Brief Background: 58 yo housewife admitted to CCU at 2115 tonight for severe anemia and STEMI symptoms.

Assessment Problem Goals Actions Evaluation Statement Observations: Evidence of Continuous Thin, anxious Impaired tissue myocardial cardiac monitoring Blood woman with oxygenation ischemia (EKG V/S q4h and prn infused, pulse stitched laceration (brain, heart) changes and Continue down to 92 rd on over occiput. RT Troponins) will transfusion of 3 and Slept in th Holding tightly Decreased trend toward 4 unit of blood snatches, no to husbands hand, oxygen carrying normal w/in 24 complete by 0600 sustained sleep. episodically weepy capacity of hours. Institute pad 2 heavily Denies any blood (anemia) Pt. will be able count. soaked pads old chest pain. States AEB to rise from bed, BSC tonight, and fresher she just feels Myocardial walk to bathroom OOB w/2 assist blood. exhausted. ischemia and back w/out tomorrow. No c/o dizzy
Vital signs:

T 97.8, P 112, R 24, BP 110/80, %sat 99 on 2 L/min.

Examination:

Loss of consciousness

dizziness w/in 24 hours

accommodation for husband tonight. Group nursing care tonight.

Roll-out bed

getting up to BSC

Breath sounds clear

 Normal S1,S2, no JVD, no peripheral edema, Impaired sense cap refill 3 sec., of situational 2+ pulses. safety Normal bowel RT sounds, no c/o pain. Dx of ACS Neurochecks: And M.A.E., PEERL, Helplessness AAOx4, and fear of Wearing procedural pain menstrual pad with moderate drainage
Labs:

Heme: After first unit Hgb 6.7, Hct 19.5, WBC 8400, Platelets 180,000 Troponins: 0.09 ng/ml in ER, 0.11 upon admission to CCU. 0300 after 3 units

Patient will spend 10 minutes in the AM planning days goals/schedule with nurse. Will read ratings on-line of gynecologist and chose one to see. Will speak to Case Manager about procedures for which her insurance will pay.

Give patient schedule for meals, tests, likely rounding times of MDs and medications Assist patient to write down questions to ask Womens Health APN re: 1. endometrial bx with analgesia & sedation 2. D&C with general anesthesia 3. Endometrial oblation procedures 4. Treatment with progesterone 5. Hysterectomy

Coordinated visits from friends around todays schedule Smiling, mood improved Pt. and husband wrote & saved list of questions on her I-pad. I didnt know I had so many options. No one ever told me.

of blood 0.12
Interview:

Patient states she knew she was anemic but hoped bleeding would stop Tearful. I didnt know what else to do. I just cant go through that biopsy again. Now Ive had a heart attack.