Nursing Care Plan Chest Pain

Assessment

1. Primary Assessment

* Airway

o How does the airway

o Is there a blockage / congestion, secretions in the airway?

o How does the sound of his breathing, if there are additional breath sounds?

* Breathing

o How breathing pattern? Frequency? The depth and rhythm?

o Do use a respirator muscles?

o Are there additional breath sounds?

* Circulation

o What about the peripheral arteries and carotid arteries? The quality (content and voltage)

o How capillary refillnya, whether there akral cold, cyanosis or oliguri?

o Is there a decrease in consciousness?

o How vital signs?


2. Secondary Assessment

Important things that need to be studied further in chest pain (coronary):

1. Location of pain
Where is a start, (coronary chest pain: from sternal spread to the neck, chin or shoulder to the left arm of the ulna)

2. The nature of pain
Feeling full, heavy feeling like cramps, squeezing, stabbing, choking / burning, etc..

3. Pain characteristics
Degrees of pain, duration, how often arise in a certain period.

4. Chronological pain
Beginning there is pain and progress in sequence

5. The situation at the time of the attack
Does arise in times / circumstances

6. Factors that reinforce / relieve pain such as attitude / body position, movement, pressure, etc..

7. Other possible symptoms whether or not a relationship with chest pain.



Nursing Diagnosis


1. Changes comfort pain (acute pain) associated with tissue ischemia secondary to arterial occlusion, tissue inflammation

2. Changes in tissue perfusion (heart muscle) associated with decreased blood flow

3. Activity intolerance related to imbalance between O2 supply and demand tissue metabolism.


Intervention

The principles of Action:

1. bedrest with Fowler position / semi-Fowler

2. Perform 12 lead ECG if necessary 24 leads

3. Observe vital signs

4. Collaboration O2 delivery and administration of drugs, analgesics, tranquilizers, nitroglycerin, calcium antagonists and observation drug side effects.

5. Install a drip and give peace to the client

6. Taking blood samples

7. Reduce environmental stimuli

8. Be calm in the works

9. Observe signs of complications