Carandang, Lance Gabriel A.

BSN 3-2

Dylan Bronks, 75-year-old male, rushed into the Emergency Department due to indigestion-
related chest pain. After dinner, at around 9pm, Mr. Bronks suddenly felt an intense sharp pain
from his stomach radiating towards his chest. His wife along with their son, drove him to the
nearest hospital and rushed to the ER. Upon assessment, Mr. Bronks looked pale and diaphoretic,
verbalized shortness of breath. Vital signs of Mr. Bronks are RR = 27, O2 Saturation = 95, HR =
91, BP = 135/75. When asked to rate the pain from 1 to 10, Mr. Bronks pointed out 7. Mr.
Bronks also verbalized that he was a smoker for 55 years and has a history of heart failure with
no current maintenance.

Vital Signs
Temp = 36.5
RR = 27
O2 Sat = 95
HR = 91
BP = 135/75
Pain = 7/10

Chief Complaint
Indigestion-related chest pains

Patient History
History of Past Illness
• History of Heart failure
• Episodes of chest pains
• Smoker for 55 years; smoked 1 pack per month.
History of Present Illness
• Patient was rushed to ER with indigestion related chest pain.
Family History
• Mother has arrhythmia.

Nursing Care Plan

Assessment Nursing Planning Intervention Evaluation

Diagnosis
Objective: Acute pain Relief of Acute Administer Verbalized
Temp = 36.5 related to Pain within an oxygen. relief of Pain
RR = 27 blockage to hour. witin an hour.
O2 Sat = 95 artery as Administer
HR = 91 evidenced by medication as Verbalized
BP = 135/75 chest pains. Within 2 days prescribed by the condition has
Pain = 7/10 of nursing care, doctor (Morphine, stabilized as
patient nitroglycerin, etc.) evidenced by
 verbalizes that normal blood
condition has Promote patient to pressure, heart
been stabilize as have adequate bed rate and
Subjective: evidenced by rest and have the breathing.
Complains normal blood head of the bed
about pressure, heart elevated.
indigestion pain rate and
radiated to the breathing. Monitor patient for
chest. blood pressure,
respiration rate,
Guarding reports of chest
position from pains.
stomach to
heart. Provide health
teaching regarding
chest pains.

Assessment Nursing Planning Intervention Evaluation

Diagnosis
Objective: Ineffective Relief of Administer Verbalized
Temp = 36.5 breathing ineffective oxygen. breathing
RR = 27 pattern related breathing pattern returned
O2 Sat = 95 to acute pain as pattern Administer to normal and
HR = 91 evidenced by medication as respiration
BP = 135/75 chest pains. prescribed by the within normal
Pain = 7/10 Within 2 days doctor. limits.
of nursing care,
patient Promote patient to Verbalized
verbalizes that have adequate bed condition has
condition has rest and have the stabilized as
Subjective: been stabilize as head of the bed evidenced by
Complains evidenced by elevated or place normal blood
about normal blood pressure, heart
indigestion pain pressure, heart Perform back rate and
radiated to the rate and rubbing or back breathing.
chest. breathing. tapping.

Guarding Monitor patient for

position from blood pressure,
stomach to respiration rate,
heart. reports of chest
pains.

Provide health
teaching regarding
chest pains.
Pathophysiology
The intense impediment of one or different enormous epicardial coronary supply routes for
beyond what 20 to 40 minutes can prompt intense myocardial localized necrosis. The
impediment is normally thrombotic and because of the crack of a plaque framed in the coronary
conduits. The impediment prompts an absence of oxygen in the myocardium, which brings about
sarcolemmal disturbance and myofibril unwinding. One of the first ultrastructural changes that
occur during MI are these changes, which are followed by mitochondrial alterations. Myocardial
tissue eventually experiences liquefactive necrosis as a result of the prolonged ischemia. The
corruption spreads from sub-endocardium to sub-epicardium. The subepicardium is accepted to
have expanded security course, which defers its passing. The cardiac function is compromised in
different ways depending on the area affected by the infarction. The infected area heals by scar
formation because the myocardium has little capacity for regeneration. Frequently, the heart is
remodeled with dilation, segmental hypertrophy of the remaining viable tissue, and cardiac
dysfunction.

Medication:
MONATASS
➢ Morphine
➢ Oxygen
➢ Nitroglycerin
➢ Aspirin
➢ Thrombolytics
➢ Anti-coagulants
➢ Sedatives
➢ Stool Softeners

Laboratory Examinations:
➢ Cardiac Troponin I
➢ Chest X Rays
➢ MRI Scans
➢ CBC Tests
➢ Electrocardiogram
➢ Echocardiogram