Posted: December 17th, 2022

Primary Diagnosis: Unstable Angina

Primary Diagnosis: Unstable Angina
Unstable angina is a type of chest pain that occurs when there is reduced blood flow to the heart muscle. It is often characterized by sudden onset, increased intensity, and longer duration compared to stable angina, which is a more predictable type of chest pain that occurs with exertion or stress. Unstable angina can be a sign of a more serious underlying condition, such as a heart attack, and requires immediate medical attention.

Symptoms of unstable angina may include:

Chest pain or discomfort that is more severe or lasts longer than stable angina
Chest pain that occurs at rest or with minimal exertion
Shortness of breath
Nausea
Sweating
Fatigue
Unstable angina is usually treated with medications to improve blood flow to the heart and to reduce the risk of future events, such as a heart attack. In some cases, surgery may be necessary to address underlying issues, such as blockages in the coronary arteries. It is important for individuals with unstable angina to work with their healthcare team to develop a treatment plan that is tailored to their specific needs.
Status/Condition: Guarded

Code Status: Full Code

Allergies: Not know allergies

Admit to Unit: Telemetry

Activity Level: Bathroom provileges

Diet: Cardiac diet

IVF (if ordered, include type and rate ): None

Critical Drips :
Heparin IV bolus 5000 units then 15 units/ kg /hr (max :1000 units/hr )

Respiratory: Nasal cannula to keep oxygenation above 94 %

Medications:
Aspirin 81 mg daily orally
Metoprolol 50 mg daily orally
Morphine 2 mg IV with intervals of 2 mg IV repeated at 15 min interval if chest pain

Nitroglycerin 0.4 mg sublingual every 5 minutes up to three tablets

Nursing Orders: Vital sings every 4 hours, bathroom privileges with Helpance, pain assessment every hours, call provider for any change in chest pain intensity , frequency and characteristic , bleeding precautions, pulse oximetry around constant.
Follow Up Lab tests: Serial troponin, BMP, CBC
Diagnostic testing : Ekg , CTA to r/p PE , ECHO doppler
Consults: Cardiologist consult
Patient Education and Health Promotion (address age-appropriate patient education if applicable): Cardiac diet , exercise, proper follow up with cardiology , use of cardiac medication

Discharge planning and required follow-up care: Cardiology

References (minimum of 3, timely references, that prove this plan follows current standard of care).

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