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This document outlines the medical orders and care plan for a patient admitted to the ICU with chest pain, suspected myocardial infarction (MI). Immediate diagnostic evaluations such as EKG and CBC are ordered on a stat basis, along with an MRI of the thoracic cavity. IV fluids are to be administered at a rate of 120 gtts/hr. The patient will maintain bed rest with bathroom privileges, and dietary restrictions are lifted as tolerated. Essential medications, vital signs monitoring, assistance with activities of daily living (ADLs), and strict intake-output are also outlined.
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Admit pt to ICU. • Dx: Chest pain. R/O MI. • EKG, CBC stat. • MRI of thoracic cavity in a.m. by w/c • IV of NS at 120 gtts/hr. • BR c BRP only. • Diet: clliq ad lib
ASA 325 mg p.o. qd. • NTG 1 prn chest pain. • VS q2h x 24 hr; then q4h. • Assist c ADLs. • Strict I&O q8h. • Obtain wt stat and qd. • Mylanta 2 Tbsp.o. pc and at HS.