Question

Carry out a care plan with each problem presented here (problem, short and long-range objectives, nursing interventions, and evaluation for each intervention.)

Case study:

64-year-old patient, admitted to the emergency room, due to throbbing chest pain after walking with shortness of breath for several days, his employee is a bank, with no known allergies, he has been an active smoker of a pack a day for 40 years with a history of Alternate Hypertension (HTN), with uncontrolled BP, for 5 years with pharmacological treatment, In his history he mentions that he is type-2 diabetic, for which he takes oral hypoglycemic drugs. He does not refer other antecedents of interest and denies Family history of heart disease. His treatment is Amlodipine 5 mg, Sinvastatin 40 mg and Metformin 850mg PO

On his physical examination he shows;

1- A BP 195 \ 110, Cardiac frequency 109

2-L Ascultation Cardiac Reveal, a soft tip puff.

3-Both hemitorax expand normally and there are no noises added to the respiratory ascultation

4-The abdomen is palpable globular and soft to the touch, with no signs of venous congestion in its physical examination.

5-The pulses are palpated normally and are symmetrical, except that the pulses in both feet are weak, it has a good capillary return.

THANK YOU

Answer 1

Problem - it could heart attack or myocardial infarction.

1.Short term objectives - give him mechanical ventilation

Improve oxygen saturation .

Control hypertension .

2. Long term objectives - ask the patient to quit smoking.

Long term control of diabetes and hypertension .

Maintain blood good lipid profile.

Increased physical activity and exercise .

NURSING INTERVENTIONS and evaluation - give anti Anginal drugs

Monitor ecg

Access the patient frequently.

Teaching lifestyle modification.

Prevention and identification of complications.