Question

Cardiac Pt A 59 vear old latino female is admitted at midnight with a diagnosis of Chest Pain. She complains of a squeezing type pain across her chest and into her left jaw area. Vital signs are: Blood Pressure-200/110; Pulse-128 beats per minute: Respirations- 26 per minute; Temperature-99.8; Saturation of Oxygen-86% on room air, pain level 9/10. During your initial assessment she is rubbing her mid-chest, grimacing and is diaphoretic. The pain has been occurring intermittently throughout the evening and night. Her color is pale except around her lips which are cyanotic. Cardiac auscultation reveals a rapid regular rhythm and a murmur, no pulse deficit. She has never had this pain before. Lungs sounds are crackles in both bases with clear upper lobes. She is afraid she is going to die. On re-assessment vital signs are Blood Pressure-180/95; Pulse-108 beats per minute; Respirations- 22 per minute Temperature-99.0; Saturation of Oxygen-90% on 2 liters per minute; Pain level 8/10. She says her chest pain hasn't changed. Heart and lung sounds are unchanged.

Documentation. Subjective, objective, and abnormalities. Also one strength and weakness of patient. Physical assessment

Answer 1

Subjective

• Squeezing paint chest and left jaw
• Pain score at 9/10
• Fear

Objective

• Vitals
  • T:99.8 =fever
  • P:128=tachycardia
  • R:26=tachypnea
  • BP:200/110 = very high
  • Saturation:86% =hypoxia
• Pale
• Lips cyanosed
• Grimacing
• Diaphoretic Auscultation:Crackles present in lungs

Abnormalities

1. Tachycardia
2. Tachypnea
3. High blood pressure
4. Fever
5. Hypoxia
6. Crackles in lungs

Strength

• The vitals have improved at the second assessment reassuring that patient is trying to recover

Weakness

• The very high blood pressure can cause complications like stroke, heart attack, etc.,