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Case Study

Complex Nursing Practice 2 CRIT3001 Semester 2, 2021

                   Skills Assessment for Internal students

 

CASE STUDY

 

Gloria McCourt, a 72-year-old female, is admitted to the Emergency Department (ED) of a General Hospital at 1030hrs following 10 minutes of crushing retrosternal chest pain at her home. The patient felt ‘lightheaded’ during the episode of chest pain and fell heavily on a mosaic table in her living area. Gloria lacerated her left forearm, and there was ‘lots of blood.’ Her husband Vladimir provided first aid and called the ambulance. The patient also fell and is complaining of pain 7 out of 10 on her left lower ribs. Gloria said to the Ambulance Officers I think I hit my head, and my neck is sore. The Ambulance Officers assessed the patient and provided interventions. A neck collar was applied. The officers applied a pressure dressing to her left forearm and elevated it. The ambulance officers liaised with the hospital ED Medical Officer (MO) and reported the findings. The MO ordered sublingual Anginine half tablet for chest pain, soluble Aspirin 300mg oral and oxygen via nasal prongs. The patient is transferred via ambulance to the hospital.

 

On initial assessment by the Emergency Department (ED) nursing staff, the patient is drowsy and responds to voice. Her voice is sometimes hoarse and high pitched. Her breathing is shallow, with asymmetrical chest movements on the left side and occasional dyspnoea on movement.  On anterior auscultation of her lungs, whilst she is sitting up, her lung fields demonstrate a mild bilateral wheeze with reduced air entry on her left lower lung field. The colour of the patients’ skin is pale, with some spotty urticarial rash on the patient’s chest. The patient’s pulse is weak, irregular, and rapid. The ED clinical staff note that her peripheries are cool/cold and clammy with a pale appearance. The lead II ECG monitor indicates sinus tachycardia with some ST elevation. The patient complains of her skin feeling itchy. The Medical Officer inserts an intravenous cannula and also takes blood samples for laboratory testing. The patient states she had been nauseous the day before, had vomited once, and has had “very little to drink”. The patient is drowsy and opens eyes to speech. Gloria is orientated to time, place, and the person obeys commands and has equal strength in all limbs. Pupils are equal 2mm and reacting to light. Her GCS is 14. The ED Nurse decides the patient is for senior medical review within 10 minutes.

 

Past medical history and surgical history include; mild osteoarthritis of the neck, lower back, and both hips, hypertension, osteoporosis, chronic anaemia. She has recently been referred to a specialist for investigation for coeliac disease, is developing chronic bronchitis, had meningitis ten years ago, and a fractured left forearm as a teenager.  The patient’s weight is 92kg, and her height is 170cms. Allergies:  almonds and penicillin.

 

Gloria’s GP had put her on Perindopril 4mg oral daily three months ago for hypertension. The patient states that she has been having dull central chest pain over the last few days, only after moderate-intensity exercise. Her GP then prescribed anginine tablets half tab sublingual prn, which relieves the chest pain. The patient was due to attend a Cardiologist appointment this coming week. The patient mentioned that she ‘had elevated cholesterol and was trying to reduce it with diet and exercise.’ The patient also stated she has smoked about 10 to 15 cigarettes a day since she was a teenager and is trying to quit.

 

Medications:  Perindopril 4mg daily, Ostelin Calcium and Vitamin D3 BD, Ferrous sulfate 325 mg

Controlled-release tablets daily, paracetamol 1 G daily prn, ibuprofen 400 mg daily prn.

 

On admission, the patient’s observations are:

 

  • Temperature:   37.3 C
  • Blood pressure:     100/60 mm Hg
  • Pulse: 118/min and irregular
  • Respiratory rate:  22/min
  • O2 Saturations: 93% on 8 l/min via Hudson Mask
  • Chest pain on admission: 5 out of 10 sharp central chest pain.
  • Peripheries: cool, pale, capillary refill greater than 3 seconds
  • Central nervous system:  Drowsy

 

 

 

The blood test results were:

 

  • Sodium – 144 mmol/L (135 – 145 mmol/L)
  • Potassium – 3.6 mmol/L (3.5 – 5.2 mmol/L)
  • Magnesium – 0.70 mmol/L (0.8 – 1.0 mmol/L)
  • Glucose random – 4.5 mmol/L  (3.0 – 7.7 mmol/L)
  • Urea – 7.50 mmol/L   (3.0 – 8.0 mmol/L)
  • Creatinine 0.09 mmol/L  (0.05 – 0.11 mmol/L)
  • Haemoglobin – 88 g/L (120 – 160 g/L)
  • Leucocytes total white cell count – 7.0 × 109 /L (4.0 – 11.0 × 109 /L)
  • Platelets – 240 × 109 /L (135 – 370 × 109 /L)
  • INR – 1.1 (1.0 – 1.2)
  • aPTT – 26 seconds (20 – 35 seconds)
  • Creatine Kinase 1500   U/L (normal female 30 – 180 U/L )
  • Troponin T 2   mg/L (normal < 0.01 ng/L)
  • Cholesterol 6    mmol/L  (normal   < 5.5 mmol/L)
  • Triglyceride 9   mmol/L  (normal < 2.0 mmol/L
  • High density lipoproteins (HDL-C) 0  mmol/L   (normal > 0.9 mmol/L)
  • Low density lipoproteins (LDL) 5 mmol/L    (normal < 3.4 mmol/L)
  • Arterial blood gas results pH 7.36 (normal range 7.35-7.45), oxygen 80 mmHg (normal 75 to 100 mmHg), carbon dioxide 44 mmHg (normal 35-45 mmHg), bicarbonate 25 mEq/L (normal 22-26 mEq/L),

 

 

Urinalysis

 

  1. Urine SG 1030, pH 6.0 other NAD.

 

A 12 lead ECG is reviewed by the Medical Officer (MO) and showing ST elevation in the lead II, III and aVF and frequent multifocal premature ventricular contractions. Arterial blood is taken for arterial blood gas analysis and sent to the laboratory. A chest x-ray is taken, showing multiple fractures to the left side lateral rib number 9, causing a small left-side haemothorax. The patient is on spinal precautions, and a cervical spine x-ray is taken and requires review.

 

The patient was prescribed oxygen therapy at 8 litres/min via a Hudson Mask and is commenced on Heparin infusion 5000 units bolus followed by 25 000 units in 500 ml at 30mls/hr. Normal Saline 1000mls @ 60 ml per hour for 24 hours.  The patient is initially nil by mouth to prepare for any procedures. The patient’s chest pain was initially described as central crushing pain 5 out of 10.  The patient is prescribed Morphine 2.5 mg to 5mg slow IV push over 5 mins every 2 to 4 hrs for chest pain.

 

After evaluation of Mrs McCourt’s assessment and investigations, the provisional diagnosis provided by the ED Medical Officer was inferior myocardial infarction (STEMI). After completing all ED medical assessments investigations and treatment, Gloria is transferred to the Coronary Care Unit (CCU) for monitoring and further cardiology investigations.

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