50 year-old-male client comes to the emergency department via EMS complaining of shortness of breath at rest and on exertion, and left hand numbness.

10:15  Patient complains of constant chest pain 7/10, with pressure, at rest. States nothing relieves pain but moving does make it worse. Pain does not radiate.  Lung sounds = crackles at bases.  1+ pitting edema noted at bilateral ankles. Applied 2L Nasal Cannula, and administered 325 chewable aspirin and 0.4 SL Nitroglycerin. 

10:20 Patient reports pain remains 6-7/10.  Administered second dose of Nitroglycerin, per Physician order. 

10:25 Chest pain remain 6/10. 3rd dose Nitro 0.04mg SL administered. Physician at beside.

11:00 Patient complaining of Sharp constant chest pain 9/10. Stat ECG initiated. Morphine 2 mg IV push x1. 

11:05 Code Heart Initiated. Patient transferred to Cath Lab

12:00 After being stabilized receiving 2 coronary artery stents in the Cath Lab, the patient is recovered in the Cath Care Unit. The patient’s vitals are stable, his chest pain is resolved and a new ECG shows that the client’s myocardial infarction has resolved. The physician enters the recovery area and let’s the nurse know that the procedure was a little “difficult” when entering the Left Femoral artery.

10:00 50 year-old-male client comes to the emergency department via EMS complaining of shortness of breath at rest and on exertion, and left hand numbness. He also states that he has a dull squeezing chest pain, and epigastric pain. He cannot eat anything since last night’s dinner of spicy Korean food.  He has a history of high cholesterol, hypertension, heart failure, smokes cigarettes 1PPD x 8 years. Patient denies use of alcohol or illicit drugs. The patient cannot recall his meds as he lost his job 3 months ago and stopped refilling his prescriptions. He cannot remember what he takes, but supplied his Pharmacy’s Phone  number.

1030 ECG

1100 ECG

1045 Quick Admit Orders

• Admit Patient to Med Surg Unit
• Full Code

• Non-Monitored

• Cardiac Diet
• Vital Signs q4 hours
• EKG in AM/PRN Chest pain
• CBC in am
• BMP in am
• Cardiac Markers qday X 3
• Insert Foley Catheter
• Strict I&O
• Consult Cardiology: + Cardiac Markers