Mrs. S is an 88-year-old patient in the nursing home. She has a history pf MI, CHF, and diabetes. She receives ASA on da...
Mrs. S is an 88-year-old patient in the nursing home. She has a history pf MI, CHF, and diabetes. She receives ASA on daily basis, and has an order for nitroglycerin’s sublingually prn chest pain.
Mrs. S. put her call light on. You the LPN answered the call light
Mrs. S. states she was having chest pain and rated it a 9/1o on pain scale. You complete a focused assessment and get nitroglycerin tab and call for the RN who is busy with a patient that has fallen/
Mrs. S’s blood pressure was 90/52before nitroglycerin. Her HR was 120. Her breathing was labored at 36 and her pulse oximetry was 85 % on Room air. There was no relief to her chest pain and her blood pressure decreased to 80/52. The RN arrives in the room and you give her report
SITUATION
BACGROUND
ASSESSMENT
RECOMMENDATION:
Homework Answers
SITUATION: Mrs S complained of chest pain rating 9/10 in pain scale. Administered Nitroglycerine s/l after pre assessment and as per prn order
BACGROUND: Mrs S is 88 year old, with history of MI, CHF and diabetes and on ASA daily
ASSESSMENT: Her BP was 90/52 mm Hg, heart rate 120 /minute and labored breathing of 36 /minute, SPO2 85% in room air. Her BP reduced t 80/52 after Nitroglycerine.
RECOMMENDATION:
- Keep ready the crash cart and call for doctor on call
- Start oxygen by mask at 4 L per minute
- Immediately do a 12 lead ECG
- Start continuous ECG and BP monitoring
- Draw blood for lab test for cardiac enzymes.
- Comfort the patient and try to relax her.
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