Case Study-Harry Tonka (Chest Pain)
Harry Tonka entered the emergency department with midsternal chest pain, which started while he was playing basketball at the gym. Harry Tonka 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 diaphoresis. His blood pressure is 175/92 mm Hg; his temperature is 99ºF, 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 to 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”.
* Midsternal chest pain * Nausea (no vomiting or diaphoresis) * Smokes (one pack a day) * Obese * High blood pressure * High temperature * High pulse rate * Hypertension (did not take controlled medication for today) * Anxious
B. Diagnose 1. Possible nursing diagnoses:
Chest pain: * Fear * Acute pain * Perfusion * Nausea Anxiety: * Cardiovascular excitation * Heart ponding * Increased blood pressure * Increased pulse * Fearful * Nausea
2. Validated nursing diagnoses include:
3. NANDA label: A vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); 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. The complete nursing diagnostic statement is:
Anxiety r/t smoking and obesity