18 Dec Primary Diagnosis: Unstable Angina

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).