Outcomes
Signs and Symptoms
Medical Dx/ Reason for
Admission/history/Age
Age
37
Past Medical History
Hypertension, HLD, GERD, Cellulitis
Objective
Short Term Goal
Patient guards chest when healthcare team tries to
palpate or auscultate. Patient started to cry and wince
when chest was palpated and auscultated.
Patient will have a reduction of chest pain by
out of 10 pain by the end of shi
Subjective
Long Term Goal
Patient stated, “I haven’t taken my Hypertension
medication in 6 months. Today I went out on my daily run,
and I started to get sharp stabbing pain in my chest that
radiated to my neck and jaw. Immediately, I stopped and
rest, but the pain did not stop. I am having so much pain.
My pain is a 9 out of 10.”
Patient will be able to teach back the im
regular exercise, diet, and medication adh
way to combat hypertension by dis
Evaluation
Reason for Admission
Angina
Nursing Diagnosis
Acute pain related to chest pain secondary
to hypertension as evidenced by
weakness, shortness of breath, angina and
history of hypertension
Was short-term goal met?
Yes, p. Patient reported a pain of 1 out of 10 by the end
Was long-term goal met?
Not met as patient is not ready for discharge
Nursing Interventions/ Rationales
Nursing Interventions
Assess
Assess patients pain level on a scale of 0-10, location, onset and duration
Assess knowledge and willingness to try non-pharmacological methods of pain reduction
Assess motivation of the patients to adhere to antihypertensive medication
Do
Give medication to the patient as ordered
Determine non-pharmacological methods that help mitigate pain
Determine what is important to the patient and obstacles they face with medication adherence
Rationales fo
Assess
Allows for an accurate assessment and nursing in
Patient may want to attempt non-pharmacologica
If the patient is not motivated then they will not
Do
To lower the patients level of pain in order to prom
To explore options such as hot/cold therapy, ROM
Identifying what is important and obstacles the pat
resources to help them