Care Planning help: Dx: R/O MI

NurseLady78 · Jun 30, 2011

I need some help with prioritizing 2-3 nursing dx including 1 short term and 1 long term goal for each dx.

I am an LPN that has been working in Pre-op for years and I haven't done a care plan in years, my job is pretty routine and even when complication occur we act not write about it, lol.

I was given this scenario in school so there was no actual assestment done and I have no additional information, please help with any suggestions. We were told we will be doing a teaching plann which I can work on his smoking cessation and nutrition status. We also were told we cannot use a 'knowledge defecit' as a dx on this care plan.

I remember that the dx should be prioritized, and to use "related to" as "as evidenced by" and site where the rationale came from but I am havign a real difficult time getting started, PLEASe help!!!

Scenario:

Time is 1900 hrs. You are working in a small, rural hospital. It has been snowing heavy all day, and the medical helicopters at the large regional hospital medical center, 4 hrs away by car (in good weather), have been grounded until morning. The roads are barely passable. "W.R.", is a 48 yr old male, works construction w/ a 36 pack a year smoking history, is admitted to your floor with a diagnosis of Rule out myocardial infarction (R/O MI). He has significant male pattern obesity ("beer belly", large waist circumference) and barrel chest, and he reports a dietary history of hight fat food. His wife brought him to the ER after he complained of unrelieved "indegestion". His admission vitals were 202/124, PR 96, RR 18 and Temp 98.2 F. W.R. was put on oxygen by nasal cannula titrated to maintain Sao2 over 90%, and an IV of nitroglycerin was started in the ER. He was also given aspirin 325mg and admitted to Dr A's service. There are plans to transfer him by helicopter to the regional medical center for cardiac catheterization in the morning when the weather clears. Meanwhile you have to deal with the limited labratory and pharmacy resources. The minute W.R. comes through the door of your unit, he announces he's just fine in a loud and angry voice and demands a cigarette.

So looking forward to some help, it is much appreciated:)))

-NurseLady78