Question

CASE STUDY

Read the case study, answer the questions, and write nursing diagnosis as directed.

A 60-year-white female is admitted at midnight with a diagnosis of Chest Pain. She complains of a squeezing type pain across her chest and into her left jaw area. Vital signs are: Blood Pressure-200/110; Pulse-128 beats per minute; Respirations- 26 per minute; Temperature-99.8; Saturation of Oxygen-86% on room air; pain level 9/10. During your initial assessment she is rubbing her mid-chest, grimacing and is diaphoretic. The pain has been occurring intermittently throughout the evening and night. Her color is pale except around her lips which are bluish. Cardiac auscultation reveals a rapid regular rhythm and a murmur, no pulse deficit. She has never had this pain before. Lungs sounds are crackles in both bases with clear upper lobes. She is afraid she is going to die. Per standing orders, a nurse administers & administers Nitroglycerin 0.4mg sublingually; applies cardiac electrodes for continuous cardiac monitoring; obtains an electrocardiogram; places a peripheral intravenous catheter with saline lock; positions patient in low Fowler's.

Later assessment as follows: vital signs are Blood Pressure-180/95; Pulse-108 beats per minute; Respirations- 22 per minute; Temperature-99.0; Saturation of Oxygen-90% on 2 liters per minute; Pain level 8/10. She says her chest pain has not changed. Heart and lung sounds are unchanged. Color is pale without previous blue changes.

• Is the type of pain this patient is having typical or atypical of cardiac type of chest pain?
• What other types of pain would indicate a cardiac type problem but would not be specifically in the chest area?
• Describe how women often present with cardiac problems and how they are different from men.
• What health history information would the nurse assess after the patient's pain is gone.
• What abnormals are present in the patient's vital signs (first set)?
• What statements by the patient depict extreme anxiety and feelings of doom?
• What labs would be drawn for this patient that would identify if the pain is from cardiac origin?
• What would the results be if the patient is having cardiac damage?
• A provider orders Aspirin 81 mg x 2 tabs by mouth chewed. What is the rationale for this order?
• What is the reason for the diaphoresis?
• The patient's skin color is abnormal, describe this in medical terms?
• Does this patient need oxygen? If so what type of oxygen administration device would be applied and what rate of flow?
• Describe how you assess JVD in this patient?
• What results would indicate that the patient has JVD?
• If JVD is present this would indicate right or left sided heart failure?
• The patient has lung crackles: Is this right or left sided heart failure?
• What type of heart sound would the nurse listen for to indicate that the patient might have left sided failure?
• A nurse would expect the provider to order what type of medication if the patient has congestive heart failure?
• Describe the rationale for your answer as well as what labs you would check before you give this medication?
• The nurse administers one nitroglycerin tablet sublingually. What will this medication do for this patient? What side effects will the nurse have to assess for and manage? How many doses of Nitroglycerin can be given and within what time period? The pain assessment must be conducted before and after each dose. The desired outcome is for the pain to decrease.
• Identify and prioritize the problem list for this client.
• Use the data in the case study to write 2 nursing diagnosis w/at least 4 interventions each)

Answer 1

She has typical chest pain

other types of pain that has cardiac problem referred chest pain aminly in the jaw, left hand pain, back pain (intrascapular), epigastric pain, neck and jaw.

after menopause, the women has absence of  estrogen which is normally protect the heart.

her blood pressure 200/110 to 180/95 , her color is pale with no blue changes. saturation is become 86 to 90%

abnormal of first vital signs are Blood pressure 180/95 mm of Hg, RR 26breaths/minute, Pulse Rate is 128 beats /minute,SPO2 is 86%, Temperature is 99.8 F

the patient said a statement " i am afraid and going to die " that indicate that she is anxious

the following investigation are done to idenify the cardiac damge which are troponin I, troponin T, CK-MB. elevated level of this investigation helps to diagnose heart problem.the Troponin I shows <0.04ng/ml. CKMB is 5-25IU/L

this patient needs clopidrogrel and aspirin tablets which is administrered to inhibits cyclooxygenease in order to prevent production of thromboxone A2 and thereby prevent platelet aggregation.

the reason for diaphorsis is that responses of cerebreal cortex due to reduced blood supply to the brain by the heart

bluish discolouration of the lips is cyanosis of the lips in medical terms

this patient needs need oxygen therapy on 2-4 liters per minute via nasal cannula

assessing Jugular Venous Pressur, patient should be supin position and head end of bed is elevated to 15-30 degree. turn the patient head away from assessing neck vein, locate external jugular vein and able to see visible pulsation of internal jugular vein and identify highest point of internal jugular vein. Place the scale at the sternal angle and place another scale at the highest point of internal jugular vein and calculate the distance of above the sternal angle with another scale intersects the scaler.

Jugular venous pressure is elevated when scale shows greater the 3 or 4 cm above the sternal angle

Jugular venous pressure is higher that indicates right heart failure

crackles in the lung that indicate left heart failure

the nurse can hear S₃ and S₄ heart sound in the left heart failure

A nurese would expect to order diuretic mainly loop diuretic, Positive ionotropes Mainly Dobutamine, dopamine and digitalis like digoxin, beta adrenergic blockers mainly atenolol.vasodilators like nitroglycerin, ACE inhibitors (ramiprill) and angiotensin II receptor antagonist like losartan pottasium. angiotensin II receptor antagonist to be given after checking urea and creatinine. while giving loop diuretic , need to monitor pottasium of the patient.

nitroglycerin can be given sublingually for chest pain. pain will be relieved within 3 minutes of administration. if pain is not relieved within 5 minutes, again 2 tablets can be given at a interval 5 minutes. reason for this giving medication is that increase coronary blood floow and prevent vasospasm and increase blood flow through colloateral coirculation.it decreases blood pressure by relaxing systemic arterial bed. side effects of this medication are orthostatic hypotension, tachycardia, flushing

First priority is1. pain

- check vital signs

- administer pain medication nitroglycerine

- administer nitrogllycerine, aspirin +clopidrogrel tablet for her

----monitor her blood pressure continuously

administer dobutamine to increase pump of heart

2.in effective breathing pattern due to chestpian as evidenced by low saturation

--make her fowler position

administer oxygen therapy

- calm her to avoid excessive responses of her body

administer loop diurteics and monitor her potasium level