Nursing presentation

Patient Name: John Doe Age: 65 Sex: Male Admission Date: March 15, 2023 Admitting Diagnosis: Acute Myocardial Infarction (AMI)

History:

• Mr. Doe has a history of hypertension, hyperlipidemia, and diabetes mellitus type 2.
• He underwent a coronary artery bypass graft (CABG) surgery 5 years ago.
• He is a retired construction worker and lives alone in a single-story house.

Assessment:

• Mr. Doe is alert and oriented to person, place, and time.
• He complains of chest pain that started 4 hours ago and radiates to his left arm.
• Vital signs are as follows: blood pressure 140/90 mmHg, heart rate 90 bpm, respiratory rate 22 bpm, and oxygen saturation 90% on room air.
• Cardiovascular assessment reveals a regular rhythm with a loud S4 sound and a 3/6 holosystolic murmur heard at the apex.
• Respiratory assessment reveals crackles heard bilaterally in the lung bases.
• Neurological assessment reveals no deficits.

Plan:

• Mr. Doe was started on aspirin, nitroglycerin, and heparin per protocol.
• He was transferred to the coronary care unit for further management and monitoring.
• Cardiac enzymes were ordered to confirm the diagnosis of AMI.
• Echocardiography was ordered to assess for any new or worsening cardiac dysfunction.
• Blood glucose monitoring was initiated to manage his diabetes.

Interventions:

• Mr. Doe was placed on oxygen therapy to maintain oxygen saturation above 92%.
• Pain management was initiated with intravenous morphine.
• Bed rest was ordered to reduce myocardial demand.
• A low-fat, low-sodium diet was ordered to manage his hypertension and hyperlipidemia.
• Education was provided to Mr. Doe regarding his condition, treatment plan, and risk factor management.

Summary:

• Mr. Doe is a 65-year-old male admitted with acute chest pain and a history of AMI.
• He is being treated for AMI with medication and monitoring.
• Cardiac enzymes and echocardiography were ordered to confirm the diagnosis and assess for any new or worsening cardiac dysfunction.
• Nursing interventions include oxygen therapy, pain management, bed rest, diet management, and patient education.