SH Brian Foster chest pain .docx - Document Nursing Notes...

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Document: Nursing Notes Model Documentation Mr. Foster is post-op day 3 for a TURP (Transurethral resection of the prostate). He is complaining of chest pain that began 5 minutes ago. He rates his pain at 6/10. He reports the pain is localized to the sub-sternal region and describes it as “squeezing pressure.” He reports the pain is constant and increasing in severity. He denies radiation but reports some pressure in the left shoulder as well. He reports the pain was accompanied by nausea at the onset, but denies emesis. The patient reports becoming increasingly anxious. He denies SOB and palpitations. He denies tenderness, redness, or changes in surgical site. • General Survey: Alert, but uncomfortable appearing middle-aged male supine in hospital bed, pale and mildly diaphoretic. Elevated respiratory rate and evident distress. • Cardiovascular: No JVD, HR between 100- 115, S1 & S2, + S4. No murmur, no rub. Occasional PVCs appreciated. BP range 92-109/57-68. No carotid bruit or thrill. • Peripheral Vascular: Capillary refill <3 seconds on bilateral fingers and toes, radial pulses 2+, posterior tibial and dorsalis pedis pulses +1. No lower extremity edema. No varicosities, no areas of focal induration or erythema. • Respiratory: Respirations quiet and unlabored, able to speak in full sentences. Lungs CTA. 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. No ST segment elevation.
Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Finding: Established chief complaint Finding: Reports chest pain (Found) Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source. Example Question: Do you have chest pain? History of Presenting Illness
Finding: Asked about onset and duration of chest pain Finding: Reports chest pain started about five minutes ago (Found) Pro Tip: Establishing the onset of a patient's chest pain is essential in diagnosing its severity as well as the comfort of the patient. Example Question: When did the chest pain start? Finding: Reports chest pain has been constant since it began (Available) Pro Tip: Knowing the duration of a patient's pain gives you a more complete picture of its severity and potential impact on the patient's health. Example Question: How long does the chest pain last? Finding: Reports sitting in bed when pain began (Found) Pro Tip: A patient's position and posture when their pain began can inform you as to the nature of the pain, as pain upon exertion often has different causes than pain upon resting.

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