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Case study 1: Mr. Belfield - Coggle Diagram
Case study 1: Mr. Belfield
Nursing Assessment
Investigation
ECG - 12 lead ECG shows ST Elevation in anterior leads
Chest X-ray
Blood tests
LDL - 4.5 mmol/L
Troponin - >99th percentile
Vital Signs
Angiogram
Objective Cardiovascular Assessment
Palpitation
Auscultation
Inspection
Subjective Patient History
SAMPLER
Signs and Symptoms
Allergies
Medications
Prescribed Blood Pressure for HTN, does not take correctly
Past Medical History
Last Meal
Events Leading to Injury
Sitting in pub
Risk Factors
OLDCARTS
O- Onset
Pain commenced one hour ago while in the pub with friends.
L- Location
Centre of chest, radiating into arm.
D- Duration
Constant chest pain
C- Characteristics
Constant, heavy, burning sensation
A- Associated Factors
Dyspnoea, anxiety, diaphoretic
R- Relieving Factors/Radiation
T- Treatment/Temporal
S- Severity
Chest pain was 8/10
Cardiac Symptoms
Pain radiating from centre of chest to arm
Heavy chest pain--> 8/10
Hypertension--> 152/92
Tachycardic--> 112b.p.m.
Clinical Presentation
Tachycardic
Chest Pain
Hypertensive
Diphoretic
Anxiety
Hypoxia - 93% SpO2
Dsynopea
Risk Factors
Non-Modifiable
Age
Sex
Ethnicity
Family History
modifiable
Standarised Nursing Language
NOC
Lifestyle changes
More active lifestyle
Reduce social smoking
Reduce alcohol
Increase physical activity
Healthier diet - Increase fruit/vegetable intake and eat balanced meals
that jack no longer has any chest pain
NIC
Medication Management
Educate patient on importance of taking blood pressure medications regularly to manage to hypertension
Pain relief - Morphine + antiemetic IV
Administration of nitrates for blood pressure management as it is a vasodilator
Anxiety management - reassure patient and/or anxiolytic.
if patients saturation levels continue to decrease could administer oxygen therapy
patient education
inform patient on the importance of his lifestyle changes.
NANDA
Risk of Atherosclerosis - Build up in artery walls which forms plaque, due to High BMI and High Cholesterol, due to poor lifestyle choices such as diet, physical activity, smoking and alcohol intake
Risk of MI - due to presented cardiac symptoms and ST elevation shown on ECG
Risk of impaired cardiovascular function- as evidenced by untreated dyslipidemia, history of smoking and sedentary lifestyle
Risk of Heart Disorders such as Coronary Artery Disease due to increased levels of cholesterol and sedentary lifestyle, leading to possible stroke