Nursing Process Paper for a Patient with NSTEMI (Non-ST Elevated Myocardial Infarction)

Nursing Process Paper for a Patient
with NSTEMI (Non-ST Elevated Myocardial Infarction)
Case Presentation
* Medical Diagnoses
On November 29, 2017, I cared for the patient, PJM at Stanford. The patient is a 50-year-old male complaining to the ED about chest pains associated with a headache and SOB around 2:30 the same day.
The diagnosis revealed a case of Non-ST Elevated Myocardial Infarction (NSTEMI). It is a type of heart attack which is commonly presented with a sudden chest pain. Patients with NSTEMI may experience varying symptoms such as varying degrees of coronary flow reduction which may or may not have complete coronary occlusion and thrombotic material embolization with coronary spasm. Some may case may also occur where in place of coronary thrombosis, myocardial necrosis takes place, especially when there is a history of a stable but diffuse severe coronary disease and other medical conditions that cause an increase in myocardial demand (de Winter & Tijssen, 2012; Planer, et.al., 2014; Ahmed, 2015).
* Past Medical History
PJM has a history of hyperlipidemia, like his father, and hypertension. His father also has a history of heart disease. He has no known allergies, no history of cocaine use, never smoked, any known diabetes case, nor MI or CAD. He has traveled recently but notes no medical problems encountered nor surgery. He is currently injecting 5 mg of metoprolol tartrate, applying nitroglycerin ointment 2% topically, and ingesting 0.4 mg tablet of nitroglycerin SL as part of facility-administered medications. Along with the mentioned medicines, PJM is also on 134 mg capsule of fenofibrate micronized which is taken every morning before breakfast, 50 mg of losartan with daily intake, and 1000-unit tablet of vitamin D taken daily.
* Chief Complaint/Date
Patient PJM complained of chest pains which are associated with shortness of breath (SOB) and mild headache. The claims that the pain is like pressure applied to the center of the chest with a severity rate of 6 out of 10. When touched, the pain does not worsen but it initially extended up to the neck region. An accompanying headache has been dealt with but there is no prior medication. Based on his accounts, he has never had chest pains prior and has never tried any medications prior to the complaint date either.
The patient does not report any experience of nausea, vomiting, numbness or tingling in the extremities, swelling of the leg, hemoptysis, diaphoresis or any radiation exposure to the back during the pain.
* Lab Report(s)
The patient was subjected to several clinical procedures: PT/APTT [419982635], APTT [4199826356], Troponin I [419982620], GFR [419982625], Comprehensive Metabolic Panel [419982619], D-Dimer [419982621], and Complete Blood Count with differential [419982618]. The procedures for Troponin I, Comprehensive Metabolic Panel, and CBC with differential gave abnormal readings.
Specific readings and details for each procedure can be seen on the supporting data in Figure 1, found in the Figures and Tables portion.
* Relevant Data
The patient is married but doesn’t have any children. He is 5’7” tall and weighs 1-03.4 kg with a BMI reading of 36.02 kg/m2. He drinks occasionally but has no known record of drug abuse of any recent sexual activity. Based on his physical exam results, he appears to be physically well and no signs of distress. His eyes, ears, nose and throat check reveal no inflammation or anything that may hint other medical problems. The pain he claims to radiate towards his neck does not show any relevant physical marks in the neck area. There is no respiratory problem upon checking and his cardiovascular rate is normal. The chest area has no physical signs of tenderness or crepitus and the abdominal region has no problems as well. The extremities are normal with no signs of cyanosis or edema, nor tenderness. His skin is warm and dry and has no signs of rashes. The neuro test presents that patient PJM is alert with no problems with speaking, no signs of facial drooping, and have no problems moving all his limbs.
Nursing Process
* Assessment
* What did you observe?
The patient doesn’t show any physical signs of distress which can attribute to the chest pain nor any signs that the pain can be cardiac in nature. There is also known the history of surgery in the chest region that can be a probable cause of the pain may be due to overexertion. However, the patient does have a history of hyperlipidemia, a genetic disorder which causes elevated lipid levels to circulate in the blood (Davis, 2017), which he most probably inherited from his father.
Having hyperlipidemia can increase a person’s risk of developing heart disease (Davis, 2017). The patient’s weight may also be a contributing factor to the spread of his hyperlipidemia.
* What did you glean from the chart?
Upon inspection, the patient’s chest pain doesn’t seem to be cardiac in nature as reflected by his history and risk factors. The pain is not related to PE either as his oxygen saturations are wnl and the PERC reading is zero. Hence, there is no need for further lab test on blood clotting. He also doesn’t haven’t had aortic dissection that could have caused the pain when overexerted since there is no pain radiating towards the back region, the x-ray shows normal mediastinum, the pulses are all normal in the extremities, and there are no neurological problems. There is also no sign that may lead the chest pain to be related to any lung disease since test results show that the patient’s lungs are clear.
* What was information from report most useful?
The pat...