iHuman Management Plan Template for NURS 6550 and NURS 6560
Primary Diagnosis: Acute Pericarditis due to PCIS (Dressler’s Syndrome)
Status/Condition: (Critical, Guarded, Stable, etc.) Stable
Code Status: Full Code
Allergies: Bactrim
Admit to Unit: Step Down Cardiac
Activity Level: Ambulatory
Diet: Low sodium
IVF (if ordered, include type and rate ): NS 0.9% 125ml/hr
Critical Drips (If ordered, include type and rate. Do not defer to ICU Protocol):
Respiratory: 0xygen 2L Nasal Cannula until O2 sat is above 95% on room air.
Medications: (Zhan, Nikus, Birnbaum, 2020).
1. Aspirin 750mg PO q 6-8hrs daily
2. Colchicine 0.5mg PO daily
3. clopidogrel 75mg PO daily – HOLD
4. atorvastatin 80mg PO daily at bedtime
5. lisinopril 2.5mg PO daily
6. carvedilol 3.125mg PO daily at bedtime
7. pantoprazole 40mg PO daily
Nursing Orders: vital signs, skin care, toileting, ambulation etc.
Follow Up Lab tests : CBC, ESR, all cardiac markers
Diagnostic testing (CXR, US, 2D Echo, etc…) Include indication for test, for example CXR to evaluate
pneumonia): (Nomoto et al., 2021).
1. 12 Lead ECG – rhythm abnormalities/irregularities
2. Troponin T (cTnT) – cardiac marker
3. Echocardiogram – pericardial effusion/tamponade
4. CBC – baseline levels
5. CK-MB – cardiac marker
6. Troponin I (cTnl) – cardiac marker
7. ESR – inflammation
8. Chest X-ray PA and Lateral – pericardial effusion/tamponade
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Consults: follow up with cardiologist outpatient
Patient Education and Health Promotion (address age appropriate patient education if applicable):
Educate the patient on the diagnosis of pericarditis and that it was due to her recent MI. Also educate
her on the possibility of a reoccurrence and how important it is to stay on her strict medication regimen
as prescribed (Ceylan, 2016). Educate the patient on the continual importance of her smoking cessation
and her risk factors of HTN, DM2, and hyperlipidemia.
Discharge planning and required follow-up care: Keep the patient overnight for observation due to
recent MI, recheck levels tomorrow, and follow up with cardiologist in 1 week if the symptoms do not
decrease. If symptoms continue to decrease, follow up in 2 weeks.
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References
Erkan Ceylan. (2016). Dressler Syndrome. Journal of Clinical and Analytical Medicine, 6(155), 718–723.
https://doi-org.ezp.waldenulibrary.org/10.4328/JCAM.3939
Nomoto, F., Suzuki, S., Hashizume, N., Kanzaki, Y., Maruyama, T., Kozuka, A., Saigusa, T., Ebisawa, S.,
Okada, A., Motoki, H., Yahikozawa, K., & Kuwahara, K. (2021). A case of Dressler’s syndrome successfully
treated with colchicine and acetaminophen. Journal of Cardiology Cases, 23(3), 131–135.
Zhan, Z.-Q., Nikus, K., & Birnbaum, Y. (2020). PR depression with multilead ST elevation and ST
depression in aVR by left circumflex artery occlusion: How to differentiate from acute pericarditis. Annals
of Noninvasive Electrocardiology : The Official Journal of the International Society for Holter and
Noninvasive Electrocardiology, Inc, 25(6), e12752. https://doiorg.ezp.waldenulibrary.org/10.1111/anec.12752