Pt: Angus Angina
50 year old male, Scottish decent
BP 165/80, HR 85, R 18, SpO2- 99%, T 36.7
Skin is warm, dry, and well perfused. Cap refill < 2seconds. Undertones matching ethnicity and background.
No pain on palpation, no evidence of lumps, masses, pulsations, heaves, or lifts.
2 hour history of central chest pain. Onset with exercise, eases with rest. Sharp, intermittent, radiating across to left shoulder. Currently 6/10, 2/10 at rest.
Patient sitting up in bed. Awake and Alert x 3. Rubbing chest at times.
Carotid: R 2+ L 2+
No JVD noted supine or with HOB elevation.
No scars, lesion, moles to chest- anterior or posterior.
No family hx of cardiac disease. Presently on metoprolol for HTN, “forgets to take it”. Smoker- 10 cigs/day x 10 years, Scottish Background.
Apical pulse (PMI)- 5th ICS, MCL 2cm, 2+. Rate: 85bpm, matching radius at 85pm.
S1, S2. No S3, 4 or murmurs noted.
- Write a SOAP note using the information provided above.
| Section | Information |
| Subjective | 2-hour history of central chest pain. Onset with exercise, eases with rest. Sharp, intermittent, radiating across to left shoulder. Currently 6/10, 2/10 at rest.
No pain on palpation, no evidence of lumps, masses, pulsations, heaves, or lifts. Presently on metoprolol for HTN, “forgets to take it”. Smoker- 10 cigs/day x 10 years |
| Objective | BP 165/80, HR 85, R 18, SpO2- 99%, T 36.7
Skin is warm, dry, and well perfused. Awake and Alert x 3. Rubbing chest at times No scars, lesion, moles to chest- anterior or posterior |
| Assessment | Decreased Cardiac Output related to chest pain increasing with exercise as evidenced by HTN and rubbing chest at times.
|
| Plan | Monitor Patient activity levels.
Educate client on the importance of not smoking and encourage a healthy lifestyle. Monitor heart rate before and after any activity. Set reminder for medication administration of prescriptions Monitor vitals at least 3 times daily |
- Write one priority NANDA diagnosis. Please use the NANDA Diagnosis Definitions and Classification 2021-2023 (Twelfth Edition) to support the development of your NANDA statement.
Risk for impaired cardiovascular function as evidenced by 2-hour history of central chest pain. Sharp, intermittent, radiating across to left shoulder onset with exercise and easing with rest.