Nursing presentation

Patient Name John Doe, 65 years old. Admission Date March 15, 2023. Diagnosis of Acute Myocardial Infarction.

History:

  • Doe’s past includes hypertension, hyperlipidemia and type 2 diabetes.
  • His coronary bypass surgery (CABG), was performed five years ago.
  • Retired construction worker, he lives alone in single-story home.

Assessment:

  • Doe can be alerted and directed to the person, place and time.
  • The chest pain radiates from his left arm and started about 4 hours ago.
  • The following vital signs can be seen: Blood pressure 140/90mmHg; heart rate 90 beats per minute, respiration rate 22 beats per minute, oxygen saturation 95% in room air
  • The cardiovascular examination revealed a consistent rhythm that included a loud, sonic S4 sound at the top and a 3-/6 holosystolic murmur at the bottom.
  • A respiratory assessment shows crackles in the lung bases bilaterally.
  • Neurological assessment reveals no deficits.

Plan:

  • Per protocol, Mr. Doe started with nitroglycerin and aspirin.
  • For further monitoring and management, he was moved to the coronary unit.
  • AMI was confirmed by the ordering of cardiac enzymes.
  • To assess any cardiac problems, echocardiography was performed.
  • His diabetes was managed by blood glucose monitoring.

Interventions:

  • To maintain an oxygen saturation of 92%, Mr. Doe received oxygen therapy.
  • Injectable morphine is used for pain management.
  • To reduce myocardial demands, bed rest was recommended.
  • To manage hypertension and hyperlipidemia, he was prescribed a low-fat, high-sodium diet.
  • M. Doe was educated about his condition and treatment.

Summary:

  • A 65-year-old man named Mr. Doe was admitted for acute chest pain.
  • The patient is receiving medication and ongoing monitoring for AMI.
  • Echocardiography and cardiac enzymes were used to confirm diagnosis and evaluate for new or worsening heart disease.
  • These include pain management, oxygen therapy, medication management and diet management.
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