Health Variations 4: 401018 - Mrs. Grace Kelly Severe Chest Pain that Radiated to her Neck - Jaw and Left Arm - Case Study Assignment Answers

August 11, 2017
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Solution Code: 1BEJ

Question: Nursing Case Study

This assignment is related to "Nursing Case Study” and experts at My Assignment Services AU successfully delivered HD quality work within the given deadline.

CASE STUDY

Mrs. Grace Kelly, a 69 year old recently retired bank chief executive officer is admitted via ambulance at 13.00 hours to the Emergency Department, accompanied by her husband. She experienced severe chest pain that radiated to her neck, jaw, and left arm, which started about 12.15 hours. The pain was accompanied by shortness of breath and sweating.

On arrival to the Emergency Department Mrs. Kelly is alert and tells you that she had experienced pain after returning home from her retirement dinner the previous evening. She has held senior management positions in the bank for 35 years. She described that pain as more of a burning, aching discomfort in her epigastrium, shoulders and back and thought it was indigestion and so took antacids. This pain continued all night and she felt it was a consequence of the evening’s celebration. However, when it became more intense and she became anxious and restless, her husband called the ambulance.

Report from paramedics

Patient had severe sub sternal chest pain that radiated to neck, jaw and left arm. She was pale and anxious.

Initial vital signs: Temperature: 37.2° C Pulse: 118 beats/minute BP: 120/70 Oxygen saturation: 93%

A 12 lead ECG was taken at her home and data transmitted to a doctor in the Emergency Department. IV cannula was inserted into the left antecubital vein. Medications administered (MONA Acronym):

  • Morphine 2.5mg IV / Maxolon 10mg IV
  • Oxygen (Face Mask 6L)
  • Nitrates: (glyceryl trinitrate 600micrograms sublingual)
  • Aspirin 100mg

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Solution:

Answer 1.

Check for: Related pathogenesis:Is the observation normal and why Related management :Nursing interventions with a justification Priority of the survey:Low/medium/high
Airway

No obstruction to the airway, no noisy breathing sounds can be heard. The patient is talking in full complete sentences.

The observation is normal since the patient is talking in a clear manner. However it is imperative to remain vigilant and keep a check constantly for any changes to the airway.

  1. A nasopharyngeal air way should be made use of as the patient is conscious. It can be utilized as a temporary measure.

  1. The cervical

Spine should be protected as movement of the cervical spine can cause a spinal injury. A cervical collar should be used for protection.

As the patient has no obstruction to the airway and is able to talk in sentences the airway priority is medium.
Breathing

RR 28 Breaths/min.

Breathing is labored in nature.

Oxygen saturation is 92%.  O.n 6L/min O2 via the Hudson mask. Bilateral basal crackles and crepitation is heard.

The observation is not normal as the patient is breathing in a labored manner, along with that crepitation sounds can be heard as well. Order a chest x ray to determine the cause of the bilateral basal crackles.

The patient should be on oxygen so that the breathing rate can be controlled and not cause the patient discomfort.

The priority of the survey is high because if the patient continues to breath in a labored manner despite the oxygen it could be indicative of a major underlying infarction.
Circulation

HR 120 bpm

BP 90/50mmHg

JVP elevated 4cm; peripheral pulses –rapid and faint;

capillary refill 4 secs; extremities cool, clammy and mottled; bilateral ankle edema; 3rd heart sound present;

Temp 37.5°C.

Cold and clammy skin is indicative of a shock.

The BP reading of the patient is indicative of hypotension or low blood pressure.

The peripheral pulse is rapid and faint which is indicative of a cardiogenic shock

Bilateral ankle edema indicates cardiogenic shock as well (O'Gara et al., 2013).

To increase the blood pressure it is imperative to elevate the legs of the patient so that the blood flow returns to normal in the lower extremities.

A central line should be placed in the patient so that it can facilitate the volume resuscitation. It also provides vascular access for numerous infusions. It helps in invasive monitoring of the central venous pressure as well (Rull, 2016).

The survey is of high priority because if it is not managed in time it can lead to a myocardial infarction.
Disability

Anxious and restless, oriented in person, time, place;

GCS 15/15

pain 5/10

Because of the low blood pressure and pain the patient seems to be anxious and restless. Monitor the patient from time to time; take readings on the Glasgow coma scale intermittently for any changes.

Monitor the vital signs of the patient.

The priority survey is of low importance.
Exposure:

No bruising is visible

Normal as there is no sign for any hemorrhage. Conduct an x-ray and an ultrasound to check for any internal hemorrhage. Priority of this survey is medium as no bruising can be a sign for some form of internal hemorrhage in the case of an impending myocardial infarction.
Fluids

I.V. inserted; no IV fluids in progress.

The observation is normal. Check for any signs of dehydration. The priority of the survey is low as the patient is not on any IV fluids.
Glucose

BGL 4.0 mmol/

The blood glucose level of the patient is low. Check for the blood glucose levels after a while. As it could be indicative of hypoglycemia. The priority of this survey is high.

Answer 2.

The two diagnostic results that are chosen to for a critical analysis are the chest X-ray and the transthoracic echocardiogram

  1. Chest x-ray: the chest x-ray of the patient indicates that the heart is of normal size. However there is presence of pulmonary vascular congestion is due to the excessive accumulation of fluid in the lungs this is mostly caused because of inflammation in the lungs or due to a congestive heart failure. While the presence of pulmonary edema is due to the vascular congestion. It leads to impairment in the gas exchange that can cause respiratory failure. It can be either because of the failure of the left ventricle of the heart to adequately help in removal of the blood from the pulmonary circulation or because of vasculature of the lung. The patient’s case can lead to a cardiac arrest because of hypoxia and respiratory failure (O'Gara et al., 2013).
  2. Arterial blood gas analysis: the investigating results of the (O'Gara et al., 2012) The ABG State that The blood pH level of the patient is 7.26 and is within the normal ranges, the level of PaO2 is looking to be a little low. The levels of HC03 is low that is indicative of a metabolic problem along with metabolic acidosis. No presence of hypoxemia (Park et al., 2015). The arterial blood gas value is responsible for indicating the acid base homeostatic along with the arterial blood oxygenation. The patient needs oxygen therapy as his ABG values are showing low levels of oxygenation. As acidosis can have a deleterious effect on the myocardial functioning. The base deficient is indicative of the occurrence and the severity of a cardiogenic shock. It is used as a marker to follow while resuscitation of the patient from shock.

Answer 3

The drug that has been chosen for the pathogenesis of a cardiogenic shock and an impending infarction is dobutamine 10 mg/kg/min p4

  • Dobutamine is a sympathomimetic drug that is used to treat heart failure and cardiogenic shock. The main mode of mechanism of dobutamine is that it causes direct stimulation of the beta receptors of the sympathetic nervous system. It is a structural analogue of isoprenaline. It is a directly acting inotropic agent and it produces mil chrono tropic, hypertensive and vasodilative effects ("Dobutamine", 2013). However it does not cause the release of endogenous nor epinephrine unlike dopamine. The onset of the drug is fast as it takes place between 1-2 minutes.
  • Dobutamine is a synthetic catecholamine. Its therapeutic effect can be monitored when the myocardial contractility is enhanced and there is a reduction in the sympathetic tone in reaction to the augmentation of the stroke volume. It thus in turn causes a decrease in the total peripheral resistance ("Dobutamine/dopamine/nitroglycerin", 2012). The hemodynamic effects that it creates are:

  1. It increases the cardiac output
  2. Decrease in systemic vascular resistance
  3. No change is visible in the arterial pressure or the heart rate.

  • The adverse effects that are caused because of dobutamine include the following:   1-10%

  1. Tachyarrhythmia (~10%)
  2. Hypertension (7.5%)
  3. Eosinophilic myocarditis (?7%)
  4. Premature ventricular beats (5%; dose related)
  5. Angina (1-3%)
  6. Dyspnea (1-3%)
  7. Fever (1-3%)
  8. Headache (1-3%)
  9. Nausea (1-3%)
  10. Palpation (1-3%)

Frequency Not Defined

  • Cardiac dysrhythmia
  • Exacerbation of coronary arteriosclerosis
  • Hypokalemia
  • Injection-site reactions
  • Syncope

The adverse effects of the drug that are being given to the patient need to be monitored constantly as chances of overdosing can also take place. Since the patient is suffering from a cardiogenic shock and an infraction care needs to be taken that the heart rate does not increase or decrease suddenly while the medication is being given as toxicity from Dobutamine is usually due to excessive cardiac ?-receptor stimulation.  

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