Care Map

Assessment

Subjective Data: 60 year old male Rates pain in L chest as a 6 on a scale from 1 to 10 objective data: Patient seems anxious when talking about the likelihood a cardiac condition

Body Systems: Here you will put your head to toe data.

Gordon Pattern: Activity-Exercise Dysfunctional Cluster data: Inability to complete daily ADLS

Gordon Pattern: Nutritional-Metabolic Dysfunctional Cluster data:

inadequate diet, loss of appetite around painful episodes

Gordon Pattern:

Self Perception

Cluster data: Use as many of these as appropriate. You do not have to fill them all.

Patient:

Gordon Pattern: Cluster data:

Gordon Pattern: Cluster data:

Priority Nsg Dx:

Impaired tissue perfusion related to cardiac condition as evidenced by chest pain.

Goal/Expected outcomes: Pt pain will be below 6 out of 10 by the end of the end of the shift today.

Interventions: * you need 3 of these

1. Physician will order an EKG

2. Administratino of pain medication and oxygen.

3. Patient will be prepped for procedure.

Nursing 120

Evidence-based rationale for interventions: ** you need rationales with a source for each intervention

Pt has positive EKG therefore the physician will order oxygen, pain medications, and a cardiac catheterization to rule out or rule in myocardial infarction or MI ( need to have a source to support your rationale.)

Evaluation:

7.Patient stated that they are chest pain free

8.Pt states her pain is still a 6 out of 10.