Mr Antonio has been readmitted to the ward following an episode of chest pain last evening. He was assessed in the ED and pathology review indicated elevated Troponin levels. He has been diagnosed with a non-ST-elevation Myocardial Infarction (NSTEMI). He has been accepted for transfer to a tertiary facility and an Angiogram has been scheduled within 24 hours. He has been transferred from ED to the cardiology ward while awaiting ambulance transfer. He requires serial Troponin levels and ECGs. Any chest pain must be reported.
His past history includes asthma and COPD, and his medications include:
Fluticasone Accuhaler 500mcg twice daily,Salbutamol MDI 2 puffs twice daily and up to puffs PRN during acute exacerbations of his COPDIpratroprium Bromide MDI 2 puffs 4 times daily and up to 4 puffs during acute exacerbations of his COPD.
Antonio has a documented allergy to Penicillin
It is the morning shift, and you are just entering the room post-handover to introduce yourself. You notice that Mr Antonio appears uncomfortable. You ask how he is, and he reports he has developed some chest pain following a walk to the toilet.
Image retrieved from Life In The Fast Lane (2023)
His vital signs now are as follows.
HR = 46BP = 86/45RR = 18T = 36.0SaO2 = 93%
In your allocated group develop your written plan of care for AT1A addressing the first 5 steps of the Clinical Reasoning Cycle.
For AT1B please initiate comprehensive assessment of your patient, and implement the plan of care that you formulated for AT1A, applying the final three steps of the clinical reasoning cycle. Your management for this patient must include the following:
Systematic assessment of AntonioProvide appropriate and prioritised nursing care: including administration of medication.Problem solving abilities incorporating clinical reasoning skills.Effective teamwork: each person allocated a designated role/s.Display effective communication between team members.Display therapeutic communication with Antonio.Accurate documentation