Discipline of Nursing & Midwifery Homework Help

RMIT University
School of Health Sciences
Discipline of Nursing & Midwifery
Bachelor of Nursing
NURS2100 Acute Care Nursing 1 2014

Case Study Assignment (30%)

The case studies:
Each of the case study assignment topics relate to one (1) of the case studies provided in the first three lecture modules for this course (Cardiovascular, Vascular and Respiratory); so please read each case study carefully as part of your preparation for selecting your topic and in completing your written assignment.

Choose one (1) of the following assignment topics:

1.    In relation to Mrs Melissa Jones (Case Study 1) and with emphasis on current research, discuss the effectiveness of stent insertion in preventing further cardiac events.

2.    With reference to Mrs Clara O’Donnell (Case Study 2), discuss the pathophysiological development of aortic aneurysms, and the roles that genetics and lifestyle play in aortic aneurysm development.

3.    Discuss how the pathophysiological changes that occur in Chronic Obstructive Pulmonary Disease (COPD) impact on the respiratory function of people such as Mrs Maria Santini (Case Study 3), and increase their susceptibility of contracting pneumonia.

Due date of assignment submission:

•    The assignment must be submitted at the beginning of Week 8 of semester by or on the due date of Monday 28 April 2014 at 1700 hours.
•    The word count for this written assignment will be 1500-1700 words.
•    You will be expected to use research or evidence-based journal articles (a minimum of seven), textbooks and appropriate authoritative web sites (not Better Health Channel, Virtual Hospital, etc.), and all references used should reflect contemporary practice.
•    All referencing is to be formatted using the APA referencing style.
•    You are required to submit an electronic copy (Word Document) of the completed case study uploaded into the Assignment Folder on the course Blackboard site. This folder is connected to Turnitin, so you only submit your assignment into one place.
•    Students are able to submit their assignment multiple times before the due date through the Turnitin submission site, in order to achieve an Originality Report of no more than 10-15%. The report takes 24 hours to be processed from assignment submission, so students wanting to review this should factor this in to their submission date.
•    The marking rubric and submission guidelines will be provided on the course Blackboard site.
•    Each student is to also have read the Assessment Declaration and Statement of Authorship on this site before submission of their assignment, and must include the RMIT electronic submission of work for assessment statement at the bottom of the title page.

Case Study1: Cardiovascular

Mrs Melissa Jones is a 48 year old lady 175 cm tall, 98 kgs, and BMI 28; was admitted with severe substernal squeezing pain that radiated to her left arm and jaw. She also complained of nausea. After receiving Aspirin 300mg, Sublingual Nitroglycerine Spray 400mcg, Morphine Sulphate 5mg IV and Streptokinase 1.5 million units IV over 30-60 minutes in the emergency department; Melissa was transferred to the Coronary Care Unit (CCU) where she was monitored. Once in the CCU, Melissa is commenced on Ramipril 2.5mg daily. Melissa is scheduled to have an angiogram.
Melissa is a high school teacher, married with two secondary school aged children. Prior to admission to hospital she smoked one packet of cigarettes per day, drank 2-4 glasses of gin and tonic per night. She stated that her diet consisted of mainly high fat take away foods, particularly in the last 6 months as her teenagers had numerous extra curricula activities after school. As such the family rarely ate together with a home cooked meal. Melissa’s father died of an MI aged 50 following a history of hypertension and type II diabetes.
Although Melissa was physically fit in the past, in the last 2 years family commitments have overtaken her own leisure and fitness regime. Melissa states that this has significantly increased her stress levels and she is rarely home before 8pm most evenings with her children’s activities.
Blood tests on admission showed: Haematology     Result     Units     Reference Range
Serum Cholesterol     9.3     mmol/L     <4
HDL     0.8     mmol/L     0.9–2.0
LDL     5.5     mmol/L     2–3.4
CK MB     1.8%     < 5% of total CK activity
Troponin I     0.0     µg/L     0

4 hours later once thrombolysis completed Haematology     Result     Units     Reference Range
CK MB     36%     < 5% of total CK activity
Troponin I     5.2     µg/L     0

Following thrombolytic therapy Melissa’s ECG shows resolved ST changes. The following day she has an Angiogram and Percutaneous Coronary Intervention (PCI) which resulted in her having a stent inserted into her Right Coronary Artery (RCA). Her post procedural management was uneventful. One day later following a cardiac rehabilitation referral and no complications she is discharged on:
Aspirin 100mg daily, Metoprolol 100mg daily, Simvastatin 40mg nocte, Ramipril 2.5mg daily, Nitrate patch 5mg, and prn Sublingual Nitroglycerine Spray 400mcg.

Case Study 2: Vascular

Mrs Clara O’Donnell is a 75-year-old woman admitted to a private hospital following a visit to her local GP. She has a one month history of fatigue, abdominal and back pain unrelieved by non steroidal anti inflammatory medication. Routine Xray showed a 6-7cm mediastinal silhouette and calcification in the wall of the abdominal aorta. Clara has smoked for the last 25 years half – one pack of low level nicotine / day. She states that she gave up one month ago when they became too expensive to purchase. She does not exercise due to pain in her feet. Her meals consist mostly of fast food, soups and sandwiches since her husband died 4 years earlier. Clara’s past medical history includes type II diabetes, hypothyroidism and hypertension. She weighs 96 kgs and 165 cm tall. BP 155/90, random blood glucose 9.6 mmol/L. Family history includes: father died of MI aged 49, mother died at aged 79 from aortic dissection.
Biochemistry Results:        Reference Range:
Fasting Glucose    7.8 mmol/L    (3.9–6.4)
Cholesterol        8.1 mmol/L    (desired < 5.2)
Triglycerides        3.2 g/L    (0.4–1.5)
HDL            0.79 mmol/L    (0.80–2.05)
LDL            5.3 mmol/L    (1.55–4.65)
Thyroxine        55 mmol/L    (58–154)

Clara is on metformin for her diabetes, lisinopril for her hypertension, and thyroxine for her hypothyroidism. She has been referred to the dietician and diabetic educator for comprehensive education.
Clara has been seen by the vascular surgeon who wants to send her for an elective surgical repair of her 6cm aortic aneurysm in two days.

Following Clara’s surgical repair of her aortic aneurysm she is cared for in the ICU. She is fully monitored via a Central Venous Catheter and arterial line and careful attention is given to ensuring there is adequate blood pressure to ensure graft patency. Periods of hypotension result in a risk of thrombosis due to a decreased level of blood flow (Wipke-Tevis et al., 2012). However hypertension may lead to pressure on the arterial anastomoses, so caring for Clara requires a delicate balance of her level of hydration and hypertension.

Following two days of ICU management, Clara is transferred to the medical surgical unit to continue her recovery and prepare for discharge. Clara is reluctant to participate in her activities of daily living (ADLs). Although her PCA (patient controlled analgesia) has been removed, she continues to fear movement and links this with surgical site pain. Clara also expresses fear about returning home as she doesn’t have family support. Her anxiety about pain and fear about sense of independence have led to a reluctance to mobilise and perform ADLs; leaving Clara at risk of developing Deep Vein Thrombosis.

Case Study 3: Respiratory

Mrs Maria Santini is 72 years old, and has been admitted with community-acquired pneumonia (CAP). Mrs Santini arrived in the emergency department, concerned about her increasing shortness of breath, high temperature, fatigue, and ‘strange’ coloured sputum. Her clinical manifestations on admission were dyspnoea, fever, and chills. Mrs Santini’s current medical history includes Chronic Obstructive Pulmonary Disease (COPD), hypertension, hypercholesterolaemia, and type 2 diabetes mellitus. Mrs Santini states that she is still a smoker despite knowing about her emphysema; but has cut down to five cigarettes per day. Her alcohol intake is limited to the occasional wine. Mrs Santini is a retired retail assistant, who lives with her husband in South Morang. Her daughter and son-in-law visit her regularly as they live close by.

Mrs Santini’s observations on arrival to the ward are:
Temperature: 37.9°C
Pulse: 92 beats per minute
Respirations: 28 breaths per minute
BP: 110/75 mmHg
Weight: 75 kg
Height: 164 cm

Her arterial blood gas results on admission were as follows:
pH: 7.27
PCO2: 56 mmHg
PO2: 70 mmHg
HCO3: 25 mmol/L
SaO2: 89%

Blood tests have been taken, for a complete blood count and urea and electrolytes. A chest x-ray taken when she was in the emergency department shows right lower lobe consolidation. A sputum specimen has been sent to the pathology department for gram stain, and culture and sensitivity. In the interim, Mrs Santini has been commenced on intravenous antibiotics Azithromycin and Ceftriaxone.

Mrs Santini has been placed on oxygen via a mask at 40%. AIDitional medications include salbutamol 3-4 hourly PRN by nebuliser, and her regular medications of fluticasone/salmeterol (Seretide), tiotropium, lisinopril, gliclazide, metformin, frusemide, and simvastatin.

Medication regimen for Mrs Maria Santini:

Azithromycin 500 mg IVI daily
Ceftriaxone 1 g IVI daily
Salbutamol 5 mg nebule by nebuliser 3-4 hourly PRN
Fluticasone 250 mcg / salmeterol 50 mcg (Seretide) 2 inhalations by inhaler (MDI) bd
Tiotropium 1 capsule (18 mcg) daily by Handihaler
Lisinopril 5 mg per orally daily
Gliclazide (Diamicron MR) 30 mg mane per orally
Metformin (Diabex XR) 500 mg mane per orally
Frusemide 40 mg mane per orally
Simvastatin 40 mg nocte per orally

Test results to date:

Sputum micro and culture indicated the causative organism to be Streptococcus Pneumoniae.
Haemoglobin – 115 d/L
Urea – 8.8 mmol/L
Creatinine – 64 µmol/L
Na – 130 mmol/L
K+ – 4.1 mmol/L
FEV1 3 months ago – 65%

Since admission, Mrs Santini has been having the salbutamol every six hours, which helps her for a time. Her antibiotics have not been changed.