...NURSING PROCESS PAPER Student Name: Date of Care: 10/14/09 Date of Admission: 10/10/09 I. HEALTH STATUS | Admitting Dx: COPD Exac/Chest Pain | Pt. Init.D.R | Rm No.353 | Age60 | SexM | RaceCaucasion | ReligionCatholic | OccupationDisabled | Surgery: Medical Treatment: Back Surgery/ Coronary Artery Bypass Grafting COPD Exac/Chest Pain | Chief Complaint/Reason for Hospitalization & Hx. of Present Illness (with 1-8 critical characteristics, Jarvis pg. 85) Chest Pain | | 1.Location: Midsternal chest pain radiating to left arm. 2. Quality/characteristics: Squeezing, tightening, felt like chest was going to explode. 3. Quantity: 8 on a scale from 1-10 4. Setting: at rest 5. Associative factors: SOB and nausea 6. Aggravating/relieving factors: Aggravated by activity, unable to relieve in any position 7. Timing (Onset, duration, frequency): Sudden and constant pain 8. Patient perception: Thought he was having a heart attack. | Other illness or conditions & year of onset. | | AllergiesNKA | COPD- 2004 Deep Vein Thrombosis -2002Anxiety-2000Depression-1998Lumbar/Cervical Spondylosis-1982HTN- 19XX-Patient cannot recall exact year | | Immediate Teaching Needs | | Hospital safety- Reminded patient to call for assistance, call light within reach, non skid footwear for reduction of falls. Talked with patient regarding fall safety. Teach non-pharmachological...
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