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Care plan on chest pain?

Posted

I've had success in the past putting these care plans together but this one has got me by the tail? Any help?

56 yo female came into dr office with substernal chest discomfort & fatigue

EKG shows sinus brady @ 56 bpm with ST-T wave changes

Previous: hx of bicuspid aortic valve and LV systolic dysfunction, last measurement of aortic valve 1.2

Family hx: father passed away w/ MI and CAD

Assesment: cardiac enzyme negative, EF 35-40%, no CHF symptoms, heart had regular rate, rhythm,no murmur,rub or gallop; lungs were clear. Nurse gave in report that she had tricuspid valve enlargement. The only abnormal lab value was HDL at 83. She was scheduled for a catheterization but I wasn't able to see the outcome of it.

Pt stated she's under quite a bit of stress at work due to company downsizing number of people on staff thus putting more work on herself. In preparing for a company event planned for Sat PM, she explained she had tingling in her left arm most of the day Fri while moving,organizing items. Saturday was back and forth with tingling and sharp achey chest pains that only lasts for seconds. Sunday she was very fatigue. Mon-Wed she worked with tingling, chest pains and pain also presented btw shoulders. Dr appointment on Thurs sent her to ED for further evaluation.

NOW!! My questions are:

1. Can I do my care plan on chest pain?

2. There isn't a diagnosis of CHF, CAD or anything other than the chest pain?

3. Could I do it on the previous findings of bicuspid aortic valve and lv dysfunction or stenosis of the aortic valve? Wasn't sure if i

should do this bc it wasn't what she was admitted for this time?

Diagnosis:

I was thinking pain, anxiety and deficit knowledge?

Any help would be greatly appreciated? I've never been this lost before? Usually I have a diagnosis of a disease, not a symptom?:eek:

jrkingRN

Specializes in Cardiovascular/Thoracic Surgery Recovery. Has 5 years experience.

Hmmm... what WAS she admitted for? Angina is certainly a disease, and you CAN do a care plan on it, however if you KNOW she has a bicuspid aortic valve, perhaps you should do your care plan on that? Angina and fatigue are certainly side effects of Bicuspid Aortic Valve Disease. Here's a website...

http://www.heart-valve-surgery.com/bicuspid-aortic-valve-symptoms.php

She was admitted with chest pain and EKG changes? I've never been so frustrated as I am right now trying to figure this one out? I will def look into the website? Thanks for your help! I appreciate your feedback.:)

jrkingRN

Specializes in Cardiovascular/Thoracic Surgery Recovery. Has 5 years experience.

Ok so let's assume you're going to do your careplan on Angina (chest pain)

1.acute pain

2.ineffective tissue perfusion

3.activity intolerance

??? Any good?