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Patient Profile: Myocardial Infarction Case

This document provides a patient profile and nursing assessment for Juan De La Cruz, a 56-year-old male presenting with myocardial infarction. The assessment includes subjective information from the patient regarding his health concerns, lifestyle habits, and medical history. Objective findings from the nurse's physical exam are also documented, such as vital signs, appearance, cardiovascular and respiratory exam findings. The assessment addresses all major body systems.

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MARIA CHARMIN M. MEJIA
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45 views5 pages

Patient Profile: Myocardial Infarction Case

This document provides a patient profile and nursing assessment for Juan De La Cruz, a 56-year-old male presenting with myocardial infarction. The assessment includes subjective information from the patient regarding his health concerns, lifestyle habits, and medical history. Objective findings from the nurse's physical exam are also documented, such as vital signs, appearance, cardiovascular and respiratory exam findings. The assessment addresses all major body systems.

Uploaded by

MARIA CHARMIN M. MEJIA
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

UNIVERSITY OF BOHOL

0186 Dr. Cecilio Putong Street


Tagbilaran City, Bohol, Philippines
Telefax No. (038)411-3101
[Link]
COLLEGE OF NURSING

Nursing Health Assessment

PATIENT PROFILE
Name: Juan De La Cruz Birth Date: January 1, 1964 Age: 56 Gender: Male
Address: Loon, Bohol Religion: Catholic Civil Status: Married
No. of children, if any:3 Occupation/Profession: Carpenter
Highest Educational Attainment: High School Level
Present Health Concern: Myocardial Infarction
Present Treatment: nitroglycerine,
PastTreatments: None
Past Hospitalizations (When & for what, include surgeries): None
__________________________________________________________________________
__________________________________________________________________________
Drug : NONE. Food Sensitivities:NONE

SUBJECTIVE OBJECTIVE
Health Perception Health Management
Pattern
Reasons for seeking health care Appearance : well dress
Mr De la cruz , 56 [Link] complaints of chest Grooming : clean
pain and epigastric pain with episodes of Expressions: weak, pale, restlessness
vomiting T 37.9 HR 82 RR: 25
Effects of illness on ADLs BP 180/110mmHg HT 5'7 WT 60
Weakness, easily tired
Use of alcohol : yes, during special occasion Skin
Use of tobacco : yes, 2 stick per day
Last Immunizations :Cannot recall Color Tan Texture Normal
Compliance with treatments Temp Cold. Lesions None
Daily Food and Fluid Intake Turgor Slow Moisture Normal
Usual Foods : rice, fried fish, pork
Eating Times : 3x a day

SUBJECTIVE OBJECTIVE
Difficulty Chewing NONE Oral Mucosa
Dysphagia. NONE Condition Normal
Sore Gums NONE Lesions none
Sore Tongue NONE Teeth No. 26
Nausea and Vomiting 50 ml vomitus
Gums Normal. Tongue Normal
Abdominal Pains NONE
Antacids NONE
Abdomen
Elimination Pattern Contour normal
Lesions None Umbilicus Normal
Bowel Habits Striae None. Vein Normal
Frequency 3X a week Color Yellow. Pain None Bowel sounds char. None
Consistency Normal Laxatives None Enemas None Masses palpated none
Suppositories NoneInfections None Colostomy None
Bladder Habits Musculoskeletal
Frequency 5x a day Color Yellowish. Pain None Gait Normal Posture Normal
Hematuria None. Incontinence None Nocturia None Extremity swelling none
Retention None Infections None Catheter None
Tenderness none
Daily Activities Symmetry Normal ROM Normal

Hygiene : taking a bath, brushing the teeth 2x a day Respiratory


Housework : cooking Thorax Shape normal
Leisure Activities : watching tv, walking Symmetry Normal Retractions Yes
Exercise Routine : walking Tenderness none
Breath Sounds
Sleep-Rest Pattern Adventitious sounds Deep breathing
Sleep Time 8pm Quality Good
Difficulty falling asleep OFTEN Cardiovascular
Sleep aids NONE Sleep medications NONE
Heart sounds
Sexuality/Reproduction Pattern Murmurs Wheezing
Female
Date began N/A Last cycle N/A
Problems None
Gravida Para Abortions Infertility
Current pregnancy None
Contraception used None
Undesirable side effects NONE
Problems on genitalia NONE
Problems on breasts NONE

Sensory-Perceptual Pattern
Perceptions of:
Vision NORMAL Smell NORMAL Hearing NORMAL
Taste NORMAL Sensation NORMAL
Aids for vision NONE
Aids for hearing NONE

Role-Relationship Pattern
Role in Family Father

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