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nursing care plan
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Nursing care plan for your patient.
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Bulacan State UniversityCOLLEGE OF NURSING
City of Malolos, Bulacan
NURSING CARE PLAN
Patient’s Initial: ___C.S._____ Age: _73 yrs.old__ Gender: __Male__ Date Handled: _April 23, 2021___
Medical Diagnosis: _Abdominal Aortic Aneurysm______ Chief Complaint: _severe back pain_________ Clinical Area: _Emergency Department_
Assessment Nursing Diagnosis Planning Intervention Rationale E
Subjective: Decreased Cardiac Short Term Goal: Independent: Short Te
• The patient has a Output related to After 8 hours of nursing - Asess for signs of myocardial - ECG changes help guide the After 8
known AAA, which has alteration in heart rate intervention, the client will ischemia: chest pain, tachycardia, or ST- timing of interventions intervent
been followed with yearly secondary to be able to display segment and T-wave changes on ECG display h
abdominal ultrasound abdominal aortic hemodynamic stability stability
testing. aneurysm as evidenced (blood pressure and cardiac - Assess the client’s hemodynamic and card
• The patient has smoked by cool and clammy output) and report decreased status. Monitor for signs of decreasing - Clients with decreasing or report de
a pack of cigarettes per extremities, heart rate episodes of dyspnea, angina cardiac output, such as tachycardia, rupturing aneurysm are of dyspn
day for 52 yrs. of 114 bpm and blood and dysrhythmias as decreased urine output, and restlessness. hemodynamically compromised. dysrhyth
• The patient has had pressure of 88/60 evidenced by: Early evaluation of warning
occasional bouts of angina mmHg. - normal heart rate signs facilitates prompt _√_ met
for the past 3 yr - normal blood pressure intervention. ___ part
- normal heart rhythm - Monitor vital signs frequently. ___ unm
Objective: - to note response to activities
• The patient has a and interventions As evide
pulsating abdominal mass Long Term Goal: - Monitor cardiac rhythm continuously - norma
• The patient’s After 1-2 days of nursing - to note the effectiveness of - norma
extremities are cool and intervention the client will be mdications or assistive devices - norma
clammy able to participate in - Schedule activities and assessments
activities that reduce the - to maximize rest periods Long Te
Vital Signs workload of the heart and - Assist with or perform self-care After 1-
• HR - 114 bpm demontrate an increase in activities for client. intervent
• BP - 88/68 mmHg activity tolerance as be able t
evidenced by: - Increase activity levels gradually as activities
- decreased occurrence of permitted by individual condition, noting workload
fatigue vital sign response to activity demontr
- decreased occurrence of activity t
dyspnea during and after Dependent:
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