Question

Case Scenario Dave Grohl is a 49-year-old make that came into the hospital complaining of chest pain. Pt stated his chest pain was a 8/10, crushing pain. The patient states he feels short of breath. Current VS: BP-159/98, HR-115, RR-26, T-97.9. He is 91% on room air. Upon assessment, pt is noted to be having pursed lip breathing and crackles in the lungs. Heart sounds are present. Non-pitting edema noted in the feet and lower legs. Write a care plan for this patient.

write a care plan for this patient.

Answer 1

Care plan:
Patient name: Mr.Dave Grohl
Age: 49years/male
present complaint: chest pain scoring 8/10, crushing pain and shortness of breath
present vital signs:
Temp; 97.9
Resp; 26
HR: 115
BP: 159/98
O2 sat: 91%
Assessment:
head to toe:
Lungs; Purshed lip breathing and crackles in the lungs
Heart: Heart sound present
Leg; Non -pitting edema present in the feet and lower legs.
Nursing diagnosis:
-acute pain
-Anxiety due to chest pain
- risk for ineffective tissue perfusion
- risk for decreased cardiac output
- risk for increased fluid volume
Nursing intervention:
-monitor continuos cardiac monitoring
-monitor patient conscious level
-measure patient intake and output
-check ECG, chest x-ray, cardiac enzymes, ABGs and electrolytes
-Administer o2 and keep all emergency equipment near to the patient bedside
-provide support to the patient to avoid fear and anxiety
-Administer antianginal, beta-blockers, analgesics as per doctors' advice.