DAY 1

Patient’s Name: MR. X Age: 61

Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 24, 2020 CHEST PAIN Ĉ Restlessness, Rapid-breathing, Self-focused
4:00 P.M. Ĉ Uncooperative @ times
Acute pain related to Ĉ Vital signs recorded as ff.:
tissue ischemia BP: 140/100 mmHg
RR: 25 bpm
CR: 140 bpm
TEMP: 37°C
02 SAT: 90%

 Admit to medical ward

 Secure consent for admission
 DIET: NPO temporarily
 IVF: Plain NSSTL @20gtts/min

Meds:
 Morphine SO4 4mg IV stat/ then PRN for
severe chest pain
 Metoprolol 50 mg/tab 1tab BID
 Aspirin 300mg/tab stat then 100mg /tab OD
 Transderm patch 5mg on ACW OD ĉ 8°
nitrates free
 O2 inhalation via cannula @4-5 cpm
 CBR 5BRP, moderate high back rest
 For close watch. Hook to cardiac monitor
 Refer.

After 5 days of confinement, the patient

demonstrates a relief of pain as evidenced by
stable vital signs, absence of muscle tension and
restlessness.
DAY 2
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 25, 2020 CHEST PAIN Ĉ Restlessness, Rapid-breathing, Self-focused
6:00 A.M. Ĉ Uncooperative @ times
Ĉ Vital signs recorded as ff.:
Activity intolerance BP: 130/100 mmHg
related to imbalance RR: 25 bpm
between myocardial CR: 140 bpm
oxygen supply and TEMP: 37°C
demand. 02 SAT: 90%

 Soft diet
 Furosemide 40mg IV stat then 20mg IV BID
 Clexane 0.4cc pre-syringe BID
 Lanoxin 0.25mg IV push stat
 Lidocaine 50mg IV push stat
 For close watch

At the end of five days confinement the patients

demonstrate measurable/progressive increased in
tolerance for activity with heart rate/rhythm and
BP within patient’s normal limits.
DAY 3
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 26, 2020 CHEST PAIN Ĉ Restlessness, Rapid-breathing, Self-focused
6:00 A.M. Ĉ Uncooperative @ times
Decreased cardiac Ĉ Vital signs recorded as ff.:
output related to the  BP: 130/90 mmHg
disease process of  RR: 25 bpm
coronary artery disease  CR: 140 bpm
(CAD)  TEMP: 37°C
 02 SAT: 90%

 Continue meds
 May sit on bed
 Soft diet
 Repeat Na+ K+ det.

At the end of five days confinement the patients

demonstrate measurable/progressive increased in
tolerance for activity with heart rate/rhythm and
BP within patient’s normal limits.
DAY 4
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 27, 2020 CHEST PAIN Ĉ Rapid-breathing, Self-focused; noted
6:00 A.M. Ĉ Cooperative @ times
Acute pain related to Ĉ Vital signs recorded as ff.:
decreased myocardial blood  BP: 120/80 mmHg
flow as evidenced by pain  RR: 20 bpm
score of 10 out of 10.  CR: 120 bpm
 TEMP: 37°C
 02 SAT: 90%

 KCl 20meg to incorporate in 1liter pf Palin NSS

@20gtts/min
 NaCl tab 1tab BID
 Continue other meds.

The patient demonstrates relief of pain as evidenced by a

pain score of lower than 3 out of 10.

DAY 5
Patient’s Name: MR. X Age: 61
Address: LARAP, JOSE PANGANIBAN, CAMARINES NORTE
DATE / TIME FOCUS DATA, ACTION, RESPONSE
JUNE 28, 2020 CHEST PAIN Ĉ Normal-breathing; noted
6:00 A.M. Ĉ Cooperative @ all times
Decreased cardiac output Ĉ Vital signs recorded as ff.:
related to the disease  BP: 120/80 mmHg
process of coronary artery  RR: 20 bpm
disease (CAD)  CR: 100 bpm
 TEMP: 37°C
 02 SAT: 90%

 Continue meds
 May dangling feet
 Atorvastatin 40mg OD H.S.