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Go through each order and explain why each was written.  Include the significance to Mr. G.’s diagnosis.  As you are analyzing the orders, draw conclusions related to the pathophysiology of the diagnosis keeping in mind the concepts of oxygenation, perfusion and circulation. For example, why is Mr. G. receiving 1000 ml normal saline @ 75ml/hr?  Think about Mr. G. with regard to his past, his present and his future, as well as risk factors.    CASE STUDY:  CORONARY ARTERY DISEASE Mr. Garcia is a 56 year old overweight financial analyst who arrives in the ER complaining of substernal chest pain radiating to his left arm.  He has had the pain for 3 hours and thought it was indigestion.  His wife insisted that he seek treatment, but he was resistant to coming to the ER.  Mr. G. has smoked 1 ½ packs of cigarettes/day for 30 years.  He has been on a mild diuretic (Hydrochlorothiazide) for the management of hypertension.  He states he had an elevated blood sugar during a recent employment physical; but has been too busy at work to see his primary physician.  His lipid profile shows a cholesterol level of 280, LDL 190, HDL 25.  His father died of an MI at age 60. He was diagnosed with depression and PTSD after serving in the military and deployment to the Middle East and is currently taking sertraline (Zoloft) 50 mg po daily.  He is being admitted with a diagnosis of Acute Coronary Syndrome, R/O Myocardial Infarction (MI). THE FOLLOWING ORDERS WERE WRITTEN ON ADMISSION: H&H, CBC, Chemistry profile, PTT, PT Cardiac enzymes (CK-MB, troponin) q8 hours x 3 Continuous cardiac monitoring 12 lead EKG upon admission and QD x 2 12 lead EKG with complaint of chest pain NTG gr 1/150 S.L. may be repeated after 5 minutes max 3 doses If pain is not relieved by NTG administer Morphine 2mg IVP, may repeat x 1 Lopressor (Metoprolol) 100 mg P.O. qd O2 via NC 2l/min to maintain SpO2 greater than 92% VS q 4h and PRN IV Normal Saline 1000ml @75cc/hr Daily weights 1800 calorie full liquid 2 Gm Na low cholesterol, no fat, no caffeine diet Bed rest with OOB to commode with assistance Aspirin 325 mg P.O. qd
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HEALTH SCIENCE
NURSING
NRB SURGICAL N

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