Posted: September 17th, 2017

case report

case report

Instructions
construct a case report. Your case report must draw upon the academic literature, be written in the third person, and have headings. Your case report should include the following:

Introduction (150 words)
Introduce your selected client and give a brief overview of their case. Provide an outline of the topics you will discuss.

Psychosocial Development and Lifestyle Choices (400 words)
Using one of the theories of psychosocial development, state which behaviours may be predicted at your chosen client’s age. For example, you might focus on the developmental theories of Levinson, Buhler or Erickson.

Identify and briefly discuss any lifestyle choices in the scenario that may have contributed to your chosen client’s current health status.

Nursing Management (800 words)
Identify two actual or potential health concerns for your chosen patient and outline nursing management strategies which could be utilized to monitor/address these health concerns.

Conclusion (150 words)
Summarise the major findings of this report.

Need 10-12 references
Please focus on nursing diagnoses and management and not the medical one.

Handover section provides a lot of the details.
Format
Use plain fonts such as arial or calibri
Use font size no less than 11
Use 1.5 line spacing
Set margins at 2.5cm
Number the pages
Please keep the good paraphrasing

Case study

Basic information
Name:Carl Paxton-Giles
Age: 54 years
Height: 185 cm
Weight: 115 kg
BMI: 33.6 kg/m2
Married
Next of kin: Wife
Covered by private insurance
Employment: chief financial officer

Past medical history
Mumps as child
Left knee arthroscopy at age 50 years
Hyperchlestrolaemai
Type 2 DM

Medical History
Diagnosis: chest pain
Allergy: Nil known
Immunization is up to date

Progress summary
Carl a 54 years old male was brought to ER by ambulance following sudden onset of central chest pain. Carl was at home asleep when he was awoken by sudden onset of central chest pain. Carl woke his wife Tanya and stating he was in pain and felt nauseous and she noted he was also sweating profusely. Tanya called an ambulance and Carl was transported to the hospital.
Ambulance officer provided GTN sprayx2 whilst on route to the hospital. Upon examination in the ER, Carl continued to complain of pain and was administered a further dose of GTN spray which relieved his chest pain. ECG showed anterior ST elevation. Carl was administered aspirin and bloods were sent to check troponin and creatine kinase (CK) level.
Carl was immediately sent to Angiography for an emergency Angiogram. Results from angiogram showed 95% occlusion to the right coronary artery (RCA). 90% occlusion to the left anterior descending coronary artery ( LAD) and 70% occlusion to the circumflex with distal disease.
Carl has been admitted to the medical/surgical ward post angiogram and is awaiting cardiothoracic review.

Care Plan
Ward diet- feeding, hygiene, skin integrity, mobility and elimination are all independent.
Assessment and monitoring
Vital signs observation, Neurovascular observation and oxygen saturation post angiogram
Continuous cardiac monitor and 12 leads ECG
Blood glucose level check every 4 hours
On oxygen supplement
Awaiting blood and ECG results
Allied health input:
Endocrinology review
Diabetic educator ontacted
Dietetics
Physiotherapy
Podiatry
Ophthalmology review
Psychosocial counseling

Handover
Carl is a 54 years old male, admitted to the ward post angiogram. He presented to the emergency department in the early hours of the morning following sudden onset of chest pain. He has no previous cardiac history and this is the first presentation to the hospital with chest pain. Apparently his father died from myocardial infarction (MI) at the same age so he is very anxious.
Carl has a past medical history of type 2 diabetes and hypercholesterolaemia. According to his wife, he is a poorly controlled diabetic and his BMI is over 33 kg/m2. He has no known drug allergies and is currently taking Metformin, Glipizide and Simvastatin. He suffered a fracture jaw and fracture left femur as a teenager and had a left knee arthroscopy4years ago. Carl is a self-confessed workaholic and works as the chief financial officer for Brody wines.
Carl’s angiogram showed 95% occlusion to the right coronary artery (RCA). 90% occlusion to the left anterior descending coronary artery ( LAD) and 70% occlusion to the circumflex with distal disease. He is awaiting urgent cardiothoracic review. The team is delayed in the operating theatre currently. It is anticipated Carl will go onto the emergency operating theatre list for coronary artery bypass grafting (CABG) later today. He is now due half hourly observations for the next hour, then hourly after that. He is due to rest in the bed for a further 2 and half hour.
He has IV access in-situ however, no fluids are currently ordered. The cardiac team has requested repeated ECG and blood following angiogram which we have not done as yet.
Carl remains on the post angiography pathway and observation are as follows:
Temperature 37
Pulse 100
Respiratory rate 20
Chest pain 3/10
BGL 11.2 mmol
Insertion site ( left groin) dry, no evidence of swelling or haematoma
Pedal pulse (left) present
Neurovascular observation left leg ( colour: pink- warmth: warm- movement: present and within normal limits- sensation: present and within normal limits).

Medical orders:
Urgent angiogram
Repeat ECG following angiogram
Repeat bloods following angiogram (Trop, CCK,APTT)
Review by cardiothoracic team post angiogram.