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    NRSG353 Assessment Task 2 –Case Study Due Date: 20th May 2016 at 5pm via Turnitin Weighting: 40% Word count: 1600 words (every question has a specific word count, which must be adhered to) Instructions: · Students are to choose one (1) of the case studies below and answer the associated questions. The assignment is to be presented in a question/answer format NOT as an essay (i.e. no introduction or conclusion). · Each answer has a word limit (1600 in total); each answer must be supported with citations. · A reference list must be provided at the end of the assignment. · Please refer to the marking guide available in the unit outline for further information. ** The following questions must be answered for your chosen case study ** The following questions relates to the patient within the first 24 hours since admission to the emergency department (ED): 1. Outline the causes, incidence and risk factors of the identified condition and how it can impact on the patient and family (400 words) 2. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology (350 words) a. This can be done in the form of a table – each point needs to be appropriately referenced 3. Describe two (2) common classes of drugs used for patients with the identified condition including physiological effect of each class on the body (350 words) a. This does not mean specific drugs but rather the class that these drugs belong to. 4. Identify and explain, in order of priority the nursing care strategies you, as the registered nurse, should use within the first 24 hours post admission for this patient (500 words). 2 Case Study 1: Myocardial infarction with history of stable angina and mitral valve stenosis Mr Tupa Savea is a 54 year old male who has been transferred to the coronary care unit (CCU) from the emergency department for management of episodic chest pain. He has a history of stable angina and mitral valve stenosis. Mr Savea is of Samoan background and has lived in regional Queensland for the last 20 years with his wife and children. He was brought in by ambulance having had chest pain and shortness of breath. He reports having similar symptoms on and off for the past two months but did not visit his GP as he assumed the discomfort was due to indigestion. Mr Savea is an ex-smoker, tobacco free for the last six months and a social drinker (approx. 10 units/week). He works full-time as an orderly at a local hospital and is active in the Samoan support community. On assessment Mr Savea’s vital signs are: PR 90 bpm and irregular; RR 12 bpm; BP 150/100mmHg; Temp 36.9°C; SpO2 98% on oxygen 8L/min via Hudson mask. He has a body mass index (BMI) of 35 kg/m2 indicating clinical obesity. Blood test results show elevated cardiac enzymes and troponin levels and cholesterol level of 8.9mmol/L. His ECG indicates that he has a ST segment elevated myocardial infarction. Mr Savea was administered sublingual glyceryl trinitrate followed by morphine 2.5 mg IV for pain in the emergency department. He reports being pain free on admission to CCU. 3 Case Study 2: Cushing’s Syndrome Ms Maureen Smith is a 24 year old female who presented to her GP for ongoing gastrointestinal bleeding, abdominal pain and fatigue which has been worsening, and was referred to the local hospital for further investigation. Maureen was diagnosed with rheumatoid arthritis (RA) when she was 15 years old, and has experienced multiple exacerbations of RA which have required the use of high dose corticosteroids. She is currently taking 50mg of prednisolone daily, and has been taking this dose since her last exacerbation 2 months ago. Maureen also has type 2 diabetes which is managed with metformin. She is currently studying nursing at university and works part-time at the local pizza restaurant. On assessment, Maureen’s vital signs are: PR 88 bpm; RR 18 bpm; BP 154/106 mmHg; Temp 36.9ºC: SpO2 99% on room air. She has a body mass index (BMI) of 28kg/m2 and the fat is mainly distributed around her abdominal area, as well as a hump between her shoulders. Maureen’s husband notes that her face has become more round over the past few weeks. Her fasting BGL is 14.0mmol/L. Blood test results show low cortisol and ACTH levels, and high levels of low high-density lipoprotein cholesterol. She is awaiting a bone mineral density test this afternoon, and is currently collecting urine for a 24-hour cortisol level measurement. 4 Case Study 3: Decompensated Liver Cirrhosis Mr Ronald Stone is a 47-year-old man who was brought in by ambulance to emergency department with haematemesis. According to his partner he vomited a total of 300 mL of fresh blood this morning. He reported that he has been spitting blood stained sputum for the last few weeks with no associated cough or shortness of breath. For the past 3 days he has complained of increasing abdominal pain but with no diarrhoea or black stools. Mr Stone tested positive for Hepatitis C virus (HCV) genotype 1A in June 2010. He has cirrhosis and a history of heavy alcohol use, although he no longer drinks. He ceased intravenous drug use 10 years ago, and stills smokes tobacco and marijuana on a daily basis. He used to work with City Rail but has been made redundant 13 months ago and has been unemployed since. He lives with his partner and 2 young children from a previous marriage. On assessment Mr Stone’s vital signs are: PR 112 bpm; RR 24 bpm; BP 105/64mmHg; Temp 37.4 °C; SpO2 94% on room air. He has a body mass index (BMI) of 31.5kg/m2 . He is lethargic but orientated to time, place and person. He has a swollen and tight abdomen typical of ascites and bilateral leg oedema. Blood test results show Hb 85 g/L, decreased WBC, platelets and albumin, and a marked increase in both serum ammonia and total bilirubin levels. 6 months ago he underwent an eosophagogastroduodenostomy (EGD) which showed grade 2 oesophageal varices. He is ordered the following medications: Vitamin K 1 mg IV stat, aldactone 25mg PO TDS, lactulose 15mls PO TDS, and vitamin B12 100mg IV TDS. He is awaiting a CT abdomen scheduled for this afternoon.


Subject Nursing Pages 9 Style APA


  1. Outline the causes, incidence and risk factors of the identified condition and how it can impact on the patient and family (400 words)

Myocardial infarction occurs when the heart muscles are damaged as a result of irregular blood flow in the heart. Stable angina is experienced by a patient as chest discomfort and pain which happens when the heart does not get enough blood supply. The shortage of blood supply may be caused by strenuous exercises or when someone performs heavy tasks which may cause one or more blood arteries to become narrow (Lloyd, 2007). Alternatively, mitral valve stenosis is a heart disease that occurs when the mitral valve in the heart becomes narrow (Lloyd, 2007). Cause of myocardial infarction include: high cholesterol levels that is mostly from the food people eat; consumption of foods with a high content of saturated fats like meat, cheese, and butter; hydrogenated fat which is also known as Trans-fat; and high blood pressure above 120/80 mm Hg.

Other risk factors include diabetes and high levels of blood sugar, smoking, advancing age, high levels of Triglyceride, a history of the disease in the family, stress, failing to exercise regularly, use of drugs like cocaine, and preeclampsia which is high blood pressure during pregnancy (Cortes et al, 2009).

The disease causes psychological problems to patients and their families. There is the struggle to adapt to a new way of life that agrees with the treatment of this disease. In addition to this, there is fear of death resulting from stress. Lloyd, 2007).




  1. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology (350 words)
  2. This can be done in the form of a table – each point needs to be appropriately referenced



The underlying pathophysiology

Chest pain

The blocking of one or more coronary arteries. This is due to the formation of plaque on the walls of the arteries that inhibits proper flow of blood. This plaque leads to intracoronary thrombus and a possible blood clot which can lead to occlusion and a possible rapture of an artery. . Lloyd, 2007).

Restrosternal pain

Blockage or narrowing of the left ventricle. An s4 and sometimes s3 gallop can be detected in a physical exam. When the myocardial infarction is so large, the left ventricle may eventually fail. (Cortes et al, 2009).

High heart rate

Cholesterol build up in the arteries may cause a high heart rate. The cholesterol leads to the formation of atherosclerotic plaque and narrows the blood veins (American Journal of Nursing, 1988).

Increases respiratory rate

This is as a result of shortage in oxygen. Irregular blood flow as a result of plaque may result to ischemia (Lloyd, 2007).


Due to impaired flow of blood and low oxygen levels, the brain may experience a shortage of blood (a condition known as brain hypoxia) which may lead to dizziness, nausea, fatigue, sweating and vomiting and may lead to stroke (American Journal of Nursing, 1988).


  1. Describe two (2) common classes of drugs used for patients with the identified condition including physiological effect of each class on the body (350 words)
  2. This does not mean specific drugs but rather the class that these drugs belong to.

The two most common classes of drugs used to treat myocardial infarction are vasodilators and cardiac depressant drugs (American Journal of Nursing, 1988).


Vasodilator drugs are used to dilate or enlarge the veins and arteries. They help in relaxing the heart muscles and smoothens the blood vessels to ensure smooth flow of blood. Apart from myocardial infarction, these vasodilators drugs (mixed or balanced) are also used to treat high blood pressure and angina (Cortes et al, 2008). Arterial dilators decrease the pressure on arteries by reducing the systematic vascular resistance. These drugs are beneficial to the patient because they reduce the after load on the left ventricle which leads to the decrease in pressure in the on the veins and the ventricles. Venous dilators are drugs that dilate the vessels and reduce the cardiac output by decreasing the blood preload on the heart. It also caused a decrease in capillary hydrostatic pressure which in turn reduces the filtration of the capillary fluid and the formation of tissue edema (Cortes et al, 2008). Mixed or balanced dilators dilate both the arteries and the veins. These drugs reduce the systematic vascular resistance and also the pressure on the arteries with little effect on the pressure on the right arteries.  These drugs include Nitridilators, Angiotensin Receptor Blockers (ARB) and Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors) (Lloyd, 2007). The vasodilator drugs have some side effects on the patients like an increase in the oxygen required. They can also result in renal retention of sodium and water that leads to a high volume of blood and cardiac output. The drugs can also affect the normal baroreceptor-mediated reflex vasoconstriction.

Cardiac depressant drugs

These drugs depress the cardiac function by reducing a patient’s heart rate and contractility which subsequently reduces the pressure on the arteries and the cardiac output. Cardio inhibitors decrease the contractions, the heart rate and the pressure on the arteries reduces the work load of the heart and the oxygen level required by the heart (American Journal of Nursing, 1988). The right supply of oxygen is important to patients suffering from angina. These drugs also block beta-adrenoceptors which is a crucial treatment to myocardial infarction patients. They can also be used to treat hypertension, Arrhythmias, heart failure alongside angina and myocardial infarction an example of cardiac depressant drugs is beta blockers. A common side effect of these drugs is that they affect relaxation. Kim, et al, 2008)

  1. Identify and explain, in order of priority the nursing care strategies you, as the registered nurse, should use within the first 24 hours post admission for this patient (500 words).

Myocardial infarction patients require urgent treatment once the symptoms are identified. On arrival at the hospital, blood tests should be done for cardiac enzyme, clotting screen, lipids, renal function, glucose and electrolytes which are done by inserting a Veflon for intravenous access (Cortes et al, 2009). There should be close clinical supervision and monitoring to check for symptoms, blood pressure, pulse, heart rate, oxygen levels and work towards pain relief. Electrocardiogram (ECG) monitoring should continue to check on the features that causes the rise of infarction. These factors are new conduction defect, new ST-segment elevation, new Q waves and ST segment elevation (Lloyd, 2007).

Percutaneous coronary intervention (PCI) or administering a thrombolytic drug can be used to restore damaged or occluded arteries. This will reduce the chances of stroke, improve the functionality of the left ventricle, and reduce reocclusion (American Journal of Nursing, 1988). This treatment should be done immediately a patient arrives at the hospital in order to reduce the chances of death. A time frame of less than 60 to 90 minutes is recommended to have started on symptoms if percutaneous coronary intervention is already done and 120 minutes if it is not (Cortes et al, 2009). In case there is an ST elevation acute coronary syndrome this treatment is crucial in case the symptoms have shown in the last 12 hours before admission. For patients whose symptoms have passed 12 hours, it is still not clear if PCI should be performed if there no sign of ischaemia noted after electrocardiogram (ECG) or a clinical examination (Kim et al, 2008).

To reduce the chances of possible vascular occlusion, a glycoprotein IIb/IIIa inhibitor should be administered to the patient (Lloyd, 2007). In addition, an unfractionated heparin or a relatively low molecular weight heparin should also be administered. A combination of aspirin and prasugrel is important for patients who are undergoing PCI and are also suffering from acute coronary syndromes to prevent any occurrence of atherothrombosis (Kim et al, 2008). This is so because patients with diabetes mellitus can contract stent thrombosis while undergoing treatment with clopidogrel. After a myocardial infarction, a balloon angioplasty can reduce the chances of death, stroke and nonfatal myocardial infarction than a thrombolytic reperfusion would (Cortes et al, 2009).

For those patients who cannot have PCI done in 90 minutes after diagnosis, they should receive a thrombolytic drug together with an unfractionated heparin (which should be administered for a maximum of 48 hours), a relatively low molecular weight heparin or fondaparinux (American Journal of Nursing, 1988).

Some patients undergo Coronary bypass surgery incase PCI has failed, or they have refractory symptoms after undergoing PCI. Patients with multivessel disease or cardiogenic shock also undergo Coronary bypass surgery (Lloyd, 2007).




American Journal of Nursing. (1988). Using a 12 lead EKG to document acute myocardial            infarction. New York, N.Y: American Journal of Nursing, Educational Services Division.

Cortes, O. L., Villar, J. C., Devereaux, P. J., & DiCenso, A. (November 01, 2009). Early   mobilisation for patients following acute myocardiac infarction: A systematic review and      meta-analysis of experimental studies. International Journal of Nursing Studies, 46, 11,       1496-1504.

Kim, D. J., Kim, D. I., Byun, J. S., Jung, J. Y., Suh, S. H., Kim, E. Y., Lee, K. Y., … Heo, J. H.   (January 01, 2008). Simple microwire and microcatheter mechanical thrombolysis with adjuvant intraarterial urokinase for treatment of hyperacute ischemic stroke patients. Acta      Radiologica (stockholm, Sweden: 1987), 49, 3, 351-7.

Lloyd, M. A. (2007). Mayo Clinic Cardiology: Board Review Questions and Answers. New          York: Informal Healthcare.




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