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Nursing - George Case Study - Pathophysiology Disease Assessment Answer

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Nursing Assessment Answer

Assignment Task:

George Case Study

The objective of this assessment is to discuss your ideas related to a focused health assessment of your case study patient. A focused health assessment concentrates on a specific area of concern, for example, if a patient is breathless, then your assessment should include a respiratory/cardiovascular and functional assessment. From the attached case studies, select one case that you find interesting. Your case study will include a number of findings that will assist you in discussing your case study patient. Your case study should include the following;
  1. Describe the sequencing of your proposed assessment.
  2. In relation to the health history, what questions will you ask? How do these inform your proposed assessment?
  3. Analyze the findings of both the health history and the focused health and clinical assessment and relate these findings to the underlying disease pathophysiology.
  4. Formulate the nursing interventions for your selected patient using appropriate evidence-based nursing literature to support your care decisions. It is essential that a clear relationship between the health history, the assessment and the process of care be outlined in your case study. Your case study must demonstrate your clinical judgment
George Case Study 1: George is a 45-year-old male of Greek descent, he is currently married with one son of 13 years of age and two daughters of 15 and 17 years old. George’s dad passed away from a “heart attack” at the age of 42 when George was a teenager. His mother recently passed away after a stroke this year. His last remaining uncle had a “heart surgery after his heart attack when he was 55 years old”. George currently works in a high-stress management position at the airport, he coaches his son's soccer team and also plays soccer on a Sunday but doesn’t participate in any other exercise. Georges body mass index is currently at 29 and his waist circumference is 100cm. George presents to his GP complaining of flu-like symptoms. The GP took his blood pressure and found it to be 174/100. Auscultation of his chest was clear. The GP ordered further testing for George including blood pathology tests. George was called back to the GP to discuss the blood results that had come back, his BP remained elevated at 167/100. The blood results included serum cholesterol 7.2 mmol/L, LDL 6.2, HDL 0.7 and fasting triglyceride 5.9 mmol/L. The GP made suggestions for lifestyle modifications that George could commence. The following week George returned home early from work one day complaining of nausea and severe pain in his back shoulder and arm, his wife became concerned as he looked “very pale and sweaty” so she drove him to the local ED. On arrival, George was assessed by the triage nurse. Using the PQRST method she confirmed that George was experiencing 9/10 pain in his left posterior shoulder and it was radiating to his left arm. The pain increased on exertion and he was triaged through to results. George was ordered an ECG, blood pathology testing, insertion of two large gauge IVC’s, 300mg of aspirin, sublingual GTN stat and PRN IV morphine. The ECG showed ST elevation in leads V3 and V4 and pathology results showed moderately raised troponin I and T. George was transferred to the coronary catheter laboratory for a primary PCI, where he proceeded to have coronary angioplasty via his right radial artery with 2 x stents inserted to his LAD. Post-procedure once George was recovered he was transferred to the Coronary Care Unit for continued cardiac monitoring and assessment. Case study Eva Mendoza 2: Eva Mendoza is a 35-year-old female involved in a bicycle accident. She was thrown over the bicycle handles and despite wearing a helmet she was found to be unconscious after hitting her head on the pavement by nearby bystanders that witnessed the event and called an ambulance. On initial assessment, it was evident that she sustained multiple cuts and grazes to her arms, legs and face and two front teeth were dislodged. On arrival in the ED Eva was classified as ATS 1. Assessments were made, and findings include; temperature 37 C, 98 pulse, 20 respirations, 100% Oxygen saturation. Incomprehensible words, pupils 5 mm and sluggish, bilateral upper and lower spastic flexion, eyes open to pain only. Eva was intubated, an IDC inserted and shenwas ventilated in preparation for transport to CT. This showed a right subdural hematoma, cerebral oedema and an intact C spine. She was scheduled for an urgent craniotomy; her GCS had dropped to 6. There was no longer any response from Eva, her right pupil was sluggish to light. Following drainage of the haematoma and insertion of a EVD, Eva was transferred to the ICU for ongoing care. In ICU, Eva continued to be ventilated and was hyperventilated to keep the PaCo2 below 30 mmHg. Ongoing assessment and management of ICP continued. Eva stabilised over the next few days and was extubated and her EVD was removed; she was transferred to the ward 72 hours later. Her GCS was 12, she was confused, localised to pain and opened her eyes to speech. Six days later, her GCS was 14, however she was very sleepy and at times continued to be confused. On mobilisation, she was unsteady on her feet. She had a weakness in her left leg. Three weeks later, Eva was transferred to the rehabilitation unit. While she was no longer confused, her memory was poor, and she lacked concentration, tired easily, tended to be impulsive and easily become distracted. When she became tired her speech slurred and she complained of blurred vision. She also complained of diminished sense of smell. Case study Adam 3: Adam is a 32-year-old man, who has had asthma since he was a child. He lives with his Uncle in Wollongong and works at the steelworks. Adam’s father died of complications from asthma when he was 40 years old, his mother is in good health, with mild hypertension. Adam’s general health is good, with a past history of an appendectomy when he was 16 years old. His weight is 78kg, and his height is 176 cm. He swims 2 km three times per week and walks 5 km three times a week. He eats a balanced diet, does not smoke and drinks alcohol in moderation. His asthma is well controlled with a daily inhalation of beclomethasone. When he has the occasional common cold he also requires salbutamol to relieve his asthma symptoms, in addition he has a yearly flu injection. While Adam tries to avoid people with colds and flu, his uncle was recently diagnosed with the flu. One week later, Adam began to feel unwell, he became dyspnoeic within a day, and had a temperature of 39 C. He wheezed and coughed and had chest tightness. He adopted his asthma rescue plan but continued to deteriorate. His uncle took him to the ED. On assessment, Adam’s temp was 38 C, pulse 115, 32 respirations, BP 160/90, SaO2 91%. Adam was using his accessory muscles to help him breathe and on auscultation, he has decreased breath sounds and both inspiratory ad expiratory wheeze. His oxygen saturation dropped to 88%. Adam was administered salbutamol via a neb and IV. Oxygen was given and a corticosteroid. Adam’s chest was again auscultated, and it was found that although he has a loud expiratory wheeze, he had better airflow. However, he was still using his accessory muscles. After the IV medication therapy, his respiratory rate dropped to 28 and his pulse to 110. Monitoring continued however after four hours in the ED, he again began to deteriorate; further salbutamol was given. His vitals included 38.2 C, pulse 145, resp 38, BP 180/90, Sa O2 87%. He has a slight tremor in both hands and was using his accessory muscles again and was having trouble speaking. He appeared very tired but was also very anxious. His medication was reviewed, and he was given IV ipratropium, methylprednisone and an antibiotic. A further four hours saw Adam begin to improve. His observations had stabilized, and he no longer had difficulty breathing. A further 20 hours later, he was no longer using his accessory muscles to breathe and was able to speak easily without dyspnoea. His vital signs included 37.2 C, 90 pulses, 16 resp, BP 140/85, SaO2 99% on room air. Adam was discharged and returned to his work 2 days later.
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