Case Note for Nursing
Prepared By: [Your Name]
Company: [Your Company Name]
Patient Details
Full Name: Tracey Gleason
Date of Birth: February 14, 2045
Age: 76
Gender: Female
Medical Record Number: 3081759
Admission Details
Date of Admission: May 4, 2060
Admitting Diagnosis: Acute Myocardial Infarction (Heart Attack)
Admitting Physician: Dr. Leonard Whitley
Ward/Unit: Cardiac Intensive Care Unit (CICU)
Medical History
Ms. Gleason has a pertinent medical history that includes:
Current Medications
The patient is currently prescribed the following medications:
Allergies
Nursing Assessment
Initial Assessment (May 4, 2060): Upon admission, the patient presented with chest pain radiating to the left arm, dyspnea, and diaphoresis. Vital signs indicated tachycardia and hypertension. ECG confirmed acute myocardial infarction.
Ongoing Care and Monitoring
Continuous cardiac monitoring
Regular vital signs assessment every 2 hours
Oxygen therapy at 2 L/min via nasal cannula
Monitoring blood glucose levels four times daily
Plan of Care
Objectives include:
Stabilize cardiac function
Relieve chest pain
Maintain normotensive blood pressure
Control blood glucose levels
Prevent complications (e.g., heart failure, arrhythmias)
Interventions
Administer prescribed medications, including nitroglycerin as needed for chest pain.
Ensure dietary modifications to a heart-healthy diet.
Initiate cardiac rehabilitation program upon stabilization.
Educate patient and family about lifestyle changes and medication adherence.
Progress Notes
Discharge Summary
Ms. Gleason is expected to be discharged on May 10, 2060. Prior to discharge, patient will undergo further cardiac evaluation and be equipped with comprehensive education on managing her condition at home. Care transition plans include home visits by a cardiac nurse and coordination with primary care for ongoing management.
These case notes are intended to facilitate a holistic approach to Ms. Gleason’s recovery, focusing on both immediate medical needs and long-term well-being.
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