NURS 493 - Cardiac Case Study.

STUDENT NAMES (STUDENT IDs): CLINICAL INSTRUCTOR(S): Mrs. Jones is a 60-year-old female patient who is coming in the emergency department by ambulance due to complaints of severe back pain that started today. The patient reports the pain is in her back. The patient also has had nausea and vomiting and has not been able to keep any medications down due to the nausea and vomiting. The paramedic that responded to the call gave a report to you that it looked like Mrs. Jones was living in poor conditions and that a lot of medication bottles were empty. Mrs. Jones lives at home alone and her only family is her daughter that lives about two hours away from her. Recent Medical History: The patient is a type I diabetic with poor blood sugar control. Her insulin regimen has recently been adjusted by her endocrinologist to lower her high blood sugars. She has a past medical history of kidney failure, chronic pain, heart murmur, anemia, substance abuse and depression. Physical assessment: The patient is positioned flat in bed when you first walk into the room. She can answer the questions of name and date of birth but does not recall what day it is today or which hospital she is in. The first action when you see this patient is to assess her and during your assessment. The patient has cracked, dry mucous membranes when she opens her mouth. Skin is tenting. You listen to lung sounds, and they sound clear on auscultation. The patient has a heart murmur on auscultation, and you note that she does have a history of a heart murmur. During your assessment, the patient starts vomiting. The emesis is yellow and clear. Emesis is about 100 cc. You note that the patient has significant bruising on her legs, ribs, and a couple bruises on her arms. Her room air saturation is 98% and respiratory rate is 22. Blood pressure is 101/60. Temperatures is 99.9 F. The patient’s heart rate is 118. Patient rates pain 6/10 in her flank area and she reports her pain radiates down her back which makes it a 10/10. Patient has allergy to penicillin and glipizide. She is a full code. Patient weighs 80kg