Posted: May 13th, 2015

Emergency Case Study

CASE STUDY: Lily Jones Lily Jones is a 72-year-old woman who lives with her husband. Last week she saw her general practitioner (GP) for a check-up, after experiencing several episodes of chest discomfort upon exertion during the past couple of weeks. Lily reported that she has been using her sublingual spray more frequently. An electrocardiograph was performed by the GP and was unchanged from previous visits. Her past medical history includes:  Ex smoker – 20 pack years  Type II diabetes – managed with oral hypoglycaemic agent. Last HbA1c was 12  Hypertension  Hypercholesterolaemia Lily insisted on going home from the GP visit to rest. She agreed to call an ambulance if her condition got worse. Question 1 Describe how each of Lily’s risk factors is significant in contributing to the pathophysiological changes associated with cardiovascular heart disease. (10 marks) During the night Lily awoke with difficulty breathing and central chest heaviness. Her husband called an ambulance and she was taken to the emergency department. On route to hospital, Lily is administered Oxygen 6 litres via a face mask because her oxygen saturation was less than 93%. An intravenous cannula was inserted in her right arm and she was administered 5mg of Morphine intravenously. Lily arrives at the emergency department and you are the nurse caring for Lily. You perform your clinical assessment upon arrival to hospital and on examination Lily is dyspnoeic and is complaining of central chest discomfort. An urgent electrocardiogram is performed (see attached). Question 2 Using a systematic approach, analyse the 12 lead ECG pictured above, providing a summary of any changes. Include a discussion of the relationship between the ECG changes and her presenting symptoms. (20 marks) Question 3 Discuss the underlying physiological processes that are likely to be contributing to Lily’s clinical assessment findings above. Consider the effect of Lily’s age in your answer. (20 marks) Question 4 With consideration for the patient’s clinical presentation, and with reference to current research findings, critically analyse potential medical treatment options and subsequent nursing care required for this patient. (20 marks) On examination Lily is dyspnoeic, she is only able to speak a few words at time, she is pale, sweaty and peripherally cool. Upon auscultation of the chest you can hear widespread fine crackles in both lungs. Her clinical assessment revealed: HR 92 beats per minute RR 22 breaths per minute BP 180/95 mmHg GCS 15/15 Temp 35.4 ºC SpO2 93% on 6L of oxygen via a Face Mask While talking to Lily, her clinical condition deteriorates. She says she is finding it increasingly difficult to breathe and she is restless. Her respiratory rate is 26 breaths per minute and more shallow than when she was first admitted. Lily is only able to speak in short sentences. Her SpO2 is 90%. Arterial blood gases and routine bloods were taken. The results are as follows: Result Reference K Na Creat Glucose WCC Hb Troponin T INR APTT 4.8 mmol/L 136 mmol /L 160 µmol/L 18 mmol/L 14 x 109gL 135 g/L 32 ng/L 1.0 35 sec (3.5-5.0) (135-145) (80-120) (4-8) (8-12) (130-170) <15 ng/L (0.9- 1.2)(25-37) ABG pO2 pH pCO2 HCO3 BE SaO2 52 mmHg 7.52 33 mmHg 24 mmol -2 86% (80-100) (7.35-7.45) (35-45) (22-26) (-2 to 2) (95-100) Question 5 Interpret the above blood results and provide a physiological rationale for any abnormality. Discuss how these alterations will influence tissue oxygen delivery and how this will impact on end-organ function. (15 marks) .Question 6 Discuss four important secondary medication groups that should be considered for Lily’s secondary prevention of further cardiac complications. (15marks)