The following questions relates to the patient within the first 24 hours:
1. Outline the causes, incidence and risk factors of the identified condition and how it can impact on the patient and family
2. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology
a. This can be done in the form of a table – each point needs to be appropriately referenced
3. Describe two (2) common classes of drugs used for patients with the identified condition including physiological effect of each class on the body
a. This does not mean specific drugs but rather the class that these drugs belong to.
4. Identify and explain, in order of priority the nursing care strategies you, as the registered nurse, should use within the first 24 hours post admission for this patient
Case Study Question 1
Mrs Sharon McKenzie is a 77-year-old female who has presented to the emergency department with increasing shortness of breath, swollen ankles, mild nausea and dizziness. During your assessment Mrs McKenzie reports the shortness of breath has been ongoing for the last 7 days, and worsens when she does her gardening and goes for a walk with her husband.
On examination her blood pressure was 105/55 mmHg, HR 54 bpm, respiratory rate of 24 bpm with inspiratory crackles at both lung bases, and Sp02 at 92% on RA. Her fingers are cool to touch with a capillary refill of 1‐2 seconds. Mrs McKenzie states that this is normal and she always has to wear bed socks as Mr McKenzie complains about her cold feet.
Her current medications include: digoxin 250mcg daily, frusemide 40mg BD, enalapril 5mg daily, warfarin 4mg daily.
The following blood tests were ordered: a full blood count (FBC), urea electrolytes and creatinine (UEC), liver function tests (LFT), digoxin test, CK and Troponin. Her potassium level is 2.5mmol/L.
Mrs McKenzie also has an ECG which showed sinus bradycardia, and a chest x‐ray showing cardiac enlargement and lower lobe infiltrates, suggesting the presence of acute exacerbation of congestive cardiac failure.
Impression: Congestive cardiac failure with ?digoxin toxicity
Case Study Question 2
Mrs Josie Shara is a 31 years old female, who was admitted after being referred by her GP due to complaints of palpitations, severe fatigue and anterior neck enlargement.
Past medical history: Caesarean section x 2, Gestational Diabetes
Allergies: Nil Known
Current medications: Nil
Social History: Josie and her family migrated from Zimbabwe last year. She had a baby 7 months ago via caesarian section and she is currently breastfeeding. She has two older children whom she reports to be helping her with the new baby. Josie is a primary school teacher in her country but she is currently unemployed. Her husband is working as a registered nurse in a nursing home.
On examination: Josie is alert and orientated. She reports that over the past few months she has increasing lethargy and sleep disturbance that she initially attributed to her recent delivery. She has unintentional weight loss of 16 kg despite having good appetite. Josie’s husband also raised concern that she has been unusually irritable and anxious. Last week, Josie saw the GP for what was presumed to be viral infection as she had fever, sore throat and night sweats but was not commenced on any medication except for paracetamol. She also noted that her neck is getting swollen but denies any dysphagia. Josie reported that she has been experiencing more frequent palpitations even at rest. She has nil complaints of chest pain but has slight shortness of breath. The ECG showed sinus tachycardia.
Observations: BP: 146/58 mmHg, HR: 127 bpm, RR: 24 bpm, Temp: 36.8C, SpO2: 98% on RA, Weight 53 kg, BGL 5.2 mmol/L
|RBC||5.3 million/mm3||2.6 to 5.9 million/mm3|
|WBC||10954 /mm3||4300 to 10800/mm3|
|Platelets||22000 /mm3||150000 to 350000/mm3|
|Haemoglobin||134 g/L||120‐170 g/L|
|Sodium||145 mEq/L||135 to 145 mEq/L|
|Potassium||4.4 mEq/L||3.7 to 5.5 mEq/L|
|Calcium||1.8 mmol/L||2.15‐2.60 mmol/L|
|Magnesium||0.89 mmol/L||0.70‐1.10 mmol/L|
|Troponin (cTn)||11 ng/L||< 15 ng/L|
|Creatinine Kinase (CK)||120 U/L||30‐135 U/L|
|TSH||0.25 mIU/L||0.4‐5.0 mIU/L|
|T3||14 pmol/L||4.0‐8.0 pmol/L|
|FT4||3.4 ng/dL||0.7‐ 1.8 ng/dL|
|Neck Ultrasound||Thyroid : Diffusely enlarged||Normal Values|
Impression: Hyperthyroidism sec to? Subacute Thyroiditis/Graves
Case Study Question 3
Mr Sam Smithson, is a 51 year old male who was admitted to the high dependency unit for investigation of melaena. He has had two previous admissions for cirrhosis in the last 6 months. He was an interstate truck driver for 15 years and is married with 4 children. Mr Smithson is a current smoker and known to consume 5‐6 bottles of beer per day. He has a history of hypertension and mild hypercholesterolemia. On assessment:
Mr Smithson is lethargic but orientated to time, place and person and slightly irritable. He is slightly tachypnoeic with moderate use of accessory muscles. His wife reported that Mr Smithson has been spitting blood stained sputum for the last few weeks with no associated cough or shortness of breath. From the previous admission record it showed that Mr Smithson has lost 9 kilos which he attributed simply to his lack of appetite. No changes were reported with his urine output. On examination his sclera is mildly jaundiced and has some “unexplained” bruises on his arms and legs. His abdomen is tight and distended and pitting oedema noted on his ankles.
Observations: BP: 115/60mmHg, HR: 110 bpm, RR: 24 bpm, SpO2: 88% on RA, 95% on 6L via Hudson Mask, Temp: 37.8C
|RBC||4.0 million/mm3||2.6 to 5.9 million/mm3|
|WBC||3500 /mm3||4300 to 10800/mm3|
|Platelets||75000 /mm3||150000 to 350000/mm3|
|Serum Ammonia||110 μm/dl||35 to 65 μm/dl|
|Total Bilirubin||4.9 mcg/dl||0.1 to 1.0 mcg/dl|
|Sodium||150 mEq/L||135 to 145 mEq/L|
|Potassium||3.4 mEq/L||3.7 to 5.5 mEq/L|
|Haemoglobin||85 g/L||120‐170 g/L|
|Albumin||24 g/L||35‐50 g/L|
|Liver Enzymes||Slightly elevated|
|BUN||22 mg/dl||7‐18 mg/dl|
|Creatinine||154 ml/min||88 to 137 ml/min|
Mr Smithson was ordered Vitamin K 1 mg IM and underwent urgent gastroscopy which showed bleeding from gastric ulcer. A diagnosis of alcoholic cirrhosis with gastritis is made.
His current medications include: aldactone 25mg PO TDS, lactulose 15mls PO TDS, neomycin sulphate 1 gram PO every 4 hours for 5 days, vitamin B12 100mg IV TDS.
Impression: Alcoholic liver disease ‐ alcoholic cirrhosis with gastritis