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..

Answer 1

BASED ON ABOVE SCENARIO

PROGRESS NOTE

Patient's name-Mr.Richard

Age-- 65 years old

Diagnosis--- Acute episode of unstable angina

SUBJECTIVE----

Presented medical history ---1. chest pain 2. Shortness of breath

Past medical history---1.hypercholesterolmia since 10 years 2.unstable angina since 2 years 3.coronary artery disease since 2 years 4.hypertension since 6 years

Phychiatric history --- no relevant psychiatric history.

OBJECTIVE

ASSESSMENT

1.On asking Richard said that chest pain is sqeezing type at the center of chest radiating towards his jaw.

2.he has not passed stools in last 2 days.

Vital signs---- temperature -37.2°C

Pulse rate 102/min. oxygen saturation 98%, blood pressure136/90mmhg.

PLAN

1.1.Vit signs every 6th hourly.

2.ECG every single day.

3.medications provide like analgesics ,antiemitic,morphine to relief the pain.

4.provide comfortable positions.

5.provide calm and quite environmen like semi Fowler's position.

6.postion changed every 4th hourly like Fowler's position to breath adequately.

7.do not lift higher weight or up down.

8.monitor pain through pain scale.

9.advise the patient to do passive exercise.