What are the priority nursing diagnoses

Reference no: EM133509744

CASE STUDY: MYOCARDIAL INFARCTION (MI)

Patient Profile

H.C., a 47-year-old Navajo woman, who was brought to the emergency department by ambulance with a burning sensation in her epigastric area extending into her sternum 6 hours prior to arrival.

Subjective Data

Per H.C., she states that she has had chest pain with activity that is relieved with rest for the past 3 months. H.C. has a history of type 2 diabetes mellitus since she was age 35. She has a smoking history of one pack a day for 27 years. H.C. has no regular exercise program. H.C. states that she has been reluctant to get medical therapy because it will interfere with her life.

Objective Data

Glasgow Coma Scale (GCS) score: 15
Height/Weight:
5'4"
80.4 kg
Vital signs:
Temp 97.9°F, HR 96 bpm, RR 19, BP 148/95, SpO2 92%
Other laboratory tests:
Na - 135 mEq/L
K - 3.9 mEq/L
Cl - 104 mEq/L
CO2 - 24 mEq/L
BUN - 21 mg/dL
Creat - 0.7 mg/dL
Ca - 8.3 mg/dL
Glucose - 210 mg/dL
Mg - 2.4 mg/dL
WBC - 7.6 103/μL
Hgb - 12.6 g/dL
Hct - 32.7%
Plt - 120 k/μL
12-Lead Electrocardiogram:
Sinus rhythm with ST elevation in lead V1, V2, V3, and V4
Left hand 20 gauge IV
Appears anxious, clutching fist
Discussion Questions

Using a separate sheet of paper, answer the following questions:

What are H.C.'s risk factors for CAD and MI?
What nursing actions should be taken for H.C.'s discomfort?
What do the specific ECG changes indicate?
What is the nurse's role in this critical situation?
Priority Decision: What is the first priority in C.S.'s care?
Identify medications to be ordered for H.C. and the purpose and side-effects of each.
Identify other possible medical interventions that are to be done for H.C.

Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

Priority Decision: What are the priority nursing measures that should be instituted to help H.C. decrease her risk factors?

Reference no: EM133509744

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