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Day 1 Patient's Name: Mr. X Age: 61 Address: Larap, Jose Panganiban, Camarines Norte Date / Time Focus Data, Action, Response Chest Pain

Mr. X, age 61, was admitted to the medical ward for 5 days of treatment for chest pain. Over the course of treatment, his vital signs stabilized, pain decreased, and activity tolerance increased. He was treated with medications including morphine, aspirin, metoprolol, and nitroglycerin to relieve symptoms and managed his coronary artery disease. By the fifth day, his pain and vital signs had improved and he was able to dangle his feet, demonstrating progressive recovery before discharge.

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Julliza Joy Pandi
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1K views4 pages

Day 1 Patient's Name: Mr. X Age: 61 Address: Larap, Jose Panganiban, Camarines Norte Date / Time Focus Data, Action, Response Chest Pain

Mr. X, age 61, was admitted to the medical ward for 5 days of treatment for chest pain. Over the course of treatment, his vital signs stabilized, pain decreased, and activity tolerance increased. He was treated with medications including morphine, aspirin, metoprolol, and nitroglycerin to relieve symptoms and managed his coronary artery disease. By the fifth day, his pain and vital signs had improved and he was able to dangle his feet, demonstrating progressive recovery before discharge.

Uploaded by

Julliza Joy Pandi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

DAY 1

Patient’s Name: MR. X Age: 61


Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 24, 2020 CHEST PAIN Ĉ Restlessness, Rapid-breathing, Self-focused
4:00 P.M. Ĉ Uncooperative @ times
Acute pain related to Ĉ Vital signs recorded as ff.:
tissue ischemia BP: 140/100 mmHg
RR: 25 bpm
CR: 140 bpm
TEMP: 37°C
02 SAT: 90%

 Admit to medical ward


 Secure consent for admission
 DIET: NPO temporarily
 IVF: Plain NSSTL @20gtts/min

Meds:
 Morphine SO4 4mg IV stat/ then PRN for
severe chest pain
 Metoprolol 50 mg/tab 1tab BID
 Aspirin 300mg/tab stat then 100mg /tab OD
 Transderm patch 5mg on ACW OD ĉ 8°
nitrates free
 O2 inhalation via cannula @4-5 cpm
 CBR 5BRP, moderate high back rest
 For close watch. Hook to cardiac monitor
 Refer.

After 5 days of confinement, the patient


demonstrates a relief of pain as evidenced by
stable vital signs, absence of muscle tension and
restlessness.
DAY 2
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 25, 2020 CHEST PAIN Ĉ Restlessness, Rapid-breathing, Self-focused
6:00 A.M. Ĉ Uncooperative @ times
Ĉ Vital signs recorded as ff.:
Activity intolerance BP: 130/100 mmHg
related to imbalance RR: 25 bpm
between myocardial CR: 140 bpm
oxygen supply and TEMP: 37°C
demand. 02 SAT: 90%

 Soft diet
 Furosemide 40mg IV stat then 20mg IV BID
 Clexane 0.4cc pre-syringe BID
 Lanoxin 0.25mg IV push stat
 Lidocaine 50mg IV push stat
 For close watch

At the end of five days confinement the patients


demonstrate measurable/progressive increased in
tolerance for activity with heart rate/rhythm and
BP within patient’s normal limits.
DAY 3
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 26, 2020 CHEST PAIN Ĉ Restlessness, Rapid-breathing, Self-focused
6:00 A.M. Ĉ Uncooperative @ times
Decreased cardiac Ĉ Vital signs recorded as ff.:
output related to the  BP: 130/90 mmHg
disease process of  RR: 25 bpm
coronary artery disease  CR: 140 bpm
(CAD)  TEMP: 37°C
 02 SAT: 90%

 Continue meds
 May sit on bed
 Soft diet
 Repeat Na+ K+ det.

At the end of five days confinement the patients


demonstrate measurable/progressive increased in
tolerance for activity with heart rate/rhythm and
BP within patient’s normal limits.
DAY 4
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 27, 2020 CHEST PAIN Ĉ Rapid-breathing, Self-focused; noted
6:00 A.M. Ĉ Cooperative @ times
Acute pain related to Ĉ Vital signs recorded as ff.:
decreased myocardial blood  BP: 120/80 mmHg
flow as evidenced by pain  RR: 20 bpm
score of 10 out of 10.  CR: 120 bpm
 TEMP: 37°C
 02 SAT: 90%

 KCl 20meg to incorporate in 1liter pf Palin NSS


@20gtts/min
 NaCl tab 1tab BID
 Continue other meds.

The patient demonstrates relief of pain as evidenced by a


pain score of lower than 3 out of 10.

DAY 5
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 28, 2020 CHEST PAIN Ĉ Normal-breathing; noted
6:00 A.M. Ĉ Cooperative @ all times
Decreased cardiac output Ĉ Vital signs recorded as ff.:
related to the disease  BP: 120/80 mmHg
process of coronary artery  RR: 20 bpm
disease (CAD)  CR: 100 bpm
 TEMP: 37°C
 02 SAT: 90%

 Continue meds
 May dangling feet
 Atorvastatin 40mg OD H.S.

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