Case Study

Case Study

Mr Henry Wilson is a 54 year old bank manager who presents to the Emergency Department with a sudden onset of shortness of breath and left sided chest pain whilst watching the evening news. The pain has been constant for one (1) hr.

He has no relevant past history and he is taking no regular medications. He is 160 cm tall and weighs 95kg.

You are the Registered Nurse caring for Mr Wilson on arrival.   

Mr Wilson states he has left sided chest pain. The pain is not exacerbated by deep breathing, coughing or movement. He is diaphoretic and has a pain score: 8/10. His vital signs are Temp: 37.2, HR: 84, BP: 150/90 mmHg, RR: 18, SaO2: 95% in RA. Glasgow Coma Score (GCS): 15. Oxygen is applied at 6 litres via a Hudson mask. Continuous cardiac monitoring and a 12 lead ECG are done (results below). 



The medical officer has inserted an IV cannula. Blood pathology has been collected, including FBC, EUC, LFT, BSL and cardiac markers.


The medical officer orders the following to be commenced immediately and then re-review.
            
• Medications: Morphine 2.5 mg IVI for pain 
                                     : Aspirin 300mg stat
                                     : Atenolol 50mg oral

• X-Ray:  Mobile chest.

The results of Mr Wilson’s cardiac markers have been processed by pathology and are as listed below: 
                       
   CK-MB:        1.0mcg/L     
                        Troponin I:    2.0mcg/L


Assessment Task:

In no more than 875 words (using your criteria sheet), apply the ABCD framework and critically analyse the clinical indicators in the case study and their significance. In particular, apply your knowledge in interpreting the attached 12 lead ECG to determine care priorities for Mr Wilson. Then identify and discuss the most important nursing interventions relevant to Mr Wilson’s needs and the rationales for these as you assess him. Your paper should demonstrate an understanding of the pathophysiology and treatment ordered by the medical officer (i.e oxygen, ECG, medical tests, medications) and your nursing responsibilities associated with this treatment. Please remember to write this paper in a formal/analytical style.

Criteria

Identifies and discusses the priority nursing interventions and relevant nursing care with supporting rationales. 
Applies patho physiology relevant to the nursing practice identified in the case study 

Identifies the pharmacological agents in the case study and discusses the associated nursing responsibilities. 
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