Coronary Disease

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Case outline

Peter Brown is a 58-year-old gentleman who has experienced an episode of crushing central chest pain while at work. Peter works as a taxi driver and a colleague has taken him to the Accident and Emergency Department. On admission, Peter is sweaty, clammy, nauseated and short of breath. He is complaining of chest pain radiating to his left arm. This is Peter’s first presentation to hospital and he has no relevant past medical history. Peter smokes approximately 20–30 cigarettes per day and takes alcohol at weekends only. Peter is anxious and is concerned that his wife and children are informed. He also states his father died suddenly following a heart attack a number of years ago. Peter is immediately triaged and taken to the resuscitation room. You are the receiving nurse. Observations on admission include:

Respiratory rate: 18 breaths per minute Oxygen saturations: 95% Blood pressure: 150/90 mmHg Pulse: 94 beats per minute Temperature: 37ºC.

On admission to hospital an electrocardiograph (ECG) has been undertaken. Peter has been diagnosed with an anterior ST segment elevation myocardial infarction (anterior STEMI). Blood samples have also been drawn for urea and electrolytes (U&E), full blood picture (FBP) and highly sensitive troponin T.

                   

Peter’s ECG shows ST segment elevation in leads V2, V3, V4 and to a lesser extent in V5. This is typical of an anterior ST elevation myocardial infarction (Hatchett and Thompson 2007). This ECG indicates that Peter should be treated urgently with a view to reperfusion therapy. Reperfusion therapy involves either thrombolytic therapy or being taken to the cardiac catheterization laboratory in order that a stent may be inserted in the culprit coronary artery.

The cardiologist has decided to take Peter to the cardiac catheterization laboratory (cath lab) to undergo a percutaneous coronary intervention (PCI) as opposed to giving him thrombolytic therapy. The cardiologist wants Peter to have clopidogrel 600 mg and aspirin 300 mg prior to transfer to the catheterization laboratory.

Following Peter’s transfer to the cath lab, he had a stent deployed to his left anterior descending coronary artery. Subsequently Peter made a full uncomplicated recovery and was discharged four days later.

Adult Health Case study

Coronary Artery Disease

Professor Gallegos Class


Case outline

Peter Brown is a 58-year-old gentleman who has experienced an episode of crushing central chest pain while at work. Peter works as a taxi driver and a colleague has taken him to the Accident and Emergency Department. On admission, Peter is sweaty, clammy, nauseated and short of breath. He is complaining of chest pain radiating to his left arm. This is Peter’s first presentation to hospital and he has no relevant past medical history. Peter smokes approximately 20–30 cigarettes per day and takes alcohol at weekends only. Peter is anxious and is concerned that his wife and children are informed. He also states his father died suddenly following a heart attack a number of years ago. Peter is immediately triaged and taken to the resuscitation room. You are the receiving nurse. Observations on admission include:

Respiratory rate: 18 breaths per minute Oxygen saturations: 95% Blood pressure: 150/90 mmHg Pulse: 94 beats per minute Temperature: 37ºC.

On admission to hospital an electrocardiograph (ECG) has been undertaken. Peter has been diagnosed with an anterior ST segment elevation myocardial infarction (anterior STEMI). Blood samples have also been drawn for urea and electrolytes (U&E), full blood picture (FBP) and highly sensitive troponin T.

Peter’s ECG shows ST segment elevation in leads V2, V3, V4 and to a lesser extent in V5. This is typical of an anterior ST elevation myocardial infarction (Hatchett and Thompson 2007). This ECG indicates that Peter should be treated urgently with a view to reperfusion therapy. Reperfusion therapy involves either thrombolytic therapy or being taken to the cardiac catheterization laboratory in order that a stent may be inserted in the culprit coronary artery.

The cardiologist has decided to take Peter to the cardiac catheterization laboratory (cath lab) to undergo a percutaneous coronary intervention (PCI) as opposed to giving him thrombolytic therapy. The cardiologist wants Peter to have clopidogrel 600 mg and aspirin 300 mg prior to transfer to the catheterization laboratory.

Following Peter’s transfer to the cath lab, he had a stent deployed to his left anterior descending coronary artery. Subsequently Peter made a full uncomplicated recovery and was discharged four days later.

Adult Health

Case study Paper

Category

Points

Percentage

Description

Pathology:

15 pts

· Define the patient’s disease process

· Explain the etiology of the disease process.

· Thoroughly explain signs and symptoms of disease process.

· State and explain any diagnostic measures utilized with this disease process.

· Cite sources

Assessment Data

10pt

· Clearly explain the difference between subjective and objection data.

· Identify Subjection and objection data that would be important to understand.

· Explain the information that would be information to understand from the chart.

· Identify the information from the chart that would be most helpful

· Identify what labs would be important to your assessment and why.

Medications

10pt

· Understand & explain first line treatment for the disease.

· Understand & explain second line treatment and why you would use second line treatment.

· Explain the patient’s medication: minimum of 3-5 medications.

· Explain the class of medication.

· Explain alternative therapies.

· Explain any Black Box warnings, contraindications, and nursing considerations for the medications.

· Identify 3-5 common side effects.

· Identify any medication interactions

· State the common indication for the prescribed medication.

· Explain 2 challenges that might prevent them from taking medication as prescribed.

· Cite sources

Diagnosis

10pt

· Provide 3 nursing diagnosis for the patients (primary physical, psychosocial and education) pertinent to this client’s medical diagnosis.

· List health assessment priorities for the nursing diagnosis.

· State 5 or more appropriate interventions with evidence-based practiced rationale for each action stated for each of the 3 primary nursing diagnosis (cite sources).

· Explain relevant lab work that is required with this medical diagnosis.

· Cite sources

Plan of care

15pt

· Explain what the patient is at risk for.

· Articulate safety concerns or issues at home.

· Explain 2 challenges that might prevent the patient from seeking medical care.

· Articulate all patient education for the patient and treatment plan.

· Explain an understanding of the diagnosis and treatment.

· Identify 2 short-term goals & 2 long-term goals.

· Identify 2 outcomes for the patients.

· Cite sources.

Discharge Instructions

10pt

· Articulate appropriate discharge instructions for these patients.

· Articulate appropriate follow-up care.

· Cite sources.

SOAPIE Note

10pt

The required elements include the following:

· Clear statement of subjective findings.

· Clear statement of objective findings.

· Clear statement of assessment findings.

· Clear statement of plan.

· Clear statement of interventions

· Clear statement of Evaluation

APA

20pts

All information taken from another source must be included on a reference listing using the 7th edition APA as per the Stratford University policy as of October 5th, 2020.

You are NOT allowed to use your book as a source Reference: You must use Peer Reviewed Sources/Articles.

Total

100

100

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