CASE NINE – Nursing Writings
Cardiac Patient Case
Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:
Subjective Data:
Mrs. Larson, a 72-year-old Caucasian woman
Admitted to the hospital with chest pain
Past Medical History (MH): hypertension, high cholesterol
Medications: hydrochlorothiazide (a thiazide diuretic) and metoprolol (a beta blocker) for high blood pressure and simvastatin (a cholesterol-lowering drug).
Allergies: bee pollen and penicillin antibiotics.
History of Present Illness (HPI): Mrs. Larson is presented to the hospital with intermittent chest pain. She states it is mild, only about 4/10 and gets better with rest. Then it comes back again. Mrs. Larson states “I am scared to do any walking or exercise because my chest hurts”. Currently Mrs. Lewis has some mild chest pain- ask her some OLDCARTS related to her current symptoms of mild chest pain.
Objective Data (Physical Exam):
Vital Signs: Oral Temp 37 C, HR 112 BPM, RR 20, and BP 148/78 mm Hg, oxygen saturation 91%
EKG reading: Sinus Tachycardia, no ST elevations
Inspection: Skin color pale. Visually appears anxious. Document rest of inspection as normal/expected finding
Palpation: document palpation as normal/expected findings
Auscultation: Apical heart rate tachycardic and regular. Document rest of auscultation as normal or expected findings.
Two Actual or Potential Risk F
1. Mrs. Larson is at risk for…………………………..because the assessment findings indicated that…………………………………
2. Mrs. Larson is also at risk for……………………………….because the assessment findings indicate that………………
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