Patient: John Smith, 65-jähriger männlich
Diagnose: Akuter Myokardinfarkt (STEMI/NSTEMI per EKG/troponin)
Aufnahme: Gestern via EMS für 30-min substernalen Brustdruck radiating to left arm/jaw, with diaphoresis, dyspnea, nausea, vomiting.
Past Medical History
- Hypertension, hypercholesterolemia, type 2 diabetes
- Former smoker (quit 5 years ago)
Social History
- Married, two adult children; retired postal worker
- Enjoys fishing, golf, family time
Home Medications
- Metoprolol succinate 50 mg daily
- Lisinopril 20 mg daily
- Simvastatin 40 mg nightly
Nursing Assessment (Current Shift)
- Position: Semi-Fowler's; alert, oriented ×3
- Vitals: BP 140/90, HR 80, RR 18, T 98.6°F, SpO₂ 94% RA
- Skin: Warm, dry, pale; mucous membranes moist
- Cardiac: Regular rate/rhythm; no murmurs, gallops, rubs
- Pulmonary: Clear bilaterally
- Abdomen: Soft, non-distended, non-tender
- Extremities: Warm, no edema, pulses 2+
Nursing Diagnoses (NANDA-I)
- Risk for Decreased Cardiac Output r/t impaired contractility, reduced coronary perfusion
- Activity Intolerance r/t imbalance between oxygen supply/demand
- Ineffective Airway Clearance r/t fatigue, retained secretions
- Deficient Knowledge r/t new diagnosis, treatment regimen, lifestyle modifications
Interventions
- Continuous ECG monitoring; q15min vitals ×1h, q30min ×2h, q1h ×4h, then q4h
- O₂ via nasal cannula to maintain SpO₂ >94%
- Cough/deep breathe q2h; incentive spirometry q1h awake
- Suction PRN; HOB ≥30°
- Assist ADLs; progressive ambulation per cardiac rehab protocol
- Education: medication purpose/side effects, low-sodium/DASH diet, activity progression, smoking abstinence, warning symptoms (CP, SOB, diaphoresis), follow-up plan
Expected Outcomes
- Hemodynamic stability; no signs of heart failure or arrhythmia
- Tolerates progressive activity without ischemic symptoms
- Maintains patent airway, clear breath sounds
- Verbalizes understanding of disease, meds, lifestyle changes, emergency plan
