Question

Scenario 3: (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 write the progress note.

Answer 1

Subject: patient chest pain shortness of breath improved and he tolerating Clea liquid diet.

Objective: - Temperature - 36.2 °c

PR - 102/min

RR - 30 min

BP - 136/90

Spo2 - 98%

Blood reports are stable troponin only little high

ECG - normal

Physical examination:-

General : alert and oriented in no acute distress

CV : normal

Resp : normal

Abdomen : hard , abdomen pain present because of no stools 2 days.

Assessment :

65 years Richard admitted for chest pain,shortness of breath,

Acute episode of unstable angina

Hospital Day 1

Acute episode of unstable angina

Continue pain control and will transition to oral pain medication

Continue clear liquid diet

Monitor input and output chart

Continue medication

BGLs QID + 0200 am daily ECG

Inform to the doctor about each episode of chest pain.

Morphine & GTN asper protocol

D/ C SAS as Patient not scaring for the 3 days

Continue inpatient observation