Nurse's Note

Patient Information: - John Smith - 1234567 - 12/03/1950 - 1 November 2024, 14:00 - Inpatient ward Subjective: - Patient reports shortness of breath and chest pain. - Chest pain is described as a pressure, 7/10 in intensity, radiating to the left arm. - Patient expresses concern about the severity of their condition and the need for further tests. - Patient and family understand the need for oxygen and monitoring. Objective: - BP: 160/90 mmHg, HR: 110 bpm, RR: 24, Temp: 37.2°C, Oxygen Saturation: 92% on room air. - General appearance: appears anxious and in distress. Skin integrity intact. No edema noted. Lung sounds: crackles in the left lower lobe. Heart sounds: regular rhythm, no murmurs. Abdomen soft, non-tender. Mobility status: ambulating with assistance. - Blood glucose level: 110 mg/dL. - Review of medical chart: recent ECG showed ST-segment elevation; orders for cardiac enzymes and chest X-ray; medication changes include aspirin and heparin. Assessment: - Nursing diagnosis: Impaired gas exchange related to potential cardiac event. - Prioritization: Administer oxygen, monitor cardiac status, and prepare for further interventions. Plan: - Administer oxygen via nasal cannula at 2L/min. - Continuous cardiac monitoring. - Prepare for blood draws for cardiac enzymes. - Notify the physician of changes in patient status. - Scheduled chest X-ray at 16:00. - Collaborate with the physician regarding further treatment options. Interventions: - Administered oxygen via nasal cannula at 2L/min. - Placed patient on cardiac monitor. - Obtained blood samples for cardiac enzymes. - Provided reassurance and emotional support to the patient and family. - Contacted the physician to report changes in patient status. Response to interventions: Patient's oxygen saturation improved to 96% on 2L oxygen. Evaluation: - Patient's shortness of breath has slightly improved. - Chest pain remains at 6/10. - Cardiac rhythm remains stable. - No new findings. Plan for Continuing Care: - Continue to monitor vital signs and cardiac status. - Await results of cardiac enzymes. - Prepare for potential transfer to the cardiac unit. - Provide ongoing patient and family education regarding the condition and treatment plan. Additional Notes: - Patient and family were educated on the importance of rest and avoiding strenuous activities. - Communication with the patient and family regarding the plan of care and potential interventions. - No safety concerns or incidents reported.