Brian Foster Documentation- Brian Foster- Shadow Health Focused Exam Chest pain Results Brian Foster is a 58-year-old man experiencing a change of status. Students determine the seriousness of his complaint and take a relevant health history. Students perform a focused cardiovascular exa m, explore...
Focused Exam: Chest Pain Results | Turned In
Clinical Nursing I - Spring 2021, NUR 121 1 Return to Assignment (/assignments/423158/)
Documentation / Electronic Health Record
Document: Nursing Notes
Student Documentation Model Documentation
Subjective
(No Documentation Made)Mr. Foster is post-op day 3 for a TURP (T ransurethral resection o
prostate). He is complaining of chest pain that began 5 minutes a
He rates his pain at 6/10. He reports the pain is localized to the s
sternal region and describes it as “squeezing pressure.” He repo
the pain is constant and increasing in severity . He denies radiatio
but reports some pressure in the left shoulder as well. He reports
pain was accompanied by nausea at the onset, but denies emes
The patient reports becoming increasingly anxious. He denies SO
and palpitations. He denies tenderness, redness, or changes in
surgical site.
Objective
Palpated PMI: displaced laterally , less than 3cm, brisk and tapping. Palpated tibial arteries: No thrill, 1+ bilaterally . Palpated dorsalis pedis: No thrill, 1+ bilaterally . Heart Sounds: S1, S2, and S4 audible, gallops. Lungs: Breath sounds present in all areas, no adventitious sounds
heard, all areas clear . EKG: Irregular with no ST elevation. • General Survey: Alert, but uncomfortable appearing middle-age
male supine in hospital bed and mildly diaphoretic. Elevated
respiratory rate and evident distress. • Cardiovascular: No JVD, HR between 100-1 15, S1 & S2, + S4. murmur , no rub. Occasional PVCs appreciated. BP range 92-109
68. No carotid bruit or thrill. • Peripheral V ascular: Capillary refill <3 seconds on bilateral finge
and toes, radial pulses 2+, posterior tibial and dorsalis pedis puls
+1. No lower extremity edema. No varicosities, no areas of focal
induration or erythema. • Respiratory: Respirations quiet and unlabored, able to speak in
sentences. Lungs CT A. RR 24-26/m, O2 saturation 97-99%. • Neuro: Alert and oriented x3, follows commands, moves all
extremities. • Skin: Diaphoresis. No pallor , redness, induration, or purulence
noted. • EKG (interpretation): Sinus tachycardia with occasional PVCs. ST segment elevation.Your Results Reopen (/assignment_attempts/9498365/reopen Lab Pass (/assignment_attempts/9498365/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Care PlanDocument: V itals Document: Nursing Notes
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