acute case study.docx

Acute Case Study 4
Assessment
Project- Written Case Study
HLTENN005 Contributing to Nursing care of a person with Complex Needs
Student Name:……………
Student ID Number:……………
Diploma of Nursing HLT54115
Box hill Institute
Introduction
The study analyzes an acute case study of 85-year-old patient Peter Chan who is suffering from multiple diseases. The report evaluates his health condition on admission in the hospital and provides a systems assessment. Finally, the paper provides five discharge goals for the patient.
Section 1
The patient was brought in by Ambulance. He has Chest Pain of the scale 6/10, a high Blood Pressure of 190/110, Hypertension and Shortness of Breath. He reports of rushing sensation in head and high chest pressure. The patient is given Glyceryl Trinitrate (GTN) Sublingual, and GTN 50 mg patch to provide faster relief from chest pain, mainly to relax the atrioventricular (AV) chambers of the heart (Stewart, 2017). 22 gm Cannula was inserted in the Right forearm of the patient.
The chest pain was on and off, worsening with activity. The patient reported to have a sore throat and produced slightly yellow sputum. It is a sign of infection in the respiratory tract mainly during bronchitis (Weil, 2018). Generally was using Asmol puffers but did not use today. The asmol puffers can give faster relief from the chest pain. Asmol contains the drug Salbutamol as an ingredient (MIMS, 2015). The patient complains of roaring in ears. He is also having the sensation of piercing ‘pins and needles’ in his feet. This piercing sensation is generally perceived in the feet when the nerves have been damaged due to high blood sugar or Hyperlipidaemia in the body (Fieldhouse, 2014). The chest pain was reported to be high during the admission but later on it subsided to 0/10 level and Blood Pressure also came down to a manageable range of 146/91 mmHg.
Cardiac Telemetry is recommended in ward to constantly monitor the electrocardiogram of the patient for a longer time (Royal Children’s Hospital Melbourne, 2016). It measures the heart rate, blood pressure and rhythm of the patient during relaxed normal conditions. Salbutamol puffs are recommended to relax the smooth muscles of the lungs, open the airways and facilitate smooth breathing (Lybrate, 2018). Prednisolone 25 mg is recommended to treat multiple issues like breathing problems, acute asthma, inflammation and allergies (Accord UK, 2016).
The diagnosis depicted worsening of infective exacerbations of COAD symptoms like shortness of breath and color of sputum. Exacerbations are consistent worsening symptoms in the patient’s health which may involve an increase in production of sputum and changes in the color of sputum along with elevated wheeze and cough. The infection may be due to allergies or due to certain pathogens like virus or bacteria or common pollutants. The exacerbations are associated with chest pain and if recorded to be severe in due course of time, may require emergency support (National Institute for Health and Care excellence, 2016).
The patient also shows symptoms of hypertension during his responses. He is unclear while replying to the questions during the assessment.
Section 2
Primary Survey and Systems Assessment
Primary Survey: The airway is inadequate and there is obstructed breathing with a cough and yellow sputum. The patient reported having Shortness...