Nursing Diagnosis for Angina Pectoris : Decreased cardiac output related to contraction disorders
NOC :
- Cardiac Pump Effectiveness
- Circulation Status
- Vital Sign Status
- Vital Signs within the normal range (blood pressure, pulse, respiration).
- Can tolerate the activity, there is no fatigue.
- No pulmonary edema, peripheral and no ascites.
- There is no loss of consciousness.
NIC
Cardiac Care
- Evaluation of chest pain (intensity, location, duration).
- Note the presence of cardiac dysrhythmias.
- Note the reduction in signs and symptoms of cardiac putput.
- Monitor cardiovascular status.
- Monitor respiratory status that indicates heart failure.
- Monitor the abdomen as an indicator of decreased perfusion.
- Monitor fluid balance.
- Monitor any changes in blood pressure.
- Monitor the patient's response to the effects of antiarrhythmic treatment.
- Set exercise and rest periods to avoid fatigue.
- Monitor the patient's activity tolerance.
- Monitor the presence of dyspnea, fatigue, tachypnea and orthopnoea.
- Suggest to reduce stress.
Vital Sign Monitoring
- Monitor BP, pulse, temperature, and RR.
- Note the fluctuations in blood pressure.
- Monitor VS when the patient is lying down, sitting, or standing.
- Auscultation of blood pressure in both arms and compare.
- Monitor BP, pulse, RR, before, during, and after activity.
- Monitor the quality of the pulse.
- Monitor the presence of pulsus paradoxus and pulsus alterans.
- Monitor the number and monitors the heart rhythm and heart sounds.
- Monitor respiratory rate and rhythm.
- Monitor lung sounds, abnormal breathing patterns.
- Monitor temperature, color, and moisture.
- Monitor peripheral cyanosis.
- Monitor the presence of Cushing's triad (widened pulse pressure, bradycardia, increased systolic).
- Identify the cause of vital sign changes.