CASE 1: Brief Description of Client
Name: E.L Age: 68
Religion: RC Height: 170cm Obese
Allergies: Unknown Gender: Male Weight: 86kg
Past Medical History: Hypertension, DM Type II, Dyslipidemia
Family History: Hypertension (Mother’s side)
DM Type II (Father’s Side)
History of Present illness:
The patient arrives at the emergency department with a chief complaint of chest pain. The patient described the pain as crushing,
squeezing, and heavy located primarily at the left side of his chest that is radiating to his left shoulder and arm. Pain scale rated at
10/10. The patient cries that the pain is constant and does not subside with rest and deep breathing. 2 hours prior to the arrival, the
patient was preparing for lunch when suddenly the symptoms presented. Upon assessing the patient, the patient is in obvious
discomfort with facial grimacing and jaws clenched, clenched fist rubbing on left chest area. The client is also pale and diaphoretic in
appearance. The patient is also complaining of shortness of breath and “a feeling they might want to throw up”.
Hemodynamic status are as follows: BP: 160/100mmHg, HR: 110 bpm, RR: 23 breaths/min, T: 36C, SpO2: 93%
Primary survey: Airway: patent airway, nasal flaring noted
Breathing: Tachypneic noted, RR 23 breaths/min
Circulation: Tachycardic at HR110bpm, BP160/100mmHg, SpO2 93%, capillary refill at 4 seconds, peripheral pulse weak
Deficits: Neurological exam grossly intact
Exposure: Unremarkable
Secondary survey:
HEENT: Facial pallor, and Diaphoresis noted, Pale conjunctiva, Pale and dry, Cracked lips noted, Evident facial grimacing noted with
teeth grinding
Neck: Midline trachea, no JVD
Chest: Rapid chest expansion, Clear breath sounds heard upon auscultation, Diaphoresis noted, Clenched fist rubbing chest area
(Levine’s sign)
, Cardiac: Tachycardic at HR110bpm, normal S1 and S2
Abdomen: Normal bowel sounds, soft, nontender
Extremities: Cold, Clammy extremities, Diaphoresis noted, Pale nail beds with capillary refill of 4 seconds
Neuro: conscious, coherent, in distress
The physician on duty referred the patient to the Cardiology Consultant on deck for medical management. An order for admission
was advised. The patient is a retired police officer, an occasional alcoholic beverage drinker and 25- pack year smoker. Patient also
mentioned having a sedentary lifestyle with sporadic exercise schedule and admits to having a diet rich in sodium, sugar, and fat
content after his retirement.
Assessment Nursing Diagnosis Goals Nursing Intervention Rationale Evaluation
Objective: Actual Problem: Short Term: Independent: Independent: Short Term:
1. Observations Decreased Cardiac After 1 hour of 1. Provide the patient 1. Reduce physical After 1 hour of
- Facial Grimace Output related to nursing intervention a calm and restful stress and tension, nursing intervention
- Teeth Grinding inadequate the patient will be surroundings, and thereby producing a the patient was be
- Facial Pallor oxygenation as able to: minimize the calming effect that able to:
- Cold Clammy manifested by chest environmental noise. can decrease
Extremities. pain, shortness of 1. Demonstrate that Limit the patient’s discomfort. 1. Partially Met. The
- Levine’s Sign or breath, and prolonged the chest pain and number of visitors, patient will be able to
Clenched fist capillary refill. discomfort is relieved and the length of verbalize a relief in
rubbing at the chest and controlled. visitation. chest pain with a pain
area. rate scale of 7/10, as
- Pale nail beds with 2. Reports of 2. Monitor the 2. Provides a basis for 10 being the highest.
capillary refill of 4 decreased episodes of patient's vital sign, evaluating the
seconds. shortness of breath. and the SPO2. effectiveness of 2. Partially Met. The
- Pain scale rated at nursing interventions, patient will report a
10/10. 3. Report a pain rate and to obtain baseline decreased episodes of
- Dyspnea or scale of 7/10, 10 vital signs for dyspnea with a 18-20
shortness or breath. being the highest. comparison, and as cpm
- Clear breath sounds well as to assess the Long Term:
heard upon 4. Regain normal skin improvement
auscultation. color. regarding the After 10-20 days of
patient’s health. nursing interventions
Name: E.L Age: 68
Religion: RC Height: 170cm Obese
Allergies: Unknown Gender: Male Weight: 86kg
Past Medical History: Hypertension, DM Type II, Dyslipidemia
Family History: Hypertension (Mother’s side)
DM Type II (Father’s Side)
History of Present illness:
The patient arrives at the emergency department with a chief complaint of chest pain. The patient described the pain as crushing,
squeezing, and heavy located primarily at the left side of his chest that is radiating to his left shoulder and arm. Pain scale rated at
10/10. The patient cries that the pain is constant and does not subside with rest and deep breathing. 2 hours prior to the arrival, the
patient was preparing for lunch when suddenly the symptoms presented. Upon assessing the patient, the patient is in obvious
discomfort with facial grimacing and jaws clenched, clenched fist rubbing on left chest area. The client is also pale and diaphoretic in
appearance. The patient is also complaining of shortness of breath and “a feeling they might want to throw up”.
Hemodynamic status are as follows: BP: 160/100mmHg, HR: 110 bpm, RR: 23 breaths/min, T: 36C, SpO2: 93%
Primary survey: Airway: patent airway, nasal flaring noted
Breathing: Tachypneic noted, RR 23 breaths/min
Circulation: Tachycardic at HR110bpm, BP160/100mmHg, SpO2 93%, capillary refill at 4 seconds, peripheral pulse weak
Deficits: Neurological exam grossly intact
Exposure: Unremarkable
Secondary survey:
HEENT: Facial pallor, and Diaphoresis noted, Pale conjunctiva, Pale and dry, Cracked lips noted, Evident facial grimacing noted with
teeth grinding
Neck: Midline trachea, no JVD
Chest: Rapid chest expansion, Clear breath sounds heard upon auscultation, Diaphoresis noted, Clenched fist rubbing chest area
(Levine’s sign)
, Cardiac: Tachycardic at HR110bpm, normal S1 and S2
Abdomen: Normal bowel sounds, soft, nontender
Extremities: Cold, Clammy extremities, Diaphoresis noted, Pale nail beds with capillary refill of 4 seconds
Neuro: conscious, coherent, in distress
The physician on duty referred the patient to the Cardiology Consultant on deck for medical management. An order for admission
was advised. The patient is a retired police officer, an occasional alcoholic beverage drinker and 25- pack year smoker. Patient also
mentioned having a sedentary lifestyle with sporadic exercise schedule and admits to having a diet rich in sodium, sugar, and fat
content after his retirement.
Assessment Nursing Diagnosis Goals Nursing Intervention Rationale Evaluation
Objective: Actual Problem: Short Term: Independent: Independent: Short Term:
1. Observations Decreased Cardiac After 1 hour of 1. Provide the patient 1. Reduce physical After 1 hour of
- Facial Grimace Output related to nursing intervention a calm and restful stress and tension, nursing intervention
- Teeth Grinding inadequate the patient will be surroundings, and thereby producing a the patient was be
- Facial Pallor oxygenation as able to: minimize the calming effect that able to:
- Cold Clammy manifested by chest environmental noise. can decrease
Extremities. pain, shortness of 1. Demonstrate that Limit the patient’s discomfort. 1. Partially Met. The
- Levine’s Sign or breath, and prolonged the chest pain and number of visitors, patient will be able to
Clenched fist capillary refill. discomfort is relieved and the length of verbalize a relief in
rubbing at the chest and controlled. visitation. chest pain with a pain
area. rate scale of 7/10, as
- Pale nail beds with 2. Reports of 2. Monitor the 2. Provides a basis for 10 being the highest.
capillary refill of 4 decreased episodes of patient's vital sign, evaluating the
seconds. shortness of breath. and the SPO2. effectiveness of 2. Partially Met. The
- Pain scale rated at nursing interventions, patient will report a
10/10. 3. Report a pain rate and to obtain baseline decreased episodes of
- Dyspnea or scale of 7/10, 10 vital signs for dyspnea with a 18-20
shortness or breath. being the highest. comparison, and as cpm
- Clear breath sounds well as to assess the Long Term:
heard upon 4. Regain normal skin improvement
auscultation. color. regarding the After 10-20 days of
patient’s health. nursing interventions
