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Source:

Nursing2015

September 2010, Volume 40 Number 9 , p 72 - 72

Author

  • Rhonda Lawes MS, RN, CNE

Abstract

COMPLAINING OF SEVERE midsternal discomfort that started about 2 hours ago, Leigh Manning, 43, arrives at your ED. She rates her discomfort as 8 or 9 on a pain intensity rating scale of 0 (no pain) to 10 (worst pain imaginable). She says that she also feels extremely tired and short of breath. You take her vital signs: tympanic temperature, 99.4° F; heart rate, 103; respirations, 28; BP, 160/90; and SpO<SB>2</SB>, 92% on room air. She's alert and oriented; her skin is pale and slightly cool and moist. Her heart sounds are normal and her lungs are clear. She has normal active bowel sounds, and peripheral pulses are 2+/0–3+.You administer supplemental oxygen via nasal cannula, establish vascular access, and attach her to a cardiac monitor. You obtain a stat 12-lead ECG and establish external electronic fetal monitoring. You also obtain blood specimens for lab work, including cardiac biomarkers, a complete blood cell count, chemistry panel, and coagulation

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