Health History
What childhood illness did the resident have?
What is: Chicken Pox and Measles
Career
What is: Diesel Locomotive Engineer
Primary assistive device for ambulation
What is: a 4-wheel walker
Type of heart attack experienced
What is: STEMI
Primary Nursing Diagnosis
What is: Chronic pain, related to previous musculoskeletal trauma secondary to a motor vehicle accident, as evidenced by the patient’s report of 6/10 aching pain, limited ROM of the right shoulder, and intermittent difficulty completing ADLs independently.
What major surgery did the resident have after his cardiac arrest?
What is: CABG (coronary artery bypass graft)
How long did a deer outsmart him?
What is: 2 years
Abnormal cardiac assessment
What is: mild pitting edema right lower leg
Cause of a STEMI
What is: A thrombus completely blocks a coronary artery
Acceptable pain goal
What is: 3/10 or less
Injuries he acquired from a motorcycle crash
What is: Shoulder break, humeral head fracture, and multiple rib fractures
Birth Place
What is: Fresno, California
Cognitive neuro assessment outcome
What is: A&OX4
What was he doing when the STEMI started?
What is: snow blowing and grabbing the mail
Non-Pharmacologic teaching for his pain
What is: Heat/cold therapy, repositioning, relaxation techniques, or deep breathing.
Reason for admission
What is: CABG from MI and Brain Injury
Who is his true family?
What is: AA Family
ADL's he struggles with and why
What is: dressing and bathing due to shoulder pain
2 pain responses are associated with chronic pain pathophysiology
What is: Allodynia and hyperalgesia
Encourage participation in what activities?
What is: PT and OT
How many times did he die?
What is: 4
Life Advice
What is: Treat people how you want to be treated.
How many medications does he take for his heart?
What is: 4
Type of Pain
What is: Chronic Pain
What exercises should he do for his shoulder?
What is: ROM and stretching