Fdar Cabg 3nesurgical

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In Partial Fulfillment of the Requirements of

NCM 112 MEDSURGE

CASE SCENARIO:

CONCEPT MAP OF MYOCARDIAL INFARCTION

Submitted to

Mrs. Rodesa Shaira Balagot Cornito RN, LPT, MAN

Clinical Instructor

Submitted by

Dirige, Megan Raphaela Gupalor, Liv Julia

Fabre, Edgie Jeric Gustilo, Dara Lorraine

Galgo, Jane Antonette Leonero, Janne Gayle

Gantalao, Maegan Pearl Leuterio, John Wilford

Gicaraya, Tristan Matthew Mantilla, Alexi Nicole

Gonzales, Mary Margareth Monje, Ira

Grabato, Kristine Marie


October 1, 2020

NURSE’S NOTES 1
DATE/ TIME FOCUS DATA, ACTION, and RESPONSE
09/30/2020 Acute pain related to D:“Pwede unya na nang mga
5:00 pm Surgical Incision pangutana? sakit jud kaayo akong
dughan tungod kay gi opera ko” as
verbalized by the patient.
-Facial grimacing and guarding is
observed.
-Patient was easily irritated and
snapped when asked about his pain
scale.
-Increase in Blood pressure and
respiratory rate.
-Shortness of breath is observed.
A:Administered pain-relieving
medication specifically Aspirin as per
doctor’s order.
-Monitored patient’s vital signs which
can be affected due to pain.
-Provided patient teaching regarding
pain control measures such as deep
breathing, music and relaxation
therapy and positive thinking.
R:Patient was able to report diminished
pain and stated that from a pain rating
scale of 7 out of 10 it has now reduced
to 5 out of 1.
-Vital signs are within normal range
-Patient is feeling more relaxed and no
longer shows facial grimacing and
guarding behavior.

Alexi Nicole C. Mantilla, XUSN3

NURSE’S NOTES 2
DATE/ TIME FOCUS DATA, ACTION, and RESPONSE
09/30/2020 Decreased cardiac D: “ luya man kaayo akong ginabati,
5:00 pm output related to tapos
alteration in heart Murag lisod bitaw iginhawa”
rate -variations in the blood pressure and
heart rate were noted.
-abnormal heart sounds and cyanosis
were observed.
A: Administered Losartan 25 mg OD for
high blood pressure and Trimetazidine 35
mg BID for Patient’s angina.
-Monitored blood pressure, heart rhythm,
rate and sound every 4 hours.
-Provided patient teaching on how to
prevent and control high blood pressure
such as compliance to medications and
having a potassium-rich food diet.
-Encouraged patient to rest.
R: Blood pressure was within normal range
-Patient verbalized that he was well
rested and demonstrated increased
tolerance to activities with no discomfort
observed.

Alexi Nicole C. Mantilla, XUSN3

NURSE’S NOTES 3
DATE/ TIME FOCUS DATA, ACTION, and RESPONSE
09/30/2020 Anxiety related to D: “Gaka-balaka jud ko og maayo pako
5:00 pm situational crises as aning akong sakit labi nag tiguwang
evidenced by nako... gadugang rajud kos problema
helplessness
sakoang pamilya” as verbalized by the
patient.
-the patient looks weak and helpless. A
-provided reassurance and comfort
measures.
-Maintained calmness during approach
to the client.
-Remained with the client at all times
when levels of anxiety are high (severe
or panic); reassure client of his or her
safety and security.
-Moved the client to a quiet area with
minimal stimuli
-Encouraged the client’s
participation in relaxation exercises
such as deep breathing, progressive
muscle relaxation, guided imagery
or meditation.
R: -patient was able to discuss his
feelings of dread, anxiety and fear.
-Patient was able to verbalized his
understanding in relaxation exercises.
-Patient was able to respond to
relaxation techniques with a decreased
anxiety level.

Jane Antonette R. Galgo, XUSN3

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