Running head: MYOCARDIAL INFARCTION

Myocardial Infarction Jane Doe Liberty University

MYOCARDIAL INFARCTION

Student Name: Jane Doe

1. Patient Profile Worksheet (1 point)

A. Personal Information Room #: 000 Gender: Male Ethnicity: African-American Age if < 90: 57 yo Place of Residence: Lives at home in Forest, VA Emergency Contact: Spouse MD: John Doe

Marital Status: Married

Admitting Diagnosis: Myocardial infarction, status post percutaneous transluminal coronary angioplasty Current Diagnosis(es): Type II diabetes mellitus, hypertension, and hypercholesterolemia Date of Current Surgery: 00/00/2013 Allergies: Penicillin and cephalosporins Code Status: Full code Mental Status: Awake, alert, orientx4

B.

Activity and Nutrition Diet order: Regular diabetic diet Route/Rate: Self, as tolerated Last Weight: 79 kg

Level of Activity: Up with assistance, asistx1 Level of self-care: Partial assist, asistx1

C.

Nursing Care Drainage devices (foley, NGT, JPs, T-tube, etc.): 2-way foley catheter Wound care/Dressing (be specific): Closed incision, surgical site, midline, chest, 4x4, medipore tape, sterile dressing change daily IV access: 18 gauge, right forearm, clean, dry and intact Frequency of vital signs: Vital signs and oximetry Q4H Frequency of Glucometer: AC and HS Supplemental oxygen: Room air Bed Surface: AtmosAir

OSA: High risk per screening Falls Risk: High risk

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D. Skill Vital signs Performing a full physical assessment Safe medication preparation Oral nutrition Using safe and effective transfer techniques Personal hygiene and bed making

Lab Assistant Initial or Reference (Perry & Potter, 2010, pp. 65-104) (Perry & Potter, 2010, pp. 107-170) (Perry & Potter, 2010, pp. 507-526) (Perry & Potter, 2010. pp. 824) (Perry & Potter, 2010, pp. 205-16) (Perry & Potter, 2010, pp. 421-63)

MYOCARDIAL INFARCTION

Patient History Worksheet The 57 yo, African-American patient in room 000 came into the Lynchburg General Hospital Emergency Department at 5 PM on 00/00/2013 with complaints of unrelieved chest pain which began at 4 PM of the same day. The patients electrocardiogram showed marked STelevation and tachycardia. The patient was rushed to the cath lab where he received emergent percutaneous transluminal coronary angioplasty. The patient was transferred from the postanesthesia unit (PACU) to the Medical Surgical unit where he is now recovering. The patients most recent physical assessment on 00/00/2013 reveals S1 and S2 with normal sinus rhythm without murmurs, clicks, or palpable thrills. The patients radial, carotid, brachial, popliteal, posterior tibial, and pedal pulses were equal and strong bilaterally. The patient has a history of type II diabetes mellitus, hypertension, hypercholesterolemia, stable angina, and malignant melanoma (2001) status post-surgical excision and radiation. The patients family history is significant for cancer and heart disease, not otherwise specified. The patient was formerly a smoker but quit in 2005; he has an 80 pack-year history. The patient reports consuming two to three 8 oz. alcoholic drinks per week. The patient denies illicit drug use. The patient states that he is retired, identifies himself as Episcopalian, and denies any special cultural support needs.

MYOCARDIAL INFARCTION II. Medications (1 point)

Student should also have medication cards or book available on clinical. Include PRNs that have been administered with the last 24 hours.

Medication

Route

Dosage & Frequency

Category/Mechanism of Action

Contraindications / Cautions

Side Effects

Use for this patient

MYOCARDIAL INFARCTION V. Top three priority Medical with Nursing Diagnosis (1 point) 1. Medical diagnosis: Myocardial infarction, status post percutaneous transluminal coronary angioplasty. Nursing diagnosis:

2. Medical diagnosis: Medical diagnosis: Myocardial infarction, status post percutaneous transluminal coronary angioplasty. Nursing diagnosis: 3. Medical diagnosis: Medical diagnosis: Myocardial infarction, status post percutaneous transluminal coronary angioplasty. Nursing diagnosis: Care Plan (1 point) Medical & Nursing Dx

Nursing Outcomes (NOC)

Nursing Interventions (NIC)

Evaluation

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References Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidenced based guide to providing care (9th ed.). St. Louis: Mosby. Assessment Technologies Institute . (n.d.). Retrieved from atitesting.com: atitesting.com Huether, S. E., & McCance, K. L. (2008). Understanding pathophysiology. St. Louis, MO: Mosby. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby. Perry, A. G., & Potter, P. A. (2010). Clinical nursing skills & techniques (7th ed.). (W. Ostendorf, Ed.) St. Louis: Mosby. Skidmore-Roth, L. (2012). Mosby's 2012 nursing drug reference: Everything you need to administer drugs safely, accurately, and professionally. St. Louis, MO: Mosby.