Harry Tonka entered the emergency department with midsternal chest pain, which started while he was playing basketball at the gym. Harry Tonka is 42 years old and 5’10” tall, and weighs 205 pounds. He smokes one pack of cigarettes per day and works in a office. On admission, he complains of nausea but no vomiting and no diaphoresis. His blood pressure is 175/92 mm Hg; his temperature is 99? F, pulse is 127 beats per minute, and respiration rate is 20 breaths per minute. He has a history of hypertension, which has been controlled with medication. He states that he forgot to take his medicine today.
Nursing Assessment Including Client Story An electrocardiogram has been performed, blood work has been drawn, and a monitor has been attached to the client. He is anxious and constantly asking if his heart monitor “looks all right”. A. Assess Symptoms: * Midsternal chest pain * Nausea (no vomiting or diaphoresis) * Smokes (one pack a day) * Obese * High blood pressure * High temperature * High pulse rate * Hypertension (did not take controlled medication for today) * Anxious B. Diagnose 1. Possible nursing diagnoses: Chest pain: * Fear * Acute pain * Perfusion * Nausea Anxiety: * Cardiovascular excitation.
* Heart ponding * Increased blood pressure * Increased pulse * Fearful * Nausea 2. Validated nursing diagnoses include: Anxiety 3. NANDA label: A vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat. Related to (r/t) factors: * Smoking * Obesity 4. The complete nursing diagnostic statement is: Anxiety r/t smoking and obesity C. Plan 1.
NOC: Anxiety self-control INDICTATOR| Never demonstrated| Rarely demonstrated| Sometimes demonstrated| Often demonstrated| Consistently demonstrated| Eliminates precursors of anxiety| 1| 2| 3| 4| 5| Monitors physical manifestations of anxiety| 1| 2| 3| 4| 5| Controls anxiety response| 1| 2| 3| 4| 5| | 1| 2| 3| 4| 5| 2. Client Outcomes: * Identify and verbalize symptoms of anxiety * Identify, verbalize, and demonstrate techniques to control anxiety * Have vital signs that reflect baseline or decreased sympathetic stimulation 4. NIC: Anxiety Reduction 5. NIC Activities: * Stop smoking * Lose weight 6. Nursing Interventions:
* If irrational thoughts or fears are present, offer the client accurate information and encourage him or her to talk about the meaning of the events contributing to the anxiety * Intervene when possible to remove sources of anxiety * Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the client’s understanding. * Teach the client/family the symptoms of anxiety. * Teach the client techniques to self-manage anxiety. * Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude.