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correct me if im wrong

We are assigned as ER nurses.

Pt came in due to chest pain (9/10) ,positioning pt at supine position aggrevates the pain as reported by the SO. Pt also is nauseated. PT's vital signs are bp 150/100 t=37.5 RR=28 and P=68. (pulse is weak). ECG was taken but it really shows that pt really has a heart problem by just seeing the pqrst pattern. Our clinical instructor told us that pt is at risk for MI although there is no physical exam results yet.

My problem is: Hypertension

Diagnosis is : Risk for decreased cardiac output related to increased vascular resistance.

(are these properly stated?) (I think i should not use "secondary to" since there is no actual diagnosis yet( results)

pharmgirl

Specializes in ER, ICU, Medsurg.

I am a complete novice at this since only started school 2 weeks ago. So, I'm going to ask a question continued on yours if you don't mind so I can learn too. Maybe if we're lucky Daytonite will chime in..LOL. At the end of " increased vascular resistance" should there be "as manifested by" or "evidenced by"????

Another question, if BP is 150/100 is that not considered hypertension? or still "risk of" ?

150/100 is already considered as hypertension. normal blood pressure is 120/80 for adults. In fact based on what i have observed , the patient already exprienced blurring of vision which is one of the signs of hypertension. And for the diagnosis, you can use secondary to in order to have complete diagnosis and as evidenced to in order to prove your diagnosis. BUT CORRECT ME IF IM WRONG. Im still very slow at making nursing diagnosis.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

pt came in due to chest pain (9/10) ,positioning pt at supine position aggrevates the pain as reported by the so. pt also is nauseated. pt's vital signs are bp 150/100 t=37.5 rr=28 and p=68. (pulse is weak). ecg was taken but it really shows that pt really has a heart problem by just seeing the pqrst pattern. our clinical instructor told us that pt is at risk for mi although there is no physical exam results yet.

assessment
: chest pain (9/10), supine positioning aggravates the pain, nausea, b/p 150/100, t 37.5c (99.5f) rr-28, weak pulse of 68, pqrst on ecg shows a heart problem.

in looking up the signs and symptoms of an mi you discover this:

  • extreme anxiety and restlessness

  • substernal pain or pressure

  • feeling of impending doom

  • fatigue

  • nausea

  • vomiting

  • low grade fever

  • dyspnea

  • diaphoresis

  • tachycardia

  • hypertension

  • bradycardia and hypotension when the inferior wall of the heart has infarcted

  • s3 and s4 sounds

  • sudden death

determination of the patient's problem(s):
based on the symptoms the patient has and information about mis, this man is most likely having an mi. while chest pain is not always a present with mis, any complaint of chest pain is
always
presumed to be of cardiac origin until proven otherwise. in ccu parlance
the 3-ps of a heart attack are pain, puking and perspiration
and this man has pain and nausea (the next best thing to vomiting). with the hypertension (150/100 is classified as mild hypertension) and the scenario telling you the ekg is showing a heart problem there is definitely something going wrong with this man's heart physiologically--this is not a risk--it is a real problem
right now
.

problem:
chest pain

diagnosis:
acute pain r/t deficient blood supply to cardiac tissues aeb patient's report of chest pain of 9 on a scale of 0 to 10 and report that turning supine aggravates the pain.

problem:
altered heart function

diagnosis:
decreased cardiac output r/t altered rhythm aeb ekg changes and weak pulse of 68.

problem:
anxiety

diagnosis:
anxiety r/t unknown danger aeb hypertension (b/p 150/100), increased respirations (rr-28) and nausea.

Thanks Daytonite that makes a lot of sense. I also wanted to ask about the RR=28, that is abnormally high right? Of course that could be related to insufficient cardiac output, but I was just curious because I didn't see anyone mention it.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

I also wanted to ask about the RR=28, that is abnormally high right? Of course that could be related to insufficient cardiac output, but I was just curious because I didn't see anyone mention it.

It is slightly high. With Decreased Cardiac Output you are looking for signs and symptoms of electrical failure in the heart (arrhythmias). congestive failure, or heart ischemia. You really are looking more for dyspnea, orthopnea and/or shortness of breath and that was not mentioned by deanikins211. I thought it safer to go with it being a symptom of Anxiety. However, symptoms can always worsen as a condition deteriorates. If respirations become labored then they become symptomatic of Decreased Cardiac Output as the heart goes under stress.

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