Nursing
NSG 110 Case Study for Concept Map #6
Mr. D.A is a 74-year-old admitted to the hospital with a diagnosis of chest pain and congestive heart failure. He has a history of acute myocardial infarction, deep vein thrombosis, hypertension, diabetes mellitus, and arthritis. He reports “spasm-like” chest pain over his breastbone and difficulty “catching my breath.”
These are the findings you assess
· Chest pain rated 4 on a scale of 0-10. “It feels like my heart is clenching like a fist – I am not sure I can call it pain.”
· VS T 99.3, P 102 and regular, R 30, B/P 172/100, his oxygen saturation is 90% on room air.
· Lungs have fine crackles throughout all lung fields
· 4+ pitting edema in bilateral ankles and feet
· Hgt 72 inches, Wgt 231 lbs
Mr. D. A. is on several medications for his congestive heart failure. “I take them exactly as they are ordered.” He is also to follow a low sodium diabetic diet. When you ask him what he has been eating he says “I don’t have time to cook the foods the doctor wants me to eat. I try to follow the diet, but I can’t live without Popeye’s fried chicken and biscuits.”