Nursing case study

Nursing case study

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Case studies are employed in the medical field to teach students and nurses. Case studies are supposed to stimulate the thinking of the trainee without significantly increasing their workload. A case study may serve several purposes since it covers all aspects of clinical practice. It is a good way to determine the decision-making ability of the student. Good case studies should be informative. This paper shall focus on one medical case about myocardial infarction. The patient is a 57-year old male who presented to the emergency department with a chest problem. The patient is quickly assessed to determine the problem. The history is taken. The patient’s name is Chris. Chris states that pain began about half an hour after dinner while he was playing with his kids. Chris describes the pain as a crushing pressure that is located midsternally and radiates to his left arm and to the back. When asked to rate the pain on the scale, he gives it a 4/10. The patient reports that he is finding it difficult to breath (SOB). On assessment, the patient is diaphoretic and pale. The doctor suspects myocardial infarction but recommends further check-ups to rule out angina, heart failure, and other lying conditions.

The tests are performed by a nurse. There are several tests that are conducted such as heart sounds, vital signs, lung sounds, pulse, signs of edema, and skin condition. MI happens when blood flow to a segment of the myocardium ceases or decreases. It results in necrosis of the heart. MI is a common presentation of CAD. About 13% of the world population died from ischemic heart disease in 2016. Most of these deaths occur in developed countries (Thygesen et al., 2019). The disease is common among wealthy people who tend to do less physical exercises. Tissue death occurs due to ischemia when the section of the heart does not receive oxygen and nutrients. Troponin is a specific marker of MI useful in diagnosis. Troponin rises within three hours of a tissue injury peaking in 1-2 days. The electrocardiogram is a useful standard procedure in the diagnosis of MI. The ECG is used by clinicians to differentiate between the two types of MI. The two types are ST-elevation MI and non-ST elevation MI. STEMIs form the least prevalent of the three types. The STEMI occurs in 25-40% of MI patients. The current guidelines have categorized myocardial infarction into five types (Reed, Rossi & Cannon, 2017).

The most predominant source of MI is atherosclerosis. Atherosclerosis occurs when a plaque on a coronary artery ruptures, leading to clot formation which further blocks the artery. Myocardial infarction proceeds in minutes. MI may also arise when the heart has limited blood supply as a result of increased oxygen demand by the rest of the body (Anderson & Morrow, 2017). Conditions such as hyperthyroidism, anemia, coronary artery spasms, and PCI failure predispose the person to MI. The risk factors for MI include the following: old age, active smoking, hypertension, diabetes mellitus, and total cholesterol. Several of these risks factors are shared with CAD. The other causes include low physical activity, past family history of MI, obesity, and alcohol consumption. Men are more predisposed to MI than women.

The patient reported that his father had died of CAD and that his aunt was currently on treatment for diabetes mellitus. Chris is a rare visitor to the hospital. Chris reports that he underwent a medical checkup the previous year, where the doctor recommended that he start doing physical activity. Chris had a high BMI, high LDL, and high total cholesterol. He says that he has not been following the doctor’s recommendations because he does not get time. As part of the empirical therapy, Chris was put on oxygen. His medical check-up report came back and the following were observed. There was no jugular vein distention. Chris had normal S1 and S2 sounds, the lungs were clear with scattered wheezes on auscultations. The vital signs also came and were as follows: the BP was 140/91, SpO2 90%, HR 93bpm, regular Ht 174cm, RR 33bpm, 110kg, and the temp was 37.0 C. Chris’s 12-lead EKG report reads as follows: “a regular sinus rhythm with repeated PVCs and three to four-beat runs of ventricular tachycardia”. ST-segment elevation in leads 1, aVL, and V2 through V6. The cardiac function tests were done but the results are yet to be available. The chest x-ray was also ordered. The doctor prescribes Aspirin 324mg PO, nitroglycerin 0.4 mg SL q5min TDS, morphine 4mg IVP when needed for the chest pain, and Oxygen to maintain the SpO2 above 92%. Statins were recommended but were to be used after discharge (Anderson & Morrow, 2017).

As the nurse in charge, it is important to immediately put this patient on oxygen therapy. Oxygen improves oxygenation and decreases myocardial oxygen demands. When the medications are availed, put the patient on nitroglycerin and aspirin. Nitroglycerin is a potent coronary vasodilator that increases blood flow to the heart muscle. However, the medication may be ineffective for MI patients and this may prompt substitution. Aspirin serves as an anticoagulant and thus decreases mortality (Anderson & Morrow, 2017).

The nurse needs to monitor the patient. Mr. Chris was still in pain after the three doses of sublingual NTG and the nurse put him on morphine 5mg and baby aspirin. However, the pain was still persistent and required further interventions. The cardiac enzymes were as follows: CK 255U/L, CK-MB 10%, troponin I 3.5ng/mL. The nurse reports to the physician who recommends a PCI. The PCI helps to relieve blockage (Reed, Rossi & Cannon, 2017). Four hours after the PCI, Mr, Chris states that he does not feel any chest pain. His vital signs have also improved. The nurse needs to advise the patient to change their lifestyle. The nurse should set targets with the patient. Advice the patient on the diet, the importance of exercise, and reduce caffeine intake. Advice the patient of the importance of compliance. The patient should seek medical attention when symptoms exacerbate.

References

Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of Medicine, 376(21), 2053-2064.

Reed, G. W., Rossi, J. E., & Cannon, C. P. (2017). Acute myocardial infarction. The Lancet, 389(10065), 197-210.

Thygesen, K., Alpert, J. S., Jaffe, A. S., Chaitman, B. R., Bax, J. J., Morrow, D. A., … & Bucciarelli-Ducci, C. (2019). Fourth universal definition of myocardial infarction (2018). European heart journal, 40(3), 237-269.

Nursing Case Study Case Studies in Nursing

Nursing Case Study Case Studies in Nursing

QUESTION 1

  1. CC: “I have been having terrible chest and arm pain for the past 2 hours and I think I am having a heart attack.”

HPI: Mr. Hammond is a 57-year-old African American male who presents to the Emergency Department with a chief complaint of chest pain that radiates down his left arm. He states that he started having pain several hours ago and says the pain “it feels like an elephant is sitting on my chest”. He rates the pain as 8/10. Nothing has made the pain better or worse. He denies any previous episode of chest pain. Denies nausea, dyspnea, or lightheadedness. He was given 0.4 mg nitroglycerine tablet sublingual x 1 which decreased, but not stopped the pain.

Lipid panel reveals Total Cholesterol 324 mg/dl, high density lipoprotein (HDL) 31 mg/dl, Low Density Lipoprotein (LDL) 122 mg/dl, Triglycerides 402 mg/dl, Very Low-Density Lipoprotein (VLDL) 54 mg/dl

His diagnosis is an acute inferior wall myocardial infarction.

1 of 2 Questions:

Why is HDL considered the “good” cholesterol?

2 of 2 Questions:

Explain the role inflammation has in the development of atherosclerosis.

QUESTION 3

  1. A 45-year-old woman with a history of systemic lupus erythematosus (SLE) presents to the Emergency Room (ER) with complaints of sharp retrosternal chest pain that worsens with deep breathing or lying down. She reports a 3-day history of low-grade fever, listlessness and says she feels like she had the flu. Physical exam reveals tachycardia and a pleural friction rub. She was diagnosed with acute pericarditis.

Question:

What does the Advanced Practice Registered Nurse (APRN) recognize as the result of the pleural friction rub?

QUESTION 4

  1. A 15-year-old adolescent male comes to the clinic with his parents with a chief complaint of fever, nausea, vomiting, poorly localized abdominal pain, arthralgias, and “swollen lymph nodes”. States he has felt “lousy” for a couple weeks. The fevers have been as high as 102 F. His parents thought he had the flu and took him to an Urgent Care Center. He was given Tamiflu® and sent home. He says the Tamiflu didn’t seem to work. States had a slight sore throat a couple weeks ago and attributed it to the flu. Physical exam revealed thin young man who appears to be uncomfortable but not acutely ill. Posterior pharynx reddened and tonsils 3+ without exudate. + anterior and posterior cervical lymphadenopathy. Tachycardic and a new onset 2/6 high-pitched, crescendo-decrescendo systolic ejection murmur auscultated at the left sternal border. Rapid strep +. The patient was diagnosed with acute rheumatic heart disease (RHD).

Question:

Explain how a positive strep test has caused the patient’s symptoms.

QUESTION 5

  1. The APRN sees a 74-year-old obese female patient who is 2 days post-op after undergoing left total hip replacement. The patient has had severe post op nausea and vomiting and has been unable to go to physical therapy. Her mucus membranes are dry. The patient says she feels like the skin on her left leg is too tight. Exam reveals a swollen, tense, and red colored calf. The patient has a duplex ultrasound which reveals the presence of a deep venous thrombosis (DVT).

Question:

Describe the factors that could have contributed to the development of a DVT in this patient explain how each of the factors could cause DVT.

QUESTION 6

  1. A 45-year-old woman is 10 days status post partial small bowel resection for Crohn Disease and has been recuperating at home. She suddenly develops severe shortness of breath, becomes weak, and her blood pressure drops to 80/40 mmHg (previous readings ~130/80s mmHg). The pulse oximetry is 89% on room air. The APRN suspects the patient experienced a massive pulmonary embolus.

Question:

Explain why a large pulmonary embolus interferes with oxygenation.

QUESTION 7

  1. A 45-year-old woman is 10 days status post partial small bowel resection for Crohn Disease and has been recuperating at home. She suddenly develops severe shortness of breath, becomes weak, and her blood pressure drops to 80/40 mmHg (previous readings ~130/80s mmHg). The pulse oximetry is 89% on room air. While waiting for the Emergency Medical Service (EMS) to arrive, the APRN places EKG leads and the EKG demonstrates right ventricular strain.

Question:

Explain why a large pulmonary embolism causes right ventricular strain.

QUESTION 8

  1. A 12-year-old girl is brought to the Emergency Room (ER) by her mother with complaints of shortness of breath, wheezing, tachypnea, tachycardia, and a non-productive cough. The mother states they had just come from a fall festival where the entire family enjoyed a hayride. The symptoms began shortly after they left the festival but got better a couple hours after they returned home. The symptoms began again about 6 hours later and seem to be worse. The mother states there is no history of allergies or frequent respiratory infections. The child is up to date on all vaccinations. The child was diagnosed with asthma. The nurse practitioner explained to the mother that her child was exhibiting symptoms of asthma, and probably had an early asthmatic response and a late asthmatic response.

Question 1 of 2:

Explain early asthmatic responses and the cells responsible for the responses.

Question 2 of 2:

Explain late asthmatic responses and the cells responsible for the responses. 

QUESTION 10

  1. A 64-year-old man with a 40 pack/year history of cigarette smoking has been diagnosed with emphysema.  He asks the APRN if this means he has COPD.

Question 1 of 2:

Explain the pathophysiology of emphysema and how it relates to COPD.

Question 2 of 2:

Explain the pathophysiology of chronic bronchitis and how it relates to COPD.

QUESTION 12

  1. Jones is a 78-year-old gentleman who presents to the clinic with a chief complaint of fever, chills and cough. He also reports some dyspnea. He has a history of right sided CVA, COPD, dyslipidemia, and HTN. Current medications include atorvastatin 40 mg po qhs, lisinopril, and fluticasone/salmeterol. He reports more use of his albuterol rescue inhaler.

Vital signs Temp 101.8 F, pulse 108, respirations 21. PaO2 on room air 86% and on O2 4 L nasal canula 94%. CMP WNL, WBC 18.4. Physical exam reveals thin, anxious gentleman with mild hemiparesis on left side due to CVA. HEENT WNL except for diminished gag reflex and uneven elevation of the uvula, CV-HR 108 RRR without murmurs, rubs, or click, no bruits. Resp-coarse rhonchi throughout lung fields. CXR reveals consolidation in right lower lobe. He was diagnosed with community acquired pneumonia (CAP).

Question:

Patient was hypoxic as evidenced by the low PaO2. Explain the pathologic processes that caused this patient’s hypoxemia.

QUESTION 13

  1. A 64-year-old woman with moderately severe COPD comes to the pulmonary clinic for her quarterly checkup. The APRN reviewing the chart notes that the patient has lost 5% of her body weight since her last visit. The APRN questions the patient and patient admits to not having much of an appetite and she also admits to missing some meals because it “takes too much work” to cook and consume dinner.

Question:

The APRN recognizes that COPD has a deleterious effect on patients. Explain why patients with COPD are at risk for malnutrition.

 

 

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