Free Med Surg Nurse Report

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I. Patient Information

II. Assessment

A. Vital Signs

• Blood pressure: 130/80 mmHg

• Heart rate: 75 bpm

• Respiratory rate: 18 breaths/min

• Temperature: 98.6°F

B. Physical Assessment

• Clear lung sounds bilaterally with no adventitious sounds

• Intact skin without any signs of redness, swelling, or lesions

• Patient alert and oriented to person, place, and time, responsive and cooperative

C. Pain Assessment

• Numeric Rating Scale: 0-10

• Current pain level: 3/10, described as a dull ache in the chest that worsens with deep breathing but improves with rest

III. Interventions

IV. Response to Treatment

V. Plan of Care

A. Nursing Care Plan

• Goals for the shift: Monitor cardiac status closely for any signs of arrhythmia or ischemia

• Anticipated Interventions: Continuous ECG monitoring, hourly pain assessment, and reassessment

B. Physician Orders

• Pending orders: ECG, cardiac enzyme levels (troponin)

• Completed orders: Initiated nitroglycerin drip as per protocol for persistent chest discomfort

C. Patient Goals

• Short-term goals: Achieve and maintain pain relief, stabilize cardiac condition to prevent further ischemic episodes

• Long-term goals: Patient education on cardiac rehabilitation and lifestyle modifications to reduce cardiovascular risk factors

VI. Communication

A. Healthcare Team

• Discussions with: Cardiologist, intensivist

• Concerns raised: Need for ongoing pain management strategy due to persistent discomfort despite initial interventions

B. Family Members

• Family involvement: The wife present during admission, updated on the patient's condition, and involved in care decisions

• Education provided: Educated on signs of heart attack recurrence, the importance of medication adherence, and recognizing early symptoms

C. Ancillary Services

• Consultations requested: Cardiac catheterization scheduled for tomorrow morning to assess coronary artery status

• Results received: Pending, awaiting catheterization findings to guide further treatment decisions

VII. Education

VIII. Follow-Up

IX. Recommendation

• Further assessments: Monitor cardiac enzymes closely post-catheterization to detect any signs of myocardial damage

• Discharge planning: Arrange home health care services for ongoing cardiac monitoring and support, ensure patient and family education materials are provided

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