La Consolacion University Philippines

Malolos City, Bulacan

CASE PRESENTATION
BSN 3
Manco, Elijah A
Valencia, Warren A.
Sebastian, Ren Leobert
CASE INTRODUCTION
- Good day, We “BSN 3” presents our case
for today, Patient X, 64 years old male, was
admitted in LCUP General Hospital with a
chief complaint of chest pain, upon taking
the health history, the patient is
hypertensive, a heavy smoker, an
occasional alcoholic drinker, and her father
died due to cardiac arrest. Vital signs were
obtained upon admission which is
presented below.
OBJECTIVES
 The Patient will be able to demonstrate
relaxation and comfort.
 The patient will be free from pain.

 The patient’s VS will return to its normal

range
 The patients activity tolerance will be back
to its normal routine.
 Assessment Diagnosis Planning Intervention Evaluation

Subjective: Acute chest After 8 hours Assess for vital Patient was advised
signs and
pain related of nursing for ICU admission
symptoms of pain
The patient to interventions such as facial for continuing of
reports of having
decreased and health grimacing, rubbing care
chest pain, Chest
myocardial teachings of neck or jaw
heaviness
reluctance to move
radiating to blood flow. the patient increase blood
shoulders. will: pressure, and
tachycardia.
Objective :  Remain Note the onset,
free from location, and
- Cold and clammy
skin pain. pattern of pain.

- Diaphoretic Oxygen Therapy

 Maintain
- Clear breath stable Pain management
sounds
vital (Morphine)
- Conscious signs.
- Blood pressure:m
Bronchodilator
170/100 mmhg  Maintain (nitroglycerine
- Heart rate :110 relax )
bpm body
- Respiratory rate: posture. Cardiac
CONCLUSION
 Pain is highly subjective. What your patient says about the
pain he is experiencing is the best indicator of that pain. If
you are caring for a patient who is in pain, it’s important
that you know the skills to assess and manage his
discomfort properly. As for Patient X, The nursing care was
successfully demonstrated and performed, with the help of
some medication, the patient’s pain was reduced or eased.
A patient who’s suffering from chest pain needs urgent
attention!!
THANKYOU AND
GODBLESS US
ALL