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N101L Care Plan - Nursing Care Plan Nursing Fundamentals (Nurs 100)

James Moore
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N101L Care Plan – Nursing Care Plan Nursing Fundamentals (Nurs 100) West Coast University

History of present illness:
Pt. admitted to ER with acute chest pain x 30 mins. Pt. was lifting weights
in his garage and began to feel pressure and burning in his chest that
radiates to his jaw, left shoulder, and neck. Pt. is diaphoretic and
experiencing SOB. Pt. states that he feels dizzy and nauseous. Pt. is
breathing rapidly and shallowly and tripoding. Pt. skin is pale, and cool to
the touch.

Family history:
Father had aortic aneurysm in 2018
Mother has type 2 diabetes, diagnosed 2011
Admission Diagnosis:
Client admitted to ER with acute chest pain, shortness of breath, and
difficulty breathing

oxygen saturation of 94% on
room air, and an oral temperature of 100.9 °F. Patient was wheeled from
personal vehicle to the ER via a wheelchair, is speaking in short, two to
three word phrases. Clients skin is cool and diaphoretic with signs of
pallor. Client states that the pain in his chest is 8/10. Client has equal
bilateral breath sounds; heart sounds are present and bounding.

Symptoms: Client is complaining of acute chest pain that radiates to his
jaw, neck, and left arm. He states that he feels. Like his “chest is burning.”
Client is having difficulty breathing and is feeling nauseous and dizzy.
plant does not normally have any issues with ADLs, and was engaging in
physical activity at the onset of incident.

Chest X-Ray- assess for pneumonia or heart failure, which could
be the reason behind the chest pain (Banasik & Copstead, 2019).
MRI and CT- used to evaluate levels of coronary plaque,
determine their stability, and evaluate CAD risk and/or
progression (Banasik & Copstead, 2019).

Registered Dietician:
A registered dietitian is a specialist on food and nutrition who can
translate this information into practical solutions for healthy
living. They utilize their expertise to aid and positive lifestyle
changes working in community hospitals, public schools, public
health care clinics, nursing homes, fitness centers, universities, or

Administer pain
medications and
continue to
monitor vitals.


N101L Care Plan - Nursing Care Plan Nursing Fundamentals (Nurs 100)

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