Question:

Patient Data: Male – Aged at 76 years.

Weight 70kg.

Height 170cm

Pre-existing medical history

According to his medical history, Anderson suffers from upper epigastric symptoms and was diagnosed with GORD in June 2016.

He was admitted to the hospital because he had unprovoked gina.

Before his admission, the only medication prescribed to him was Nexium (esomeprazole), 20mg twice daily for four weeks.

After being on the medication for four weeks, Mrs Anderson decided not to return to her doctor for any further consultation.

Additionally, he has been experiencing increasing fatigue, occasional palpitations, progressive bilateral lower extremity and oedema.

He smokes 15 cigarettes a days and has no allergies.

These are the Vital Signs

BP – 160/90. HR – 88. RR – 22, SaO2 – 95%. T – 36.7Pathology:

Cholesterol

Total cholesterol 7.1 mmol/L

Low-density cholesterol (LDL) 5.2 mmol/L

High-density Lipoprotein (HDL), cholesterol 1.0 mmol/L

Creatinine 100

INR 1.8

Magnesium 0.66mmol/LPotassium 2.7 mmol/LSodium 135 mmo/L

Toponin TM 0.03

Urea 2.6 mg/L

ECG taken within five minutes of arrival to ED. (According to hospital protocol – see below).

Recent medical history

Today, Mr. Anderson refuses to get out from bed due to increasing fatigue.Task:

The above case study can be used to demonstrate the clinical reasoning framework.

Levett Jones T. (Ed.). (2013).

Clinical reasoning: Learning how to think like nurses.

Pearson Australia.

Page 5-9 for the plan of nursing care for this patient.

Think about the pt.

Take into account the pt.Collect cue/information

Assessment of A,B.C.D.E

Get the information processed

Identify issues/problemsEstablish goals

Take action

Analyse the results

Reflect on the learning process and how you can learn more.

Answer to Question: NURS2164 Introduction To Acute Specialty Nursing

Please consider Pt.

Situation

Mr. Anderson, who is 76 years old, was admitted at the hospital’s emergency section with angina suspected to be unprovoked.

Initial observation indicated that Anderson was experiencing fatigue, occasional palpitations, progressive bilateral lower extremity pain and angina (Source: Records in the emergency room).

Collect cue/Information

Review

Mr. Anderson said that he has extreme fatigue, occasional palpitations, and progressive bilateral lower extremity elevation (according to the patient’s account).

Medical Parameters

Patient’s Parameter

Normal Parameter

Blood Pressure160/90120/80

Heart Rate88

60 to 100 beats each minute

Respiratory Rate22

12 to 25 cents per minuteOxygen Saturation (SaO2)95%

98 to 100%Body Temperature (T degree Centigrade)36.737

Table: Standard Adult Observation (SAGO), Chart by Mr. Andersonhttps://www.safetyandquality.gov.au/wp-content/uploads/2012/02/RPA-observations-policy-directive.pdf

Figure: ECG of Mr. Anderson was taken within five minutes of arriving at the Emergency DepartmentPatient Is Having An Myocardial Infarction, S-T Elevation Mi

It would be nice if you could talk about it instead of Cholestrol.

Name of the testPatient Report

Normal Parameter

Cholesterol total7.1 mmol/LBelow 5.2 mmol/L (Boekholdt et al., 2012)

Low density lipoproteins, (LDL),5.2 mmol/L2.59-3.34 mmol/L (Boekholdt et al., 2012)

High Density Lipid (HDL).1.0 mmol/L1.3-1.5 mmol/L (Boekholdt et al., 2012)Creatinine1000.5 to 1.1 milligrams (Boutten et al. 2013)

Magnesium0.66 mmol/L

2 to 4 mmol/LPotassium2.7mmol/L

3.6 to 5.2 mmol/L, according to Shay et. al. 2012Sodium135 mmo/L135-145 mmol/L (Shay et al., 2012)TroponinT <0.03mirco gram per liter<0.01 mirco gram per liter (Shay et al., 2012)Urea2.6 mmol/L 2.5 to 8. mmol/L (Brisco. Coca. Chen. Owens. McCauley. Kimmel & Testani. 2013). INR ratio1.8 1.1 and below (Haibo Jinzhong Yan & Xu2012) Table: Blood Test Report on Mr. Anderson taken after his admission to the Emergency Department Previous Nursing and Medical Results In June 2016, he was diagnosed as having Gastro Oesophageal Reflux Disease. Nexium (Esomeprazole), 20mg, was the only medication we were allowed to take. This was for a period of 4 weeks. Mr. Anderson stopped seeing the doctor after he had taken the medication for 4 consecutive weeks. Mr. Anderson has a past medical history with upper epigastric pain. (Source: Prescription and previous medical reports). Collect New Information Airway: Patient may speak (airway is patent). Source: emergency dept Breathing: Normal (source, emergency dept.) Circulation: 160/90 bloodpressure (source : daily check-up). No Disability NA Exposure Recall knowledge Do not worry about writing anything in Recall Knowledge. Process Information Translate Understanding the signs and symptoms Compare normal vs. unusual The ECG of the patient showed that he had Myocardial Infarction. The patient complained of fatigue and occasional lower extremity oedema. All of these symptoms may indicate MI (Thygesen. et. al., 2012). Current Signs & Symptoms The blood test showed Mr. Anderson had high levels total cholesterol, a common problem for his age. The alarming sign of high levels of LDL (bad) cholesterol is however, LDL is bad cholesterol. The liver doesn't use it or break it down. Unused cholesterol is deposited in the heart arteries, leading to angina (chestache). (Nichols (2013) The high levels of cholesterol within the blood cause Mr. Anderson to feel extremely fatigued (Six, et. al., 2013, 2013). His heart is not pumping sufficient blood to the distant sections of his body. This is due to hardening of arteries which decreases the efficiency. This reduced blood supply is leading to fatigue (Eckhardt DeVon Piano Ryan Ryan, &Zerwic (2014) Discriminate Identify Relevant Information and Non-relevant Information The only relevant information available for Mr. Anderson is that he has high levels blood cholesterol and high levels LDL. This could indicate atherosclerosis, which can lead to coronary heart disease (angina). Information that is not relevant to Mr. Anderson's case is that he has low levels in magnesium in his blood and high levels in serum creatinine. Recognize Inconsistent Information Hypomagnesium is a sign that Mr. Anderson still has GORD. Hypomagnesium, which is low blood magnesium and thereby electrolyte imbalance, can be caused by a problem in the stomach or bowel. The kidneys are responsible for excreting the magnesium. On the other hand, high level of creatinine in the blood serum indicated defect in renal function which may be cited as another cause of hypomagnesium(Sakaguchi, 2014). Prioritize The Most Important Information Mr. Anderson has a permissible HDL level. This is a good sign since HDL absorbs LDL. The liver should be notified. Additional important information: High level of blood cholesterol LDL levels high High blood pressure How to narrow down information Patient is having High BP Normal RR Increased fatigue Occasional PalpitationProgressive bilateral lower extremity Information Gaps There is no indication that he has had any prior GORD disease. Relationship According to the blood tests, Anderson has high levels blood cholesterol. The high LDL levels (Six, et. al., 2013,) are responsible for Anderson's high cholesterol. LDL that isn't absorbed into the kidneys is stored in the arteries as plaques, which are waxy deposits. Plagues block the arteries, causing a loss of elasticity (Rapsomaniki et. al., 2014). This causes hardening and blockage of the arteries. In addition to reducing blood flow, it also causes stress in the heart that pumps more blood. This can result in chest pain and/or angina. Also, Mr. Anderson has bilateral lower extremity oedema (Six et al. 2013, 2013). This is another sign that he may have heart disease. Oedema is defined as the accumulation of watery fluid in tissues and cavities. Oedema can also result from renal dysfunction due abnormal salt retention (Shlipak Matsushita Arnlov Inker Katz Polkinghorne&Levey (2013)). Inference The analysis of Mr. Anderson's symptoms, and the relationship between them, has led us to conclude that Mr. Anderson suffers from angina caused by an increase in blood cholesterol. (Rapsomaniki, and others, 2014). This chest pain could indicate coronary or ischemic cardiac disease. An adverse situation such as coronary heart disease could lead to sudden cardiac death or heart failure. (Six, and others, 2013). The GORD, his medical problem that had been plaguing him previously, might have been cured. However the low magnesium level in his blood seems to be an indication of this (Thrift. 2013). Matching Anderson was admitted to the hospital after having unprovoked and past history of upper epigastric discomfort and GORD. ECG reports showed high blood pressure and elevated levels of total cholesterol in the blood. These factors could indicate that Angina is a form of arthritis. He also smokes 15 cigarettes a day, which could be responsible for his chest pain. A high level of chain smoking can cause blockage in the pulmonary arteries. This could lead to fatigue and chest pain. Messner& Bernhard (2014) have shown that chain smoking has a direct relationship to the development of cardiovascular disease. Progressive bilateral is another sign of cardiac problems. Serum creatinine levels are high, which is evidence of a kidney problem (Shlipak Matsushita Arnlov Inker Katz Polkinghorne&Levey 2013). Mr. Anderson's urea levels are normal, which is not typical for someone with a kidney disease (Shlipak Matsushita Arnlov Inker Katz Polkinghorne&Levey (2013)). Prediction The clinical case study of Mr. Anderson revealed that Anderson is suffering from heart problems, and is now experiencing chest pain. High levels of cholesterol in blood are the main cause of cardiac problems (Rapsomaniki, Piano, Ryan, &Zerwicz, 2014). This extra cholesterol is building up over the cardiac vessels, leading to their hardening and eventually chest pain (Eckhardt DeVon. Piano. Ryan., &Zerwic., 2014). Anderson is suffering from severe fatigue and palpitations. The body isn't getting enough oxygen and cells are not receiving enough ATP. This causes fatigue. This may indicate a coronary heart disease or an ischemic cardiovascular disease. It may also lead to a sudden heart attack and myocardial damage (Eckhardt. DeVon. Piano. Ryan. &Zerwic. 2014). Because of the possibility of oedema becoming fatal, Mr. Anderson should be careful about how much fluid he drinks. Identify Problems/Issues Mr. Anderson has high blood cholesterol and high blood blood pressure. He may be suffering from Arthrosclerosis that can lead to heart disease (Eckhardt DeVon. Piano. Ryan. & Zerwic. 2014). The highest concentration of LDL (bad) cholesterol is the most serious and urgent concern that must be dealt with immediately. LDL remains unutilized, and the liver fails its duty to use it or break it down. This cholesterol accumulates in the arteries leading to arthrosclerosis which can cause hardening and angina. The heart can't pump enough blood from the distant sections of the body which causes fatigue (Eckhardt DeVon Piano & Ryan, 2014).Establishment Of Goals To improve the overall state of Mr. Anderson, i want to take some basic physiological steps Measuring his oxygen saturation is a way to identify the reason for his fatigue (Chen, DeVon and Piano, Ryan, &Zerwic 2014). In order to control the progression of bilateral lower extremity swelling (Meeus. Goubert. De Backer. Struyf. Hermans. Coppieters&Calders., 2013). In extreme fatigue, he may be unable to breathe and refusing to leave the bed (Meeus. De Backer. Struyf. Struyf. Hermans. Coppieters&Calders., 2013). Also, let us know when you plan to reach your goals. ECG shows that he is suffering from MI. An ECO cardiogram is required to confirm if there is a MI.Please also talk about establishing goals regarding his cholesterol levels and blood pressureinterventions SMART goals Specific: Echocardiogram of Heart to examine the current image of heart Measurable. The Echo cardiogram will allow you to identify the severity level of plaque formation Realizeable: An Echo cardiogram is easy to perform Realistic: Echo cardiograms will be a useful tool in diagnosing disease. (Rapsomaniki et. al., 2014). Timely: It is imperative to get an echo cardiogram done immediately Action Plan Mr. Anderson is refusing any movement outside of the bed due to extreme fatigue. The nurse has the responsibility to call the doctor for more advice. In order to monitor his heart rate, respiratory rates and oxygen saturation, we need to send him to a machine that can give live video feeds. The attending nurse must inform doctor to order Echo cardiograms, endoscopy and a kidney function test. Echo cardiograms can provide images of the heart by using standard ultrasound techniques, including Doppler and two-dimensional, three-dimensional, or 3-D (Donofrio. Moon-Grady. Hornberger. Copel. Sklansky. Abuhamad&Lacey. 2014). Endoscopy can provide a true picture of the stomach (Shaheen Weinberg Denberg Chou Qaseem &Shekelle), 2012. Evaluation To date, there has been no improvement in his condition. The nurse should keep an eye on his blood pressure, urine production, and respiratory rate (Gottlieb. Stebbins. Voors. Hasselblad. Ezekowitz. Califf& Hernandez., 2013). You could also mention keeping him on ECG monitor until further investigation is done. Reflection on Learning Process If I am ever faced with a similar situation, I will be able to avoid anxiety and fear. I will confirm that both the echocardiogram (and kidney function test) were performed on time. I will also keep an hourly record of the oxygen saturation rate, respiratory rate, urine output and other vital signs. I will also communicate directly with the patient to assess if there is any discomfort or distress. Communication is crucial to provide high quality nursing. At the same time it reduces initial fear (Riley 2015.References:Boekholdt, S. M., Arsenault, B. J., Mora, S., Pedersen, T. R., LaRosa, J. C., Nestel, P. J., ... & DeMicco, D. A. (2012). A meta-analysis of the association of LDL cholesterol, non HDL cholesterol and apolipoprotein B levels in patients receiving statins with cardiovascular risk: Jama, 307(12), 1302-1309.Boutten, A., Bargnoux, A. S., Carlier, M. C., Delanaye, P., Rozet, E., Delatour, V., ... & Pieroni, L. (2013). Jaffe methods which are enzyme-free but not compensated achieve the desirable specifications of NKDEP for normal levels of creatinine. Results of the French multicentric analysis. Clinica chimica acta, 419, 132-135.Brisco, M. A., Coca, S. G., Chen, J., Owens, A. T., McCauley, B. D., Kimmel, S. E., & Testani, J. M. (2013). The Blood Urea Nitrogen - Creatinine Ratio identifies a potentially fatal but high-risk form of renal dysfunction in patients with severe decompensated cardiac failure. Circulation: Heart Failure, CIRCHEARTFAILURE-112.Haibo, Z., Jinzhong, L., Yan, L., & Xu, M. (2012). Low-intensity, international normalized ratio (INR), oral anticoagulant treatment in Chinese patients with mechanical valve prostheses. Cell biochemistry & biophysics, 62.1(1), 147–151.Jneid, H., Anderson, J. L., Wright, R. S., Adams, C. D., Bridges, C. R., Casey, D. E., ... & Peterson, E. D. (2012). 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update). Circulation, CIR-0b013e318256f1e0.Shay, C. M., Van Horn, L., Stamler, J., Dyer, A. R., Brown, I. J., Chan, Q., ... & Elliott, P. (2012). Food and nutrient intakes and their associations with lower BMI in middle-aged US adults: the International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP). American journal of clinical nutritional science, ajcn-045056.Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., White, H. D., ... & White, H. D. (2012). Third universal definitions of myocardial damage. European heart journal, 33 (20), 2551-2567.