Case Study-Harry Tonka
Tank entered the emergency department with Midwestern chest pain, which started while he was playing basketball at the gym. Harry Tank is 42 years old and 5’10” tall, and weighs 205 pounds. He smokes one pack of cigarettes per day and works in a office. On admission, he complains of nausea but no vomiting and no depression.
His blood pressure is 175/92 mm Hag; his temperature is OFF, pulse is 127 beats per minute, and respiration rate Is 20 breaths per minute. He has a history of hypertension, which has been controlled with medication.
He states that he forgot o take his medicine today. Nursing Assessment Including Client Story An electrocardiogram has been performed, blood work has been drawn, and a monitor has been attached to the client. He is anxious and constantly asking if his heart monitor “looks all right”. A.
Assess Symptoms: * Millstream chest pain * Nausea (no vomiting or depression) Smokes (one pack a day) * Obese * High blood pressure * High temperature * High pulse rate * Hypertension (did not take controlled medication for today) B. Diagnose 1.
Possible nursing diagnoses: Chest pain: Fear * Acute pain * Perfusion * Nausea Anxiety: * Cardiovascular excitation Heart bonding * Increased blood pressure * Increased pulse * Fearful Nausea 2. Validated nursing diagnoses include: Anxiety * Anxious 3. AND label: A vague uneasy feeling of discomfort or dread accompanied by an autonomic response (ten source oaten nonspecific or unknown to ten Uninominal); a feeling of apprehension caused by anticipation of danger.
It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat. Related to (r/t) factors: * Smoking * Obesity 4.
NICE: Anxiety Reduction 5. NICE Activities: * Stop smoking * Lose weight 6. Nursing Interventions: * Have vital If irrational thoughts or fears are present, offer the client accurate information and encourage him or her to talk about the meaning of the events contributing to the anxiety * Intervene when possible to remove sources of anxiety * Explain all activities, procedures, and issues that involve the client; use medicinal terms and calm, slow speech.
Do this in advance of procedures when possible, and validate the client’s understanding.
* Teach the client/family the symptoms of anxiety. * Teach the client techniques to self-manage anxiety. * Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude.
