Coronary arteries disease and hypertension (History of illness (The…
Coronary arteries disease and hypertension
Discharge summary : patient admitted to the facility due to cardiovascular disorders and pain in the groined area because of bladder cancer, during the patient days in the rehab nursing home he has received physical therapy and treatment of pain management with the hope of returning back to patient normal baseline so that he can return home.
Discharge plan: upon patient discharging home the patient should be educated on the need to smoking cessation, exercising to try and lower cholesterols level, the patient and the caregiver/ family members needs also teaching about medication administration and pain management. Prior to discharge the patient may need a wheelchair and front wheel walker and also need to make a follow up appointment with oncology doctor to continue with her radiation therapy treatment.
History of illness
The patient had orchiectomy two months ago , radiation and chemo therapy treatment too and he is on pain medication aspirin, gabapentin and atorvastation
This patient life has been impacted negatively his dependence has been curtailed due to weakness to be able to ambulate plus the pain
Signs and symptoms manifested are high blood pressure, difficulty voiding due to bladder cancer
Patient stated that he experiences pain in the chest, and groined area and difficulty breathing
Nursing care plan
At any given time when I assessed the patients pain he will report to me as being 3 -6 out of scale of 10
The acute pain is probably related to chest pain and from cancer of bladder as evidence by patient reports pain around the groin area.
Short term goal patient reports pain management regiment achieved comfort function goal without adverse effects
Asses the need for exercise to low cholesterol level
Explain the importance of low fat and low carbohydrates diet to control cardiovascular disease
Long term goal patient able to ambulate without falling
Use of assistive devices ambulation such as gait belt, walker and wheelchair
Helping patient achieve mobility to be able to start walking
Goal not met patient needed more time with therapy and staff to increase mobility
Ambulation prevents more risks of cardiovascular disorders and Increased level of independence
Coronary arteries disease the wall of the blood vessels narrows down .
The risk factor that may have led to the diagnoses could be: smoking, poor diet full of saturated fats, lack of exercise
The stenosis , the damage of the heart muscles,
Chest pain ( angina),sleep apnea,diabetes,
The patient complained of chest pain
The secondary diagnoses is Cancer of the bladder
Signs and symptoms: pain in the groom area and problem with voiding
Pertinent data collection
Normal results for the other labs
The patient lab results shows high level of cholesterol
Donepezil twice a day
Nicotine patch applied one a day
Asprin the dose is 5-8mg every 6 hours