Fatima El Nadir Case Study - Report Writing - Nursing Assignment Help

Assignment Task:

Case study: Fatima El Nadir

Background information: Mrs. El Nadir is a 75 year old Syrian female who is a new admission to the Coronary Care Unit (CCU). She presented to the Emergency Ward (ED) with her husband and son complaining of increasing shortness of breath, fatigue and unexplained rapid weight gain over a two-week period. Mr El Nadirs husband has indicated that she has been reluctant to attend hospital. Past medical history Hypertension for 20 years Osteoarthritis left hip GORD Myocardial infarction (age 63) Chronic heart failure Past surgical history Laparoscopic Cholecystectomy (age 55) Medications Omeprazole 40 mg daily Rosuvastatin 20 mg PO daily Lisinopril 5mg PO daily Furosemide 20 mg PO bd Paracetamol//Osteo 665 mg - two tablets tds Family history Father deceased (age 61) - Acute Coronary Syndrome Known family history of hypertension Social history Lives with husband and 2 adult children and does not always remember to take medication Actively involved in the activities of her Mosque and Islamic community Height: 169 cm Weight: 105 kg (previously 95 kg) Admitting vital signs in ED

•  Respiratory rate 36 bpm
•  SpO2 91% on room air
•  Blood pressure 185/110 mmHg
•  Heart rate 128 bpm
•  Temperature 37.6°C Diagnostic results Chest X-ray indicates cardiomegaly with right and left ventricular hypertrophy; fluid in lower lung fields Provisional diagnosis Acute decompensation heart failure Intervention orders
•  Furosemide 40 mg IVI stat
•  Potassium Chloride 40 mEq PO bd ? Enalapril 5 mg PO daily
•  Milrinone 50 microg/kg IVI over 10 minutes ? Enoxaparin 40 mg daily ? Continuous ECG monitoring
•  1.2 L/ day fluid restriction
•  2 gram/day sodium restricted diet
•  Titrate O2 to keep SpO2 > 95%
•  Strict fluid balance chart
•  Daily weight
•  Serum electrolytes and cardiac enzymes 8 hourly x 3 You are the admitting nurse in the CCU responsible for Mrs El Nadir’s care. On presentation you note she is having difficulty breathing with extreme shortness of breath. She looks pale; skin cool and diaphoretic. She has been assessed as moderate for VTE risk.

Case study questions:

1. Describe your primary and secondary assessment of Mrs El Nadir. Outline any additional subjective and objective data you would expect to find.

2. Explain Mrs El Nadir’s presentation and clinical assessment findings in relation to the underlying pathophysiology.

3. Describe and provide rationales for the medications prescribed prior to admission and the current pharmacological intervention orders for Mrs El Nadir. Identify and discuss any issues that may arise for Mrs El Nadir from the current pharmacological intervention orders.

4. Outline the plan of care for Mrs El Nadir and include rationales for proposed interventions (actions).

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