Question

Scenario: (Chest Pain, Shortness of Breath) Richard is a 65 year old client is admitted to your ward after an acute episode of chest pain. Current diagnosis is Acute episode of Unstable Angina. This is day two in the ward. Past Medical history reveals hypercholesterolemia x 10 years, DMT2 x 5 years, unstable angina x two years, coronary artery disease x two years and hypertension x six years. No relevant social or psychiatric history found.

Nurses call bell rings. As an EN you are answering the call bell. Client states that he is having sever chest pain. Verbalise your actions:

Assessment On asking Richard states that the chest pain is squeezing type at the centre of the chest radiating towards his jaw. Pain started as he was in the toilet trying to open his bowels. Richard states that he has not passed stools in the last two days. LOC: alert and oriented.

Vital signs: T= 36.2°C, PR=102/min RR=30/min BP=136/90 SaOz=98% on room air BGL 12.0 Pain: 9 out of 10

Relevant Investigations: Troponin 1 = 0.9 Troponin 2 = 1.5 Troponin 3 = 0.3 Urea = 4.Smmol/L Creatinine = 126 Micromol/L Na+ = 142 mmol/L K+= 3.1 mmol/L Ca2+ = 1.8 mmol/L Mg2+ = 0.5 MMOl/1. Current treatment plan: 4/24 Vital Signs BGLs QID + 0200am Daily ECGs Aperients PRN Analgesics and antiemetic's PRN TED stockings Toilet privileges if pain free Inform doctor about each episode of Chest Pain. Morphine and GTN as per protocol.

Based on the above scenario, please briefly write the progress note in a paragraph style not in seperate sentences.

Answer 1

Mr.Richard is a 65year old, admitted in this ward 2 days ago, after an acute episode of chest pain and diagnosed to have Unstable angina.On admission he was experiencing chest pain and shortness of breath. Regarding his medical history he had a background of coronary artery disease for 2 years with previous episode of unstable angina 2 years back.Furthermore, he has been suffering from  hypercholestrolemia for 10 yrs, Type 2 diabetes mellittus for 5 years and hypertension for six years.His social and psychological history was unremarkable. After addmision he was having one episode of chest pain,it was squeezing type radiating to jaw .Pain started when he was trying to pass stool.He verbalizes that, he is constipated for 2 days.On physical examination , he is alert and oriented.On assessment his temperature was 36.2C, Pulse rate =30/mt, BP=136/90 mm Hg, SaO2=98%on room air , BGL12.0 and pain score 9 out of 10.His blood results, revealed Troponin1=0.9, Troponin 2=1.5, Troponin3=0.3, urea 4.5mmol/L, Creatinine=126mmol/L, Na+142mmol/L, K+=3.2mmol/L, Ca2+=1.8mmol/LMg2+= 0.5mmol/L. He has been prescribed Aperients PRN ,Analgesics and antiemetic's PRN, and apply TED stockings. In addition to that monitor blood glucose level four times aday and at 2.00am, vital signs every fourth hourly and take daily ECG. Provide bedside commode until pain free. Inform doctor about each episodes of pain. Inj.Morphin and nitroglycerin is ordered to administer according to the protocol.