Country : Australia
Mr M Case Study Myocardial Infarction Nursing Assessment Answer
Assessment Task:

Mr M Case Study Myocardial Infarction Nursing Assessment Answer

PATIENT SCENARIO :
Mr M, a 73-year-old man, was admitted to the medical ward of a hospital in your country with complaints of increasing dyspnoea on exertion. He has type II diabetes, cardiovascular disease, and chronic kidney disease. Mr M is a retired engineer who lives with his wife in an apartment on the fourth floor (no lifts in the
building) and he is normally able to attend to activities of daily living, cooking, cleaning and shopping. He has two adult children who live nearby.

Subjective data

  •   Had a myocardial infarction at 68 years of age
  •  Has experienced increasing dyspnoea, frequent cough, and oedema in the legs over the last 5 weeks
  •   Has to sleep with head elevated on three pillows

Objective data

  •   In some respiratory distress, use of accessory muscles, respiratory rate 34 breaths/min
  •   Heart murmur
  •   Skin cool and diaphoretic
  •   Venous leg ulcer on left ankle
  •  Bloated abdomen

Physical examination

  •   Pulse full and bounding: 102 bpm, blood pressure: 162/106 mmHg, O2 saturation: 88% (room air)
  •   T emperature: 36.8oC
  •   Urinalysis: protein++++; pH 6.8; SG 1.020; blood, glucose & ketones – nil

Diagnostic studies
Serum: K 6.3 mmol/L; HCO3 15 mmol/L; Urea 22.7 mmol/L; Creatinine 390 μmmol/L; eGFR 12 mL/min/1.73m2; Hb 98 g/L; HbA1C 7.5%.

  •  Chest X-ray result: left ventricular hypertrophy; fluid in lower lung fields
  •   ECG: normal sinus rhythm

Collaborative care

  •   Frusemide 250 mg BD
  •   Peridopril 8 mg daily
  •   Lercanidipine 10mg daily
  •   Atorvastatin 10mg daily
  •   Calcium carbonate 600mg TDS
  •  Calcitriol 0.5μg daily
  •  Lispro 25% 12 units BD
  •  Oxygen 6 L/min via Hudson mask
  •  Daily weight
  •   Renal diabetic diet and 1,500ml fluid restriction
  •   Referral to vascular surgeon for arteriovenous fistula formation and to the nurse-led pre-dialysis multidisciplinary clinic

 

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  • Posted on : October 10th, 2018
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