CRIT3001 - Complex Nursing Practice - Michael Kwon Case Study - Nursing Assignment Help

Assignment Task

CASE STUDY

Michael Kwon is an82-year-old male. Hewas admitted to the Emergency Department (ED) of a General Hospital at 1030 hrs after he had experienced sharp central chest pain, which lasted for about 10 minutes while he was at his home. Mr Kwon claimed that he felt “light-headed” during the chest pain and fell heavily ontothe sharp edges of a natural Jarrah wood table in his living room.  He lacerated hisright leg and there was ‘lots of bleeding.’ His wife Gloria applied first aid and called the ambulance. Mr Kwon claimed that he also “fell onto the ground and complained of pain 5 out of 10 at rest, on his right lower ribs.”

When the Ambulance Officers attend to Michael, Gloriaclaimed, “I think Michael hit his head and he is complaining that his neck is sore.” The Ambulance Officers assessed Mr Kwon and provided interventions.  Aneck collar was placed insitu,hisright legwas elevatedand a pressure dressing was applied. After that, the ambulance officers liaised with the hospital ED Medical Officer (MO) and reported the findings. The MO ordered sublingual Anginine half tablet for chest pain, soluble Aspirin 300mg oral and oxygen via nasal prongs. Mr Kwon was transferred via ambulance to the hospital.

On initial assessment by the ED nursing staff,Mr Kwonwasslightly drowsy and only responded to voice. His voice washoarse, harsh andhigh-pitched. His breathing was shallow, with occasional dyspnoea on movement. Michael displayed asymmetrical chest movements on the right side. On anterior auscultation of his lungs, whilst he was sitting up, his lung fields demonstrated a bilateral wheeze with reduced air entry on his right lower lung field. The colour of Michael’s skin waspink to pale with some mild spotty urticarial rash on his chest. 

Mr Kwon's pulse was irregular,weak and rapid. The ED clinical staff note that Michael’s peripheries are cool and clammy with a pale appearance. The lead II ECG monitor indicates sinus tachycardia with some ST elevation. Mr Kwon complained that his skin “isfeeling a little itchy”.  The Medical Officer inserted an intravenous cannula and also took blood samples for laboratory testing. Michaelclaimedhe had been “nauseous overnight, had vomited once andhad very little to drink overnight and this morning.”

Mr Kwonwasslightly drowsy and opened his eyes to speech. Michael was orientated to time place and person obeyed commands and hadequal normal power in both arms, normal strength in hisleft leg and mild weakness in his right leg. His pupils were equal 3 mm and reacted to light. His GCS was 14. The ED Nurse decided thatMr Kwon was for senior medical review within 10 minutes. 

Mr Kwons past medical history and surgical history include; hypertensionfor 10 years and he was diagnosed one month ago with stage one chronic renal failure. Michael has osteoarthritis of his neck, lower back, and both hips, and he had an inguinal hernia repair in his twenties. Mr Kwons weight was 102 kg and hisheight was 186 cms. Allergies includemilk, shellfish andIbuprofen. 

While the Registered Nurse (RN) attended to Mr Kwon he stated that he had been having “dull central chest pain over the last two weeks.” Michael claimed this “only occurred after moderate-intensity exercise like when he would play tennis.” His GP hadprescribed anginine tablets half tab sublingual prn, which was effective to relieve the chest pain. Mr Kwon had been given a Cardiologist appointment for the coming week. 

Mr Kwon claimed“he had elevated cholesterol and was trying to reduce it with diet and exercise.” He claimed he was “also trying to lose weight and is playing tennis and walking daily.”Michael also stated hehad smoked “just a few cigarettes,about 5 a day, since he was a teenager and is trying to quit.”

Medications included:  Perindopril 4mg daily, anginine tablets half tab sublingual prn, paracetamol 1 G daily prn,Naproxen 250 mg BD with food,

On admission Mr Kwon’s observations were:

• Temperature: 37.1 C
• Blood Pressure: 102/62 mm Hg
• Pulse:126/min and irregular 
• Respiratory rate: 23/min
• Oxygen saturation: 95% on 10 l/min via Hudson Mask
• Chest pain on admission: a pain score of 5 out of 10sharp central chest pain. 
• Peripheries: cool, pale, capillary refill greater than 3 seconds
• Central Nervous System (CNS): Drowsy

The blood test results were:

• Creatine Kinase 1950  U/L (normalmale 60 – 220 U/L )
• Troponin T 5.5mg/L(normal < 0.01 mg/L)
• Cholesterol 5.6mmol/L (normal < 5.5 mmol/L)
• Triglyceride 2.1   mmol/L  (normal < 2.0 mmol/L
• High density lipoproteins (HDL-C)  0.9  mmol/L (normal > 0.9 mmol/L)
• Low density lipoproteins (LDL)  3.8 mmol/L (normal < 3.4 mmol/L)
• Sodium - 144mmol/L (135 – 145 mmol/L)
• Potassium – 3.6mmol/L (3.5 – 5.2 mmol/L)
• Magnesium – 0.80 mmol/L (0.8 – 1.0 mmol/L) 
• Glucose random –4.2  mmol/L(3.0 – 7.7 mmol/L)
• Urea – 7.80  mmol/L (3.0 – 8.0 mmol/L) 
• Creatinine 0.10  mmol/L (0.05 – 0.11 mmol/L) 
• eGFR 92 mL/min/1.73 m² 
• Haemoglobin –94 g/L (120 – 160 g/L)
• Leucocytes total white cell count – 7.0 × 109 /L (4.0 – 11.0 × 109 /L)
• Platelets –190 × 109 /L (135 – 370 × 109 /L)
• INR - 1.2   (1.0 – 1.2) 
• aPTT – 32 seconds (20 – 35 seconds)

Urinalysis

1. Urine SG 1030, pH 6.0, protein + and other NAD. 

A 12 lead ECG was performedand reviewed by the MO. The ECG showed ST elevation in lead I, aVL, V3, V4, V5 and V6 and frequent multifocal premature ventricular contractions. Arterial blood was taken for arterial blood gas analysis and sent to the laboratory. A chest x-ray wasperformedand the result showed multiple fractures to the right side lateral rib number 9 causing a small right-side haemothorax. A cervical spine x-ray was also taken. 

Mr Kwon was prescribed oxygen therapy at 10 litres/min via a Hudson Mask and was commenced on a Heparin infusion 5000 units bolus followed by 25 000 units in 500 ml at 30mls/hr. Normal Saline 1000mls @ 80 ml per hour for 24 hours.  Michael was initially nil by mouth to prepare for any procedures. Mr Kwon's chest pain was initially described as central crushing pain with a pain score of 5 out of 10 at rest.  Michael was prescribed Morphine 2.5 mg to 5mg slow IV push over 5 mins every 2 to 4 hrs for chest pain. 

After evaluation of the Mr Kwon’s assessment and investigations,the provisional diagnosis provided by the ED Medical Officer wasanterolateralST-elevation myocardial infarction (STEMI). After completion of all ED medical assessments investigations and treatment Michaelwas transferred to the Coronary Care Unit (CCU) for monitoring and further cardiology investigations.

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