Primary Diagnosis: Unstable Angina
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 assistance, 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).