John Doe Patient Age 65 Male Admitting Date March 15, 2023 Diagnosis Acute Myocardial Infarction
History:
- Mr. Doe is a diabetic type 2 with a past history of diabetes, hypertension and hyperlipidemia.
- He had undergone a CABG (coronary artery bypass) 5 years earlier.
- A retired construction worker, he lives by himself in a one-story single family home.
Assessment:
- Mr. Doe pays attention to time, date, place and person.
- His chest pain began four hours ago, and it has now spread to his left shoulder.
- As follows: oxygen saturation 90 on room air, blood pressure of 140/90 mmHg and heart rate of 90 bpm.
- A regular heartbeat is detected with a S4 noise and 3/6 murmur at the peak.
- The crackles are heard on both sides of the lungs.
- Neurological assessment reveals no deficits.
Plan:
- According to protocol, aspirin was given, along with nitroglycerin and heparin.
- His condition was monitored in the cardiac care unit.
- The diagnosis of AMI is confirmed by ordering cardiac enzyme tests.
- The echocardiogram was performed to determine if there were any changes or worsening of cardiac disease.
- His diabetes was managed by implementing blood glucose testing.
Interventions:
- He was put on oxygen therapy in order to maintain his oxygen saturation level above 92%.
- The pain was treated with intravenous Morphin.
- The bed rest order was given to decrease myocardial need.
- To manage hypertension, he was prescribed a diet low in sodium and fat.
- M. Doe was educated about his health condition, treatment plans, and risk factors management.
Summary:
- Mr. Doe, a 65 year old male with a history AMI and acute chest pain was admitted to the hospital.
- The patient is receiving medication for AMI and being monitored.
- To confirm the diagnosis, and to assess any worsening or new cardiac dysfunctions, echocardiography and cardiac enzymes were ordered.
- Nurse interventions can include pain management, oxygen therapy, bed rest and diet management.