Nursing Care Plan for Myocardial Infarction Patient

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NURSING CARE PLAN
NUR 302, NUR 304, & NUR 305
Student name: ____________________________________________
Instructor name: _________________________________________
Date: __________________________________________________
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Background Information
Initials:
AB
Age:
22 Years
Gender: Date of Admission:
Male 12/17/2018
Allergies:
No reported allergies
Chief Complaint for Hospitalization:
AB is an 18-year-old American boy who lodges a complaint of 8 based on a 9-10 scale of chest pain. He reports that the chest pain radiates from the left arm extending to his jaw.
AB reports that the pain started one day ago, and he thought he was experiencing a normal hurt burn. He also complains of nausea. However, the pain excruciated until he started
experiencing shortness of breath even when performing the slightest activity. He reports extreme fever rising up to 39.0 degrees Celsius.
Admitting Medical Diagnosis (es):
Chest pain/Angina secondary to probable Myocardial infarction.
Pathophysiology the disease:
Acute Myocardial infarction refers to regional myocardial necrosis based in the endocardium. It is secondary to occlusion of the renal artery. A majority of patient's experience
Myocardial infarction due to obstruction caused by coronary disease. The position of infarction occurs within the occluded blood vessel. The central left coronary artery occlusions
are typically causing a large anterolateral infarct whereas the right coronary obstruction results in inferior infarct occurrence. There may be anomaly patters of blood supply to the
posterior wall resulting in unexpected areas of an infarct.
Signs and symptoms:
The symptoms of Myocardial infarction include chest pain which may extend to the jaw or arm. Other symptoms include sweating breath shortness, vomiting, nausea and
pressure.
Vital signs
1. B/P 160/100
2. HR 78 bpm
3. RR Shorter RR interval
4. Temp 39.0 degrees C
5. O2 Sat 90%
6. Pain Level 9 on a scale of 9-10
IV Catheter site and Type:
No Catheter installed
Urinary Catheter
No Catheter installed
Diet:
Normal diet
Activity: Include any therapy order
The patient does not have a therapy order as per now.
Major Secondary Diagnosis (s
The patient reports past chest discomfort and extreme elevation of body temperature rising to 39.0 degrees Celsius.
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Pathophysiology (Definition): The general chest pain in acute myocardial infarcted patient is usually followed by dominant symptoms of fatigue. It is intense and unending for
approximately 30-60 minutes. It is usually described as impulsive causing a pressure sensation which comes out as sharp, burning and aching. The extreme fever could have been
caused by unspecific past conditions since it is not related with Myocardial infraction.
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Signs and symptoms:
Indigestion caused by epigastric features.
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___Aching pain in the chest
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Extreme Fever (39.0 degrees Celsius)
Treatment (medical/surgical/nursing/ other: _Determine whether the patient has ST-elevation Myocardial infarcted or non-STEMI. Treatment of patients who report chest
pains should be implemented since it helps to recognize the ischemic origin. There should be a provision of supplemental oxygen if the oxygen saturation is below 90%.
Immediate administration of chewable aspirin. Nitroglycerin is administered for active chest pain. Prevention and relief of complications.
History of Present Illness: The patient reports prior illnesses of hV 7453 mutation NICM 2/2 LITRE PHENOYPE. Pat cases of complicated anterior wall previously diagnosed.
He started becoming hyposensitive after the IVAD implantation. AS has been recently discharged on the hospital and antibiotics have been recently discharged from antibiotic
omtibio.__ The patient has experienced trauma currently and in the
past____________________________________________________________________________________________________________________________________________
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Past Medical History (PMH): _ AS has previously been diagnosed with cardiomyopathy. There is a prior diagnosis of heart failure with quite a dispensation.
Hepaciviral infarction and plural effusion due to CHF.
Past Surgical history: Reported cases of insertion of infusion into the vena cava PICC without subcutaneous port or pump.
Medications Taken at Home: Aldactine 25 mg oral tablet, 12.5 mg oral daily. Amiodarone 200mg oral tablet. Oral Asprin 81 mg. Oral cardesartan 4 mg tablet. Cefazolon 6
grams. Cholecalliferol 5000 units oral tablets. Folic acid 1mg administered daily. Magnesium oxide, 400mg oral tablets. Multiple vitamins, euronten, sidenofic, warfarin.
Immunizations against influenza.
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Cultural/Spiritual Assessment:
AS is a normal Christian
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