Case study ( Three Correct Nursing diagnose Action + Identify person-centered goal of care + clear rational of each nursing action + evaluate strategy determine for action

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Cardiac Case Scenario – David Parker

Handover Report (ED to Ward 6D- Cardiology) 20th April 2020 @ 1500

MRN: 365 555 DOB: 26.06.1955

Introduction

This is David Parker, a 64-year-old male who was brought in by ambulance following an episode of chest pain whilst

working on his farm at home. David’s wife Sophie and one of their employees, did not witness the initial chest pain incident

but had found David clutching his chest in agony in the farmhouse, collapsed on the kitchen floor. David had stated that

the onset of chest pain commenced whilst he was out in the paddock fencing @ 10:00hrs. Sophie phoned the ambulance

against David’s wishes due to his rising anxiety and concern regarding the farm. David’s wife and two children accompanied

him to the emergency department.

Situation

On examination in the ED upon arrival @ 12:00hrs, David initially presented looking pale and diaphoretic, breathless, alert

and orientated but experiencing obvious distress, tachycardic and hypertensive, complaining of nausea, and suffering from

pain radiating to his left arm, neck and teeth areas. His central chest pain had been constant lasting for roughly two hours

from onset and David is currently experiencing a score of 8/10 requesting pharmacological analgesic relief in the ED. A

STAT dose of IV Morphine is administered post insertion of a size 18 cubital Fossa Intravenous Cannula (CF IVC). An urgent

ECG is performed on David by the admitting Nurse which shows ischaemic injury (ST elevation) in the anterior leads. David

does not have any PmHx risk factors of head injury, malignancies, stroke or gastric bleed and progresses towards

thrombolytic treatment administration. A confirmed diagnosis of an acute Myocardial Infarction is the admission reason

for David, also known as STEMI (ST-Elevation Myocardial Infarction). David has an elevated Troponin level at 0.25g/L.

Background

David is an aboriginal man who lives at home on his sheep farm in regional NSW with his wife Sophie and their two young

children. PmHx includes: Osteoarthritis, hyperlipidaemia, hypertension (HTN) usually well-controlled, Type II Diabetes

Mellitus (T2DM) (Diet controlled), ETOH (Ethyl alcohol) usually drinks three bottles of wine per week and smokes one

packet of cigarettes per week.

Assessment – Observations are as follows

- BP 150/90

- HR 108 BPM

- SaO2 95% on RA

- RR 24

- Temp 36.8⁰C

- GCS 15/15 (E=4, V=5, M=6)

- Pain Score 8/10

- BGL 14.1mmol/L

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Recommendations

The Emergency Department Medical Officer has transcribed a clinical plan as follows:

• Insertion of CF IVC

• Formal Bloods including: Formal Full Blood Count, Formal Urea, Electrolytes, Creatinine (UEC’s), Troponin Level

• Arterial Blood Gas

• Commence & titrate Glyceryl Trinitrate Infusion (GTN) to blood pressure and pain Maintaining DBP >60mmHg

• Morphine 2.5mg IV PRN

• Commence Thrombolytic treatment rTPA (Alteplase)

• Monitor GCS and vital observations please

• Consider Alcohol Withdrawal Scale (AWS)

• IV fluids 80mls/hr as charted

Additional: He is concerned about his farm and sheep at home. David is becoming increasingly agitated and impatient with

his family and rudely giving abrupt orders towards staff caring for him.

Charts available:

• SAGO & Neurological Observations Chart

• AWS Chart

• Fluid Balance & Fluid Order Chart

• Medication Chart