Could it be a heart attack or Pneumonia?

Nurses General Nursing

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Patient M. Dean is a 53 years old male with a DX of CVA with Left sided weakness who came to the ER to be evaluated for chest pain, and respiratory discomfort which started two days ago, but suddenly escalated .... RR. 9 irregular and guarded, HR. 130 and regular, BP. 180/90, Oral Temp. 101 degrees (F) He also denies injury related to accident, however he thinks that he may be having a heart attack. How do we proceed to evaluate this patient, and what possible diagnosis medical,as well as nursing diagnosis would be made?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

We are happy to help...is this for school?

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Specializes in Emergency Room, Trauma ICU.

Is this for a school assignment?

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Specializes in Complex pedi to LTC/SA & now a manager.
Patient M. Dean is a 53 years old male with a DX of CVA with Left sided weakness who came to the ER to be evaluated for chest pain, and respiratory discomfort which started two days ago, but suddenly escalated .... RR. 9 irregular and guarded, HR. 130 and regular, BP. 180/90, Oral Temp. 101 degrees (F) He also denies injury related to accident, however he thinks that he may be having a heart attack. How do we proceed to evaluate this patient, and what possible diagnosis medical,as well as nursing diagnosis would be made?

So how do YOU think you evaluate?

What do YOU think the anticipated medical diagnosis will be?

Based on your assessment what do you think the potential nursing diagnosis will be?

We will help & guide you but you need to tell us what you think.

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Specializes in critical care.

Isis, do you have any thoughts about where to start with this patient?

His medical history - how could the CVA be relevant here?

His vitals - What might a dropping RR but increasing pulse and BP tell you? Might his temp have anything to do with that?

What is the absolute most acute need right this very second? What is the very first thing you need to do to determine if that need is an actual need? What tools will you use?

What has to be assessed immediately (and how?), and what can wait until that is done?

Nursing diagnoses are going to be about what this patient NEEDS. Clear your brain of medical diagnoses for a second. Look at what is going on with this patient. What does he NEED? If you step back to look at the big picture in your background, you will see his needs.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Are you sure the respiratory rate is 9 (nine) with a temp, tachycardia, difficulty breathing/chest pain, and HTN?

but suddenly escalated …. RR. 9 irregular and guarded, HR. 130 and regular, BP. 180/90, Oral Temp. 101 degrees (F)
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How long ago was the CVA (Permissive HTN)? What did the MRI say location and occlusion wise? Hemorrhagic or ischemic? CT w and w/o contrast? TPA used? or IR?

LOC? 9 resp is odd unless we are talking herniation from hemorrhagic bleed=dead soon. Cushing's triad..

Lung sounds?

Other pertinent hx?

Too many variable for a DDX with this scant info.

Serial cardiac enzymes, BMP, coags, redo CT (head and neck as well as ABD ), chest xray, ABGs maybe. Permissive HTN based off of previous CVA or drop BP by 10% at the most (monitor MAP).

NO NITRO for CP in lieu of recent CVA....

I don't see where pneumonia fits in here but BC x2, lactic acid (doubtful sepsis though) or sputum cultures if need be....empiric ABX

Go from there

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Good thing this isn't a live patient.....OP seems to be on hiatus! :)

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Specializes in Oncology.

What's the o2 sat? ABG? With a RR of 9 and guarded I would really be thinking this patient might need intubation.

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Proceed with ABG's and please treat that hypercapnia/hypoxemia accordingly.

Nursing diagnosis is: Ineffective breathing patterns I am embarassed to say.

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What's his O2 sat showing? What does his chest rise look like? Does he have retractions? Does he look panicked? How is is color, cap refill, and temperature of hands and feet? Is he fully oriented?

As far as medical diagnosis (PNA vs heart attack), that's not my job as a nurse. I can guess, but my main job in the meantime is to support the patient and call the doc. You can make your nursing diagnosis as given above and elaborate on it further when the medical diagnosis is made.

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What's his O2 sat showing? What does his chest rise look like? Does he have retractions? Does he look panicked? How is is color, cap refill, and temperature of hands and feet? Is he fully oriented?

As far as medical diagnosis (PNA vs heart attack), that's not my job as a nurse. I can guess, but my main job in the meantime is to support the patient and call the doc. You can make your nursing diagnosis as given above and elaborate on it further when the medical diagnosis is made.

Doesn't mean you can't take a stab at it...he asked for med diagnosis as well. I completely ignored the nursing diagnosis in mine I vowed to never use them again when I left school.

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