Medical Dx FSCC Clinical Tool: Medical Diagnosis

Student_________________ Clients Initials_______ Clinical Week_______

Pathology of Disease: Describe the pathology related to your patients medical diagnosis. Include textbook signs and symptoms

Coronary artery disease (CAD) is a broad term that includes stable angina pectoris and acute coronary syndromes. Coronary artery
disease affects the arteries that provide blood, oxygen, and nutrients to the myocardium. When blood flow through the coronary arteries is
partially or completely blocked, ischemia and infarction of the myocardium may result. It is responsible for more deaths in older adults
than any other disease. Coronary artery disease is called the silent killer because the disease develops slowly and silently for decades,
going unnoticed until it produces a myocardial infarction. Arterial narrowing within the coronary circulation are often the result of poor
lifestyle choices such as; smoking, stress, a diet rich in fatty foods, not exercising enough, but can also occur due to a familial disposition
to coronary heart disease, and diabetes mellitus. The disease tends to worsen as people age, affecting men more than women. A common
characteristic of CAD is hypertension, with blood pressure diastolic reading greater than 90mm Hg, and systolic readings greater than
140mm Hg. Other characteristics include: pain, burning, or pressure in the angina pectoris (occurring with exertion, emotion, exposure to
cold air, or eating too much at one time),often the pain may radiate to the upper extremities, shortness of breath (SOB), diaphoresis,
nausea, and vomiting.

Information acquired from: Medical-Surgical Nursing 5th Edition, Ignatavicius & Workman; Fundamentals of Nursing 6th Edition, Potter
and Perry; MayoClinic.com, http://www.mayoclinic.com/

Textbook Picture Client Presentation

Signs and Symptoms: Signs and Symptoms: The patient was recently admitted to the hospital with aortic
Hypertension, pain, burning, or pressure in atherosclerosis, and an ischemic heart. Had bypass surgery performed on Feb 25, 2006.
the angina pectoris (occurring with
exertion, emotion, exposure to cold air, or
eating too much at one time),often the pain
may radiate to the upper extremities,
shortness of breath (SOB), diaphoresis,
nausea, and vomiting.
Medical Management including medications, diagnostic tests & surgery:
The client is taking Lasix, Vasotec, Hytrin, and KCl was ordered on 3/9/06 for CAD. The
Medical Management including client also takes antilipidemics Zocor and Lopid to lower cholesterol. The client also takes
medications, diagnostic tests & surgery: bronchodilators Albuterol, Serevent, and Spiriva for breathing difficulties due to COPD. The
Treatment options include: client had a complete CBC, Blood gas workup, PT, INR, BUN, Creatinine, Na, K, Cl, Ca, on
Surgical approaches such as coronary 3/9/06. Client is currently having 3L of oxygen administered by nasal cannula to assist with
angioplasty, stent placement, atherectomy, breathing difficulties.
and coronary artery bypass surgery.
Medications that control hypertension,
lipid accumulation in arteries, beta
blockers, statins, nitrates.
Lifestyle management options include a Prognosis: Client is taking medications to reduce and maintain her diagnosis. The surgical
low-fat and low cholesterol diet, reduce salt wounds are healing without any signs of infection. Patient currently is having difficulties
intake, quit smoking, exercise with airway management, due to COPD, and refuses to give up smoking. The patient has
Diagnostic tests include: ECG, 24 hour vital signs monitored daily.
ECG monitoring (Holter),
Electrocardiography, Cardiac enzymes,
Chest x-ray, Blood gases, Potassium,
Serum lipids, Echocardiogram, Nuclear
imaging, MUGA, Cardiac catheterization
w/angiography

Prognosis: The client can reduce and

maintain the affects of CAD by eating a
healthier diet, quit smoking, reduce stress,
monitor blood pressure, exercising
sensibly, and taking medications
Nursing Care Nursing Care
Monitor clients blood pressure, pulse rate, Monitor clients blood pressure, pulse, respirations, O2 saturation, weigh client daily,
administer prescribed medications, teach administer prescribed medications, assess and change wound dressings, encourage patient to
patient to make healthier lifestyle choices eat a healthy diet, control pain, and maintain comfort. Encourage patient to quit smoking.
such as: quit smoking, exercise, stress
reduction, low-fat diet choices, low-
cholesterol diet choices, lower salt intake,
and to know the signs and symptoms of a
MI.

How does your client compare to what is considered usual medical/nursing interventions?

My client has been well cared for by the Thomas Hospital staff and physicians. The patients medications are administered as needed; the
VS are taken q4h; the patient is being kept comfortable with oxygen administration and pursed-lip breathing; the patient is still not eating
enough, and is being treated by a speech therapist to assist is mastication and swallowing.