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Cardiac Nursing (NSG 481)
West Virginia University
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2/12/2021 PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due Week 1 | Completed | Shadow Health
westcoast.shadowhealth/assignment_attempts/8916007 1/
PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due We
1 Results | Completed
Physical Assessment - WCU - January 2021, nurs190-ie_nurs190_202101spi_vr4w
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Documentation / Electronic Health Record
Document: Nursing Notes
Student Documentation Model Documentation
Subjective
Pt reports chest pain started about 5 mins ago Chest pain is constant Patient wasa just sitting when the chest pain began the pain is contant , reports pain of 6/ describes pain as heavy squeezing pressure right in the middle of the chest Patient reports left shoulder hurting a tiny bit denies neck pain denies jaw pain patient denies any stress reports high blood pressure reports high cholestorol Denies regular excercise routine Patient only drinks alcohol on weekends 2/3 beers Patient reports cardiac tests and stress test are normal Diet is as follows typical breakfast is granola bar and instant shake lunch is turkey sub dinner is grilled meat and vegatables denies family histroy of stroke denies history of pulmonary embolism Grandfather died of heart attack on maternal mothers side denies sleep issues denies fever denies chills denies respiratory issues reports that he takes lipitor and lisinopril daily denies crushing pain denies tearing pain reports bowel movement this morning bowel movement was normal. denies throat issues
Mr. Foster is post-op day 3 for a TURP (Transurethral resection o prostate). He is complaining of chest pain that began 5 minutes a He rates his pain at 6/10. He reports the pain is localized to the s sternal region and describes it as “squeezing pressure.” He repo the pain is constant and increasing in severity. He denies radiatio but reports some pressure in the left shoulder as well. He reports pain was accompanied by nausea at the onset, but denies emes The patient reports becoming increasingly anxious. He denies SO and palpitations. He denies tenderness, redness, or changes in surgical site.
Your Results Lab Pass (/assignment_attempts/8916007/lab_pass
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Care Plan
Student Survey
Document: Vitals Document: Nursing Notes
Suppor t
2/12/2021 PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due Week 1 | Completed | Shadow Health
westcoast.shadowhealth/assignment_attempts/8916007 2/
Student Documentation Model Documentation
Objective
Appearance no visible abnormal findings Jugular venous distention 1 cm above sternal angle chest is symmetric no visible abnormal findings inspected hands and fingernails no visible abnormal findings Inspected lower extremities and toenails no visible abnormal findings Inspected lower extremities for edema no edema present Tested capillary refill on fingers Less Than 3 seconds Tested capillary refill on toes Less Than 3 seconds Palpated carotid arteries right side no thrill 2 + expected Palpated corteroid artery left side no thrill 2 + expected Palpated PMI displaced laterally brisk and tapping Less Than 3 cm
palpated right brachial pulse no thrill 2+ Palapted Left brachial pulse no thrill 2+ Palpated right radial pulse no thrill 2+ palpated left radial pulse no thrill 2+ Palpated right femoral pulse no thrill 2+ Palpated left femoral pulse no thrill 2+ Palpated right popliteal pulse no thrill 2 + Palpated left Popliteal pulse no thrill 2+ Palpated right tibial pulse no thrill 1+ palpated left tibial pulse no thrill 1+ palpated right dorsalis pedis pulse no thrill 1+ palpated left dorsalis pedis pulse no thrill 1+ measured vitals auscultated right carotoid pulse no bruit auscultated left carotoid pulse no bruit Auscultated heart sounds S1,S2,and S4 audible extra gallops auscultated abdominal aorta no bruit Auscultated right renal pulse no bruit ausucltated Iliac pulse no bruit Auscultated femoral pulse no bruit auscultated left renal pulse no bruit auscultated left Iliac pulse no bruit Auscultated left femoral pulse no bruit Auscultated breath sounds breath sounds present in all areas No adventitious breath sounds All breath sounds clear performed EKG EKG irregular , no st elevation
General Survey: Alert, but uncomfortable appearing middle-age male supine in hospital bed, and mildly diaphoretic. Elevated respiratory rate and evident distress.
Cardiovascular: No JVD, HR between 100-115, S1 & S2, + S4. murmur, no rub. Occasional PVCs appreciated. BP range 92-
- No carotid bruit or thrill.
Peripheral Vascular: Capillary refill <3 seconds on bilateral finge and toes, radial pulses 2+, posterior tibial and dorsalis pedis puls +1. No lower extremity edema. No varicosities, no areas of focal induration or erythema.
Respiratory: Respirations quiet and unlabored, able to speak in sentences. Lungs CTA. RR 24-26/m, O2 saturation 97-99%.
Neuro: Alert and oriented x3, follows commands, moves all extremities.
Skin: Diaphoresis. No pallor, redness, induration, or purulence noted.
EKG (interpretation): Sinus tachycardia with occasional PVCs. N ST segment elevation.
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Documentation - Shadow Health
Course: Cardiac Nursing (NSG 481)
University: West Virginia University
