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History of Present Problem:
Mary Johnson, a 56 year old women, presented to the ED stating that when she woke up this morning she started have some jaw pain and felt “a little short of air.” States she has had 2 weeks of nausea and heartburn and has felt “more tired” than normal over the past 1-2 months. She stated she has taken omeprazole for 2 weeks and it has not helped her heartburn. Mrs. Johnson currently denies chest pain.
Mrs. Johnson lives at home with her husband. She teaches kindergarten at a local school and is active in her community. She has 2 grown children that live out of town. She states she smokes 6 cigarettes a day and rarely has time to exercise. She and her husband eat out at least 2-3 times a week.
What data from the histories are important, RELEVANT, and have clinical significance for the nurse?
|RELEVANT Data from the Present Problem:||Clinical Significance:|
|RELEVANT Data from the Social History:||Clinical Significance:|
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medications treat which conditions? Draw lines to connect.)
|PMH:||Home Meds:||Pharm. Classification:||Expected Outcome:|
Diabetes Type II
|1. Omeprazole 20 mg daily2. Atorvastatin 40 ng HS3. Lisinopril 20 mg daily
4. Metformin 500 mg BID
|Current Vital Signs:||P-Q-R-S-T Pain Assessment:|
|R: 24||Region:||“In my jaw”|
|O2 Sat: 90% Room Air||Timing:||Constant|
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
|RELEVANT VS Data:||Clinical Significance:|
|GENERAL APPEARANCE:||Resting on stretcher, appears anxious.|
|RESP:||RR equal, appears labored. Shortness of air without exertion noted. Lungs clear bilaterally, no adventitious sounds noted.|
|CARDIAC:||Heart sounds S1/S2 noted. No murmurs noted. All distal pulses noted 2+. No edema noted.|
|NEURO:||Alert and oriented x 4. Moves all extremities without difficulty. No weakness noted.|
|GI:||Bowel sounds active x 4 quadrants. No tenderness upon palpation. Pt reports heartburn nausea x 2 weeks. No reports of vomiting.|
|GU:||No abnormalities noted.|
|SKIN:||Pink and warm. Skin intact.|
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
|RELEVANT Assessment Data:||Clinical Significance:|
|RELEVANT Results:||Clinical Significance:|
|Basic Metabolic Panel (BMP)|
|Complete Blood Count (CBC)|
(6 hours ago)5
(6 hours ago)6.6
What data recognized as clinically significant by the nurse?
|Relevant Lab Results:||Clinical Significance:||Trend: (Improving/Woresening/Stable)|
- What is the primary problem that your patient is most likely presenting?
- What is the underlying cause/pathophysiology of this primary problem?
- What interventions will you initiate based of these priorities? Make sure to LIST AND EXPLAIN at least 6.
Mrs. Johnson is rushed to the cardiac catheterization lab where it is found she has 2 major cardiac blockages. Going through her left radial artery, the physician places 2 new stents. After the patient is recovered in the cath lab, she is then admitted to the telemetry unit in the hospital.
- What nursing assessment(s) will you need to initiate immediately post-operative for the patient from cath lab? Explain at least 4.
- Johnson has the following post-operative medications ordered. Please explain the rationale for each:
- Nitroglycerin 0.4 mg SL every 5 minutes x 3 doses PRN chest pain
- Metoprolol tartrate 12.5 mg PO BID
- Eliquis 5 mg PO BID
- Brilinta 90 mg PO BID
- ASA 81 mg PO daily
- What are the most important discharge/education priorities you will reinforce with the patient to prevent future admissions with the same problem?
- What is the patient likely experiencing/feeling right now?
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