MED SURG NURSE REPORT

Prepared by: [Your Name]

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I. Patient Information

Field	Details
Name	John Doe
Age	55
Medical Record No.	MRN123456
Admitting Diagnosis	Acute Myocardial Infarction

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

Time	Medication Administered	Treatment/Procedure
08:00	Nitroglycerin 0.4 mg sublingual	Administered for chest pain relief
10:30	Aspirin 325 mg PO	Given for antiplatelet effect
13:00	Morphine 2 mg IV	Administered for persistent chest pain

IV. Response to Treatment

Time	Assessment of Response	Changes in Condition
09:00	Chest pain relieved after nitroglycerin	Pain scale reduced to 1/10, patient more comfortable and able to breathe easier
11:00	Aspirin taken without adverse effects	No significant changes observed in pain or vital signs
14:00	Morphine provided partial pain relief	Pain reduced to 2/10, patient resting comfortably with improved ability to move

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

Topic	Details
Medication	Detailed explanation of nitroglycerin use, emphasizing proper administration technique and potential side effects such as headache and hypotension
Condition Management	Emphasized importance of rest, stress reduction, and adherence to prescribed medications to optimize cardiac function
Lifestyle Modifications	Discussed dietary changes focusing on low-sodium and heart-healthy diet, smoking cessation advice, and regular aerobic exercise recommendations

VIII. Follow-Up

Date	Follow-Up Action
2 days post-discharge	Follow-up appointment scheduled with cardiologist for review of cardiac catheterization results and adjustment of medication regimen
1 week post-discharge	Cardiac rehabilitation referral initiated for a structured exercise program and ongoing education on heart health management

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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