Question

1.   Mr. Davis

The patient presents to the ER with recurrent headaches, fatigue, and blood pressure of 185/102. The patient is a long-time smoker, lead a relatively sedentary lifestyle, and has a BMI of 39. History of acid reflux. The patient is going to be kept for overnight observation and administer medications to help control his blood pressure.

Patient Blood pressure is taken just before transferring to the Med/Surg. Floor 156/87.

Nursing assistant taking the Vital signs: Temp 98.8, Pulse 101, B/P 178/98 this was just taken when the patient arrives at the floor.

The nursing assistant reports to the RN that the patient is complaining of chest pain.

With the patient information provided a NANDA Nursing Diagnosis and related to?

Answer 1

Ans .- Assessment Tool

Repositioning tends not to change chest pain caused by an AMI. If repositioning improves the pain, perhaps the issue is of musculoskeletal origin, pleuritic, or pericarditis. Present with atypical chest pain and other symptoms such as dyspnea, weakness and fatigue.

The majority of patients experiencing an AMI will report with chest painthe pain is atypical or even absent (a silent myocardial infarction) . It must be remembered that every patient is different and they will not all present with the classic substernal chest pain. patients with an AMI will experience radiating pain. Common sites include the anterior chest, shoulders, arms, neck and jaw. Some patients describe jaw pain feeling like a dull ache or a toothache.

Accompanying symptoms of an AMI may include nausea, vomiting and diaphoresis. The patient may also experience dizziness, hypotension and bradycardia or a feeling of impending doom and feeling scared.

Angina is typically short-lived and lasts for 2-5 minutes if the precipitating factor is relieved, for example exercise . Pain associated with AMI is not usually intermittent, though can be.

Perform a 12-lead ECG and have it checked by a medical officer as soon as possible.

• Performing and interpreting a 12-lead ECG is a vital assessment in the setting of chest pain. An ECG will help the medical team determine if and when a patient requires reperfusion therapy to treat the cause of the chest pain.

• Nurses may be encouraged to review a 12-Lead ECG with an experienced clinician to identify ECG changes that indicate a patient experiencing an ischaemic event. It is imperative that a medical officer, cardiologist or intensivist reviews the ECG. Always ensure you are treating the clinical signs and symptoms of the patient to maximise oxygenation and perfusion to the myocardium. It is suggested that a nurse should obtain a previous ECG conducted on admission or previous cardiac event. Early CPR and Defibrillation decrease mortality rates.

• Ensure easy access to a defibrillator.

  Maintaining access to a defibrillator is included in the current guidelines on the management of acute coronary syndromes (ACS) as a priority in the acute management of chest pain (Chew et al. 2016). This is because access to a defibrillator avoids early cardiac death caused by reversible arrhythmias. Patients who are having an AMI can have associated arrhythmias.

• Senior medical staff may then order diagnostic blood tests such as a full blood examination (FBE), troponin, biochemistry and electrolytes.

  Lastly, diagnostic blood tests may be ordered. Commonly, this includes testing a patient’s troponin levels. Troponin is a cardiac enzyme or marker of ischaemia/infarction.