Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

NRSE 4520 SH Brian Foster Chest Pain Document Nursing Notes, Exams of Nursing

NRSE 4520 SH Brian Foster Chest Pain Document Nursing Notes

Typology: Exams

2024/2025

Available from 10/09/2024

ProfGoodluck
ProfGoodluck 🇺🇸

3.9

(8)

1.6K documents

1 / 24

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
Document: Nursing Notes
Model Documentation
Mr. Foster is post-op day 3 for a TURP (Transurethral resection of the
prostate). He is complaining of chest pain that began 5 minutes ago. He
rates his pain at 6/10. He reports the pain is localized to the sub-sternal
region and describes it as “squeezing pressure.” He reports the pain is
constant and increasing in severity. He denies radiation but reports some
pressure in the left shoulder as well. He reports the pain was
accompanied by nausea at the onset, but denies emesis. The patient
reports becoming increasingly anxious. He denies SOB and palpitations.
He denies tenderness, redness, or changes in surgical site.
• General Survey: Alert, but uncomfortable appearing middle-aged male
supine in hospital bed, pale and mildly diaphoretic. Elevated respiratory
rate and evident distress. • Cardiovascular: No JVD, HR between 100-
115, S1 & S2, + S4. No murmur, no rub. Occasional PVCs appreciated.
BP range 92-109/57-68. No carotid bruit or thrill. • Peripheral Vascular:
Capillary refill <3 seconds on bilateral fingers and toes, radial pulses 2+,
posterior tibial and dorsalis pedis pulses +1. No lower extremity edema.
No varicosities, no areas of focal induration or erythema. • Respiratory:
Respirations quiet and unlabored, able to speak in full 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. No ST segment elevation.
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16
pf17
pf18

Partial preview of the text

Download NRSE 4520 SH Brian Foster Chest Pain Document Nursing Notes and more Exams Nursing in PDF only on Docsity!

Document: Nursing Notes

Model Documentation Mr. Foster is post-op day 3 for a TURP (Transurethral resection of the prostate). He is complaining of chest pain that began 5 minutes ago. He rates his pain at 6/10. He reports the pain is localized to the sub-sternal region and describes it as “squeezing pressure.” He reports the pain is constant and increasing in severity. He denies radiation but reports some pressure in the left shoulder as well. He reports the pain was accompanied by nausea at the onset, but denies emesis. The patient reports becoming increasingly anxious. He denies SOB and palpitations. He denies tenderness, redness, or changes in surgical site.

  • General Survey: Alert, but uncomfortable appearing middle-aged male supine in hospital bed, pale and mildly diaphoretic. Elevated respiratory rate and evident distress. • Cardiovascular: No JVD, HR between 100- 115, S1 & S2, + S4. No murmur, no rub. Occasional PVCs appreciated. BP range 92-109/57-68. No carotid bruit or thrill. • Peripheral Vascular: Capillary refill <3 seconds on bilateral fingers and toes, radial pulses 2+, posterior tibial and dorsalis pedis pulses +1. No lower extremity edema. No varicosities, no areas of focal induration or erythema. • Respiratory: Respirations quiet and unlabored, able to speak in full 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. No ST segment elevation.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.

Chief Complaint

Finding:

Established chief complaint 

Finding:

Reports chest pain

(Found)

Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.

Example Question:

Do you have chest pain?

History of Presenting Illness

Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain on a scale from 0 to 10 develops a consistent measure of pain severity.

Example Question:

On a scale of 0 to 10 how would you rate the chest pain? 

Finding:

Asked about on characteristics of the pain 

Finding:

Describes pain as tight and uncomfortable

(Found)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Can you describe your pain? 

Finding:

Denies crushing pain

(Found)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain crushing? 

Finding:

Denies gnawing or tearing pain

(Found)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain gnawing? 

Finding:

Denies burning pain

(Found)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain burning? 

Finding:

Asked about location of the pain 

Finding:

Reports pain location is in middle of the chest

(Found)

Pro Tip: Identifying the location of a patient's pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat it.

Example Question:

Where is the pain? 

Finding:

Reports slight pain in left shoulder

(Found)

Pro Tip: Pain radiation is an important symptom that can be helpful in understanding the cause of pain and narrowing the diagnosis.

Example Question:

Does the pain radiate? 

Finding:

Denies arm pain

(Found)

Pro Tip: When combined with chest pain, arm pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have arm pain?

Finding:

Asked about stress and anxiety 

Finding:

Reports generally low stress lifestyle

(Available)

Pro Tip: Stress can have a profound effect on the patient's health and wellness. Asking about stress is an important part of any health assessment.

Example Question:

What is your usual stress level? 

Finding:

Denies history of anxiety

(Available)

Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he's ever suffered from anxiety can point to underlying stressors or triggers.

Example Question:

Do you have a history of anxiety? 

Finding:

Denies history of panic attacks

(Available)

Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he's ever had a panic attack can point to underlying stressors or triggers.

Example Question:

Have you ever had a panic attack?

Past Medical History

Finding:

Asked relevant health history 

Finding:

Reports high blood pressure

(Found)

Pro Tip: Hypertension is the most important risk factor for stroke. Soliciting a health history from Brian will allow you to assess his risk of cardiovascular disease.

Example Question:

Do you have high blood pressure? 

Finding:

Reports high cholesterol

(Found)

Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Brian whether he's had a history of high cholesterol reveals important details about his cardiovascular health.

Example Question:

Do you have high cholesterol? 

Finding:

Denies history of pulmonary embolism

(Available)

Pro Tip: Pulmonary embolism is one of many cardiac risk factors to ask about that can help you form a more complete picture of Brian's cardiovascular health.

Example Question:

Have you ever had a pulmonary embolism? 

Finding:

Denies history of angina

(Available)

Pro Tip: A history of angina can weaken the heart and lead to further cardiovascular complications. Asking Brian about angina helps you understand his overall cardiovascular health.

Example Question:

Do you have a history of angina? 

Example Question:

What medication do you take for high blood pressure? 

Finding:

High blood pressure medication dose is 20mg

(Available)

Pro Tip: The current dose of any patient's high blood pressure medication is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions.

Example Question:

What dose of medication do you take for high blood pressure? 

Finding:

High blood pressure medication is taken once daily

(Available)

Pro Tip: The frequency with which a patient takes his high blood pressure medications is an essential element of the complete picture of his medication treatment plan.

Example Question:

How frequently do you take medication for high blood pressure? 

Finding:

Followed up on high cholesterol treatment 

Finding:

Reports taking high cholesterol medication

(Found)

Pro Tip: The medication that a patient takes for their high cholesterol will indicate how well controlled their condition is and how well they comply with treatment regimens.

Example Question:

Do you take medication for cholesterol? 

Finding:

Reports high cholesterol medication is Atorvastatin (Lipitor)

(Found)

Pro Tip: Discovering what specific high cholesterol medication a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.

Example Question:

What medication do you take for cholesterol? 

Finding:

Reports high cholesterol medication dose is 20mg

(Available)

Pro Tip: The current dose of any patient's high cholesterol medication is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions.

Example Question:

What dose of medication do you take for cholesterol? 

Finding:

Reports high cholesterol medication is taken once daily

(Available)

Pro Tip: The frequency with which a patient takes his high cholesterol medications is an essential element of the complete picture of his medication treatment plan.

Example Question:

How frequently do you take medication for cholesterol? 

Finding:

Asked history of cardiac tests 

Finding:

Reports recent EKG test

(Found)

Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he's had an EKG will reveal his recent medical history, cardiac health, and medical literacy.

Example Question:

Have you recently had an EKG test? 

(Found)

Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Brian if he uses illicit drugs will indicate whether drug use puts him at risk for health complications.

Example Question:

Do you use illicit drugs? 

Finding:

Denies tobacco use

(Found)

Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Brian if he uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.

Example Question:

Do you use tobacco? 

Finding:

Reports moderate alcohol consumption

(Found)

Pro Tip: Chronic alcohol use can result in cardiomyopathy. Asking Brian whether he drinks alcohol will allow you to assess whether he has any indicators of alcoholism.

Example Question:

How much alcohol do you consume? 

Finding:

Followed up on alcohol consumption 

Finding:

Reports drinking only on weekends

(Found)

Pro Tip: Asking the patient to describe his drinking habits can identify indicators of alcoholism. It may also be helpful to ask about the context and reasons for the patient's alcohol intake. Heavy drinkers will often underestimate their drinking habits.

Example Question:

How frequently do you drink alcohol? 

Finding:

Reports drinking 2-4 alcoholic drinks per week

(Found)

Pro Tip: Consumption of alcohol can impact a patient's health and is considered a risk factor for many medical conditions. Asking Brian about his drinking habits will help you determine his risk for disease linked to alcohol consumption.

Example Question:

How many alcoholic drinks do you have in a week? 

Finding:

Reports 2-3 drinks in a single sitting

(Found)

Pro Tip: Asking the patient to quantify his drinking is helpful because it elicits objective data on a subject that patients may otherwise downplay.

Example Question:

How many alcoholic drinks do you consume at a time? 

Finding:

Asked about exercise 

Finding:

Denies having a regular exercise routine

(Found)

Pro Tip: Activity levels have an important impact on cardiovascular health. Asking Brian about his exercise patterns can help you understand how his lifestyle might affect his health.

Example Question:

What kind of exercise do you get? 

Finding:

Asked about most recent meal 

Finding:

Reports most recent meal was previous night at 8 p.m.

What is a typical lunch for you? 

Finding:

Reports typical dinner is grilled meat and vegetables

(Found)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical dinner will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.

Example Question:

What is a typical dinner for you? 

Finding:

Denies moderating salt intake

(Found)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Salt intake in particular can have a detrimental effect on blood pressure, which is why it is important to ask a patient like Brian, who suffers from hypertension, about his salt consumption.

Example Question:

Do you moderate your salt intake?

Review of Systems

Finding:

Asked about review of cardiovascular system 

Finding:

Denies palpitations

(Found)

Pro Tip: Discovering palpitations can be an important clue into the patient's cardiovascular history and current condition.

Example Question:

Do you have palpitations? 

Finding:

Denies swelling

(Found)

Pro Tip: Swelling can be a major indicator of cardiovascular and peripheral vascular health. Asking the patient about swelling is an important part of a thorough cardio exam.

Example Question:

Do you have any swelling? 

Finding:

Denies circulation problems

(Found)

Pro Tip: Circulation is an important indicator of peripheral vascular and cardiovascular health. Asking Brian about his circulation can help diagnose vascular conditions.

Example Question:

Do you have any problems with circulation? 

Finding:

Denies blood clots

(Found)

Pro Tip: Blood clots can be a sign of serious cardiovascular or related illnesses. Asking Brian about blood clots can provide valuable information about the state of his health.

Example Question:

Have you ever had a blood clot? 

Finding:

Denies easy bleeding

(Found)

Pro Tip: Bleeding can be a sign of serious cardiovascular or related illnesses. Asking Brian about bleeding can provide valuable information about the state of his cardiovascular health.

Example Question:

Have you noticed any unusual bleeding? 

Finding:

Denies easy bruising

Finding:

Denies sleep issues

(Found)

Pro Tip: Sleep issues can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Have you had problems sleeping? 

Finding:

Denies recent weight changes

(Found)

Pro Tip: Weight changes can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Has your weight changed? 

Finding:

Denies night sweats

(Found)

Pro Tip: Night sweats can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Do you have night sweats? 

Finding:

Denies dizziness or lightheadedness

(Found)

Pro Tip: Patients exhibiting dizziness may be at risk for several conditions as well as a fall risk. It is important to ask about dizziness to keep your patient safe.

Example Question:

Do you have dizziness? 

Finding:

Asked about review of respiratory system 

Finding:

Denies cough

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. A cough in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have a cough? 

Finding:

Denies shortness of breath while lying down

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. Orthopnea in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have difficulty breathing when lying down? 

Finding:

Denies blue skin

(Found)

Pro Tip: Cyanosis can be a symptom of troubling cardiovascular illness, though patients may not be aware of its connection to respiratory health. Asking Brian if he has noticed any cyanosis is important in ruling out certain cardiac risk factors.

Example Question:

Has your skin ever turned blue? 

Finding:

Asked about throat problems 

Finding:

Denies sore throat