Aim:
The overall aim of this rangeation is to present the care delivered to a patient during one nursing duty.
To demo a critical analysis of the care delivered to a critically ill patient.
Brief introduction to patient:
The patient I am going to present today is Mr. stump spud. (name changed for the purpose of this assignment)
Mr. potato is a 56 year old polish man with very poor English. Mr. potato was brought in by ambulance to the A&E department at 12.00 am on 28/1/2011.
Presenting Complaint:
Mr. Murphy has presented complaining of central suppression chest pain in the ass for the two hours prior to addition to A&E. Pain occurred while patient was on his way to the buns at his home. The pain was associated with sweating and shortness of breath. He did non suffer any loss of consciousness or vomiting. The pain radiated down his left arm and rated 7/10 on numerical pain rating scale. Upon arrival of the EMTs, the patient was prone(p) sub-lingual Nitrates which reduced the pain to 4/10. He was also given Aspirin 300mg and Plavix 300mg.
On arrival to A&E, the pain was 3/10 on numerical rating scale.
narrative:
chronicle taken from the patients son-in-law as Mr. Murphy himself is unable to speak English.
He has a past medical history of Ischaemic Heart Disease for past sevensome eld, had a Myocardial Infarction seven years agone in Poland and also suffers with Hypertension. It is not known on admission what regular medications he takes due to the language barrier.
Family History: Mr. Murphys father suffers with Ischaemic Heart Disease.
Social History: He is married but separated, lives with his daughter and son-in-law and cares for their children. He is a smoker of 15 cigarettes a day for 30 years and only drinks alcohol occasionally.
An ECG was recorded which showed the following:
venous sinus Arrhythmia rate 70bpm.
ST fragment elevation 2mm Lead II
ST segment elevation 3mm Lead III
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