please help to write progress report for the patient in case study below. What is progress report of this patient
The patient, Junetta Cooper’s, the husband brought her to the emergency department this morning at 0815 because she was experiencing angina unrelieved by nitroglycerin. She has been evaluated in the emergency room, and she is now awaiting cardiac catheterization tomorrow to evaluate the extent of the coronary artery disease.
Mrs. Cooper is a 75-year-old African American woman who has had primary hypertension since age 55 years. Her blood pressure has been treated with antihypertensive drugs. She has a 1-year history of stable (exertional) angina pectoris secondary to CAD. Her pain has been successfully controlled with the nitroglycerin patch and sublingual nitroglycerin tablets.
When she arrived to the ED, vital signs were: BP 154/90 mmHg, HR 90/min, RR 14/min, and SpO2 96%. The first set of cardiac enzymes were negative, and she had no ECG changes indicating that she was not experiencing a myocardial infarction, but the angina pain persisted intermittently. The provider ordered treatment with sublingual nitroglycerin, morphine, and aspirin to relieve her immediate symptoms, and clopidogrel and fondaparinux as a safety precaution. She is not complaining of pain at this time. She took her daily meds for hypertension at home before coming here. The provider included her home meds in the orders, as she will need to continue on these while she is here. Oxygen is running at 1 L/min by nasal cannula and an IV with lactated Ringer’s and 5% dextrose is infusing at 100 mL/hr.
Mrs. Cooper’s vital signs are being continuously monitored and documented every hour, and she is due for pain and vital signs assessment per the provider’s orders. Get Nursing Help Today
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