Reference no: EM131953494 , Length: word count:2500
Acute Care Nursing Practice Assessment -
Case Study - Peter Stanhope
Background information -
Mr Peter Stanhope is a 70 year old Caucasian male who was admitted to the Coronary Care Unit (CCU) with complaints of increasing shortness of breath, fatigue and unexplained rapid weight gain over a two week period.
Past medical history - History of hypertension for 20 years with an MI at the age of 58.
Past surgical history - Laparoscopic Cholecystectomy (age 55)
Medications -
- Ranitidine 150 mg PO prn every 8 hours for reflux
- Lipitor 40 mg PO daily
- Enalapril 2.5 mg PO daily
- Frusemide 40 mg PO bd
Family history
- Father deceased (age 62) - Acute Coronary Syndrome,
- Known family history of hypertension
Social history
- Lives alone and does not always remember to take medication
Height: 169 cm Weight: 105 kg (previously 95 kg)
Admitting vital signs in ED
- Respiratory rate 36 bpm
- Blood Pressure 170/110 mmHg
- Heart Rate 105 bpm
- Temp 37.9 oC
Diagnostic results -
- Chest X-ray indicates cardiomegaly with right and left ventricular hypertrophy; fluid in lower lung fields
Intervention orders
- Frusemide 40 mg IVI stat
- Potassium Chloride 40 mEq PO bd
- Enalapril 5 mg PO daily
- Milrinone 50 microg/kg IVI over 10 minutes
- Continuous ECG monitoring
- 2 gram/day sodium restricted diet
- Titrate O2 to keep SpO2 > 93%
- Strict fluid balance chart
- Daily weight
- Serum electrolytes and cardiac enzymes 8 hourly x 3
You are the admitting nurse in the CCU responsible for Peter's care. On presentation you note Peter is having difficulty breathing with extreme shortness of breath. He looks pale; skin cool and diaphoretic.
You are required to refer to the Case study - Peter Stanhope, and complete Part 1 and Part 2 questions.
Case study questions:
Part 1: Describe your initial assessment of Peter including a detailed description of your systematic approach. Outline any additional subjective and objective data you would expect to find.
Part 2: Following your initial assessment of Peter and considering the current intervention orders, develop a plan of care with patient centred goals.
Your plan of care should be prioritised and include;
- Short term (bedside) and long term (rehabilitation) goals,
- All goals should be in the SMART format
- Interventions (actions) to achieve the required goals (including multidisciplinary care)
- How the goals or outcomes are measured
- Rationales using current literature and evidence for each intervention to be implemented.
Attachment:- Assignment File.rar