Relevance of the Case
Why is this case important to you?
What are the reasons this case was chosen?
What makes graduate RNs so interested in this topic?
Nursing Assessment and Case Presentation
Provide a complete case description that includes the salient patient information, physical assessment data, and any relevant investigations.
Make sure that your nursing assessment is person-centered.
Be as descriptive and use data from as many sources possible (e.g. handover reports, patient histories, physical assessments, patient charts, results investigations, nursing/medical assessment previously done).
Patients must remain anonymous and confidential.
This section concerns “Collect cues/information” derived from the Clinical Reasoning Cycle.
Process the information (from the CRC)
Clinical Priorities and Patient Problems
Identify the clinical priorities that will be used to manage this patient.
Based on assessment data, the clinical priority is the top or most pressing patient problem or issue.
Identify and resolve problems/issues using the CRC
Describe your patient’s goals, and the desired outcomes.
Setting goals (from CRC).
Describe the actual nursing and/or other collaborative interventions used in order to manage clinical priorities.
Here, only include interventions or activities (not assessment or evalution).
It is important to keep a nursing perspective: Make sure that you clearly identify all of the nursing management, and highlight the nursing care that was provided alongside any other medical interventions.
Take Action (from CRC).
These are the evaluation data.
This is your actual patient assessment data to assess if each intervention is effective.
You must outline the key learning points, areas for further investigation and key issues in your case study.
Answer to Question: NSB026 Nursing Practice Capstone
Relevance of the Case
Myocardial attack is also known by the clinical name of heart attack.
This is believed to be the main reason for most deaths around the world.
This is important as a correct diagnosis can save many lives.
MI can be fatal and is a grave health problem.
This is a serious disease. One-third of patients who develop it die.
Researchers are working hard to prevent this.
The pathophysiology and symptoms of the disease are becoming more apparent, which is increasing the potential for research in this area.
Nursing Assessment: Case Presentation
Patient’s case history
The hospital has admitted a 59-year-old male.
He said that he has suffered from severe chest pain for over 90 minutes.
Asthma has been a problem for him in the past but it is now under control and has never become severe.
Salbutamol continues to be his Asthma medication.
Endoscopy confirms that he may have gastro-oesophageal regurgitation with Oesophagitis.
He is a cigarette smoker, and can smoke as many as 20 cigarettes a day.
It was not reported that he had consumed alcohol.
Annotations from the past
History of gastroesophageal reflux associated with Oesophagitis.
The patient’s father, who died of myocardial damage at the age 62, was not related to any other family members.
Heart rate: 95
Blood pressure: 140/95
24 hour respiratory rateSaturation-94%
A day of smoking 20 cigarettes
26 kg/m2 is the body mass index
Fasting lipid profileCholesterol- 6.8 mmol/litre
HDL cholesterol – 1.2mmol/litre
LDL cholesterol: 4 mmol/litreTriglycerides- 3.5mmol/litre
The hospital performed an immediate ECG, which showed a 3mm ST section elevation in V1-V2 and an acute myocardial attack.
Aspirin was administered to him in loading doses.
Clinical Priorities – Patients Problems
Patient Problems ListSevere chest Pain.
A lack of bread
Nausea or vomiting can be caused by epigastric discomfort.
Exercise vigorous sweating
Outcomes and goals for patients
The ability to restore the cardiac muscle function
The best way to relieve your chest pain
To reduce cardiac workload
To revascularise your coronary vessel.
To stabilize the heartbeat.
Preservation of myocardial tissue must be done.
Myocardial Infarction patients should be treated with evidence-based nursing.
A loading dose is given of Aspirin, Clopidogrel and Clopidogrel.
Morphine may be administered to relieve pain if it is not already gone.
You should check for chest pain when oxygenation is occurring.
Vasoconstriction can also be caused by oxygen, which makes the situation even more difficult.
Only use oxygen when necessary.
With aspirin, nitroglycerine may be combined.
It increases blood flow and dilates blood vessels.
To monitor life-threatening arrhythmias, it is important to perform continuous ECG.
Nursing staff should also be alert for premature ventricular beats.
You should monitor your vital signs both before and during the administration of the drugs.
It is also important to monitor blood pressure when administering nitro-glycerine.
As the patient is being assessed, the nurse must be careful.
Infusion of IV, attaching electrodes for ECG monitoring.
The patient should be told to remain in a supine place to reduce hypotension.
Counselling should be done and the patient should be informed.
Nurses should ensure that patients feel secure, as they can suffer anxiety from the disease.
Nurses are expected to act ethically in all aspects of their work.
A patient’s recovery is made possible by the presence of moral dilemmas between him and his family.
Aspirin And Clopidogrel Help With Reliving the Pain
An hour after his admission, he underwent a primary percurtanous coronary procedure. A stent containing an eluted drugs was inserted into his narrowed right anterior descending coronary.
Within 60 minutes, it was discovered that the patient is now free from pain and that his ECG reports show a partial resolution.
Case studies are usually based upon real cases from nursing practice.
The purpose of case studies is to learn about different diseases.
We can gain a detailed understanding of MI through such a case study.
We discover that the main cause of MI is when blood cannot reach your heart. This is due to damage to the tissue.
We also learn more about nursing interventions such continuous monitoring for signs, medication administration, which gives us a better understanding about the role of nurses and doctors.