Journal 5

G.L. is a 66 -year old male, who has been admitted the Cardiac floor for chest pain after a severe
car accident. G.L. stated today that he was having shortness of breath and also chest pain. After
doing a 10 minute assessment on Mr. G.L., I noted that his right foot was cold and had weak
pulse and his left foot was warm to touch. In addition, Mr. G.L. has difficulty swallowing after
his car accident.
Other information I need to know, is an image of his chest to see what may be causing the chest
pain and labs such troponin level to see any heart muscle damage. I would notify a cardiologist
to inform him or her on the findings and to order these labs and exams. Patients such as G.L can
be suffering from a pulmonary embolism due to the fact that his right foot was cold, and a clot
could have formed and traveled to the lungs. This usually happens to patients who are bed ridden
or immobile such as Mr.G.L. himself. This condition is serious and life threatening because it
can interfere with oxygenation and clots can travel to the brain and cause a stroke.
The reason for a collection of lab works and a CT of the chest, is so that we as health care
providers can rule out conditions and to prevent severe problem. I know this is the best decision
because we will be able to quickly treat the problem before it gets worse. I can ask other staff
members such as the lab techs to draw blood and also inform the cardiologist about assessment
notes and request a CT scan. According to WebMD, it is noted that doctors will do tests to rule
out any problems that may be similar to pulmonary embolism.
I know I made the right decision, because the CT scan showed PE bilaterally in the lungs. Now
the doctor has order Lovenox, which is a blood thinner to help with the blood clot. Assessing and
noticing the difference in the lower extremities is what I did well.