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.