Case Study
Mr Henry Wilson is a 54 year old bank manager who presents to the Emergency Department with a sudden onset of shortness of breath and left sided chest pain whilst watching the evening news. The pain has been constant for one (1) hr.
He has no relevant past history and he is taking no regular medications. He is 160 cm tall and weighs 95kg.
You are the Registered Nurse caring for Mr Wilson on arrival.
Mr Wilson states he has left sided chest pain. The pain is not exacerbated by deep breathing, coughing or movement. He is diaphoretic and has a pain score: 8/10. His vital signs are Temp: 37.2, HR: 84, BP: 150/90 mmHg, RR: 18, SaO2: 95% in RA. Glasgow Coma Score (GCS): 15. He is treated in the Emergency Department and a 12 lead ECG is done (results below).
The medical officer has inserted an IV cannula.
The medical officer orders the following to be commenced immediately and then re-review.
• Oxygen Therapy
• Blood pathology to be collected, including FBC, EUC, LFT, BSL and cardiac markers.
• Medications: Morphine 2.5 mg IVI for pain
Aspirin 300mg stat
Clopedigrol 600mg
Anginine
• X-Ray: Mobile chest.
The results of Mr Wilson’s cardiac markers have been processed by pathology and are as listed below:
CK-MB: 1.0mcg/L
Troponin I: 2.0mcg/L
Assessment Task:
As a guide in no more than 1000 words (using your criteria sheet), apply the ABCDE framework and critically analyse the clinical indicators in the case study and their significance. In particular, apply your knowledge in interpreting the attached 12 lead ECG to determine care priorities for Mr Wilson. Then identify and discuss the most important nursing interventions (at least two priority interventions) relevant to Mr Wilson’s needs and the rationales for these as you assess him. Your paper should demonstrate an understanding of the pathophysiology and treatment ordered by the medical officer (i.e oxygen, ECG, medical tests, medications) and your nursing responsibilities associated with this treatment. Discuss 2 of the 4 medications identified. Please remember to write this paper in a formal/analytical style.
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