Running head: PATIENT CARE PLAN
Patient Care Plan
Student HS
Health and Healing- Medical/ Surgical Theory: NRSG 2001
Student Name
February 06 2025
, PATIENT CARE PLAN 2
Patient Assessment/Organizational Plan
Pt. Initials: C.R Age: 69 Describe ONE nursing problem of high priority
Primary Diagnosis: Risk for Decreased Cardiac Output
Unstable Angina C.R.’s primary nursing problem is risk for decreased
Unstable angina is a type of acute coronary syndrome cardiac output related to his diagnosis of unstable
(ACS) characterized by sudden and unpredictable angina, right-sided heart failure, and Acute Coronary
chest pain due to reduced blood flow to the heart Syndrome (ACS). Unstable angina is characterized by
muscle. Unlike stable angina, it occurs at rest or with reduced blood flow to the heart muscle, which can
minimal exertion and is a medical emergency. In impair the heart’s ability to pump effectively. This is
C.R.’s case, his symptoms of severe chest pain, further complicated by his right-sided heart failure,
diaphoresis, and ST-segment depression on ECG which results in fluid retention and increased workload
confirm this diagnosis. Unstable angina is often on the heart. According to the American Heart
caused by plaque rupture in coronary arteries, leading Association (AHA, 2021), patients with ACS and heart
to partial blockage and ischemia. Without prompt failure are at significant risk for decreased cardiac
intervention, it can progress to myocardial infarction output due to impaired myocardial contractility and
(Byrne et al., 2023). increased systemic vascular resistance. C.R.’s
symptoms, including fatigue, shortness of breath, and
mild pulmonary congestion on chest X-ray, are early
indicators of compromised cardiac function. If left
unaddressed, this could progress to cardiogenic shock
or life-threatening arrhythmias (Lim & Pruthi, 2022).
Nursing interventions must focus on monitoring for
signs of worsening cardiac output, such as
hypotension, tachycardia, and decreased urine output,
while optimizing his hemodynamic stability through
medication management, fluid balance monitoring,
and patient education.
Secondary Diagnosis: Activity and Living Arrangements:
Type 2 Diabetes Mellitus (T2DM) C.R. is currently independent in all activities of daily
Type 2 Diabetes Mellitus (T2DM) is a chronic living (ADLs), including personal hygiene, dressing,
metabolic disorder characterized by insulin resistance eating, and transferring. However, his right-sided heart
and hyperglycemia. In C.R.’s case, his HbA1c of 7.5% failure and unstable angina have significantly impacted
indicates suboptimal glycemic control, increasing his his stamina and ability to engage in physical activity.
Patient Care Plan
Student HS
Health and Healing- Medical/ Surgical Theory: NRSG 2001
Student Name
February 06 2025
, PATIENT CARE PLAN 2
Patient Assessment/Organizational Plan
Pt. Initials: C.R Age: 69 Describe ONE nursing problem of high priority
Primary Diagnosis: Risk for Decreased Cardiac Output
Unstable Angina C.R.’s primary nursing problem is risk for decreased
Unstable angina is a type of acute coronary syndrome cardiac output related to his diagnosis of unstable
(ACS) characterized by sudden and unpredictable angina, right-sided heart failure, and Acute Coronary
chest pain due to reduced blood flow to the heart Syndrome (ACS). Unstable angina is characterized by
muscle. Unlike stable angina, it occurs at rest or with reduced blood flow to the heart muscle, which can
minimal exertion and is a medical emergency. In impair the heart’s ability to pump effectively. This is
C.R.’s case, his symptoms of severe chest pain, further complicated by his right-sided heart failure,
diaphoresis, and ST-segment depression on ECG which results in fluid retention and increased workload
confirm this diagnosis. Unstable angina is often on the heart. According to the American Heart
caused by plaque rupture in coronary arteries, leading Association (AHA, 2021), patients with ACS and heart
to partial blockage and ischemia. Without prompt failure are at significant risk for decreased cardiac
intervention, it can progress to myocardial infarction output due to impaired myocardial contractility and
(Byrne et al., 2023). increased systemic vascular resistance. C.R.’s
symptoms, including fatigue, shortness of breath, and
mild pulmonary congestion on chest X-ray, are early
indicators of compromised cardiac function. If left
unaddressed, this could progress to cardiogenic shock
or life-threatening arrhythmias (Lim & Pruthi, 2022).
Nursing interventions must focus on monitoring for
signs of worsening cardiac output, such as
hypotension, tachycardia, and decreased urine output,
while optimizing his hemodynamic stability through
medication management, fluid balance monitoring,
and patient education.
Secondary Diagnosis: Activity and Living Arrangements:
Type 2 Diabetes Mellitus (T2DM) C.R. is currently independent in all activities of daily
Type 2 Diabetes Mellitus (T2DM) is a chronic living (ADLs), including personal hygiene, dressing,
metabolic disorder characterized by insulin resistance eating, and transferring. However, his right-sided heart
and hyperglycemia. In C.R.’s case, his HbA1c of 7.5% failure and unstable angina have significantly impacted
indicates suboptimal glycemic control, increasing his his stamina and ability to engage in physical activity.
