NSG 323 Module 2 Discussion

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Robeson Community College *

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323

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Health Science

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Feb 20, 2024

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docx

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NSG 323 Module 2 Discussion Taylor Ralston Evidence-Based Assessment Think of a time in your nursing practice in which assessment was key in determining a course of action to improve the health of your patient. This could be basic care you provided on your unit, an emergent situation with a patient, or health promotion and disease prevention. Use information from your readings, your experiences, and outside references as needed to answer the discussion questions. Please write out a SOAP note or ISBAR based on this patient and the problem you addressed. See Module 1 for review of SOAP notes & Handoff presentation. Without identifying your patient (HIPPA), list the subjective and objective data that was of importance. Note how you used diagnostic reasoning and the nursing process to guide problem- solving for your patient. How did you identify immediate priorities for this specific patient? How was evidence-based practice incorporated into your care? Make sure that you list specific information based on your experience rather than a general overview of these topics. A 58-year-old American Indian female presented to the Emergency Department for Chest Pain with sudden onset 1 hour prior to arrival . Subjective: Patient reports “I feel like something is sitting on my chest, when the pain comes on, I feel like I cannot breathe. My pain is a 10/10.” When nurse asked patient had any medications been took prior to arrival patient states “My daughter gave me a baby aspirin and nitroglycerin, but it has not helped.” Objective: Upon attaching patient to continuous cardiac monitoring patients heart rate was 140bpm, elevated blood pressure (systolic 210). Patient attached to EKG machine and showed continuous ST elevation on multiple leads, and critical reading of “STEMI” on strip. Elevated troponin 1,896. Assessment: Acute Pain related to myocardial ischemia as evidence by ST elevations, elevated troponin and elevated HR and BP Plan: Patient will be given STEMI protocol medications (Brilinta, Heparin and Aspirin) and then sent to cardiac catheterization to improve cardiac output and tissue perfusion. Patient will then be sent to PCCU for post-surgical monitoring of cardiac catheterization. Patient will have decreased pain level of 7/10 within 2 hours of cardiac catheterization. Patient reports medical history of diabetes and hypertension, stated she is complaint with home medication, but her blood pressure had not been under control the past couple of days. Prolonged hypertension and hyperglycemia can lead to cardiac ischemia due to inability of blood to flow properly. This can cause an increased risk of having a heart attack. It is important that healthcare
professionals reinforce the importance of keeping diabetes and blood pressure under certain parameters to maintain a healthy life.
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