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Nursing presentation

2 min read
Posted on 
May 24th, 2023
Home Homework Help Nursing presentation

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.

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