pain or open communication verbalizing,
Temperature: 37.4 P properly causing it of relaxatio radiating pain is a sign between the client “My chest
O2 Sat: 83 % A to over work which n of worsening angina and nurse, and it is and back feel
T results to angina techniques pectoris and it might the most important so much
T pectoris if not put the patient’s life in aspect of nursing better. The
E treated quickly it danger. The health according to pain is gone”
R will cause team should always be Hildegard Peplau’s
N infarction. updated with recent Interpersonal
signs and symptoms. Relations Theory

3. Administer 3. Giving medications

supplemental oxygen like Oxygen is a part

ALFREDO BAULA JR. BSN3A

 by means of nasal of the Care, Cure,
cannula or face Core Model of Lydia
mask, as indicated. Hall. The act of
professional nursing
R: O2 through nasal lies under the cure
cannula or facemask model.
will Increases the
amount of oxygen
available for
myocardial uptake and
thereby may relieve
discomfort associated
with tissue ischemia.

4. Provide the patient 4. Florence

with privacy and nice Nightingale’s theory
ambiance. state that in order for
a patient to heal fast,
R: A good resting the environment must
place will decreases be changed
external stimuli, which accordingly by which
may worsen anxiety it promotes healing.
and cardiac strain.

5. Administer 5 and 6. Giving

medications as medications like
indicated: Oxygen is a part of
Antianginals the Care, Cure, Core
(nitroglycerine), as Model of Lydia Hall.
prescribed by the The act of
doctor. professional nursing
lies under the cure
R: Nitrates are useful model.

ALFREDO BAULA JR. BSN3A

 for anginal pain control
for quick treatment.
There’s a limited dose
to it. [Assess the
patient after 15-20
minutes.]

6. Administer
medications as
indicated: Analgesics
(Morphine). as
prescribed by the
doctor.

R: Intravenous (IV)
morphine is the usual
drug of choice for
severe pain, like
acute-phase/recurrent
chest pain unrelieved
by nitroglycerin.
Morphine reduce
severe pain, provide
sedation, and
decrease myocardial
workload.
7. Dorothea Orem’
theory of Self-care
7. Instruct patient to Deficit also applies
do relaxation with the social and
techniques: psychological needs
- Teach the patient of a person not just
about deep breathing physical. Teaching
and panting exercise the client how to self-
manage her anxiety
- Teach the patient attacks is an act of
assisting others in the
ALFREDO BAULA JR. BSN3A
 about distraction or provision and
diversion tactics. management of self-
care to maintain or
- Teach the patient to improve human
relax muscles. functioning.

- Teach the patient

about positive talking
to self.

R: Helpful in
decreasing perception
and response to pain.
Provides a sense of
having some control
over the situation,
increase in positive
attitude.

8. Providing
8. Provide the patient adequate rest is also
with adequate resting included in Faye
period. Abdellah’s 21 nursing
problems
R: Conserves energy
and enhances coping
abilities.

ALFREDO BAULA JR. BSN3A