1,500 word written report ( Case study)DetailsThe objective of this assessment is to relate the...

Question

1,500 word written report ( Case study)DetailsThe objective of this assessment is to relate the process of clinical assessment to the delivery of patient care by selecting and implementing appropriate assessment techniques and demonstrating clinical judgment. You will need to record yourself carry out a 10 minute focused health assessment of your case study patient. A focused health assessment concentrates on a specific area of concern, for example if a patient is breathless, then your assessment should include a respiratory/cardiovascular assessment. Your case study outline will include a number of findings and a health history that will assist you in further discussing your case study patient and responding to the questions listed below. You will need to refer to literature to support findings, nursing interventions and further recommendations. Your case study submission should include the following: 1. Ten minute video of your focused assessment, this assessment should be limited to the area of complaint. 2. A written report comprising: a. An analysis of the findings of both the health history and the focused health assessment and relate these findings to the underlying disease pathophysiology. b. A set of recommendations for your selected patient using appropriate evidence based nursing literature to support your care decisions. Style and format Case study reportSubject Learning Outcomes3. Demonstrate clinical judgment through the overt association connecting health history, assessment and nursing care 4. Relate the processes of clinical assessment to the delivery of patient care, by selecting and implementing appropriate assessment techniques

Anju Lata · Accepted Answer

Assessment 2: Case study
SNPG962	1
SNPG962 Assessment 2 case study	7
Assessment 2: Case study
Student name:
Student number: 
Link to video of assessment: 
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Assessment 2: Case study
Analysis of findings 
George, a 45 year old greek man, who was diagnosed with Myocardial Infarction was brought to Emergency Department with key complaints of nausea and severe pain in left posterior shoulder radiating to the left arm. The case study will discuss all the assessments I performed for George and the nursing care provided to George during his stay at ER.
The assessment involved taking subjective data from his wife during history taking process, regarding the health condition of George and as an objective data collected during medical examination. The purpose of the assessment is to diagnose the health problem most accurately, take effective clinical decisions to treat it and develop a care plan for the patient.
Health history
The patients reported with life threatening condition like severe chest pain cannot afford 10-15 minutes for focused History taking and Physical Examination. In such cases, systematic and focused approach is followed to interview the patient and perform examination. It begins with identifying the Primary complaint. In this case, it is Acute Chest Pain.
First he was assessed for Airway Obstruction and was evaluated to ensure sufficient ventilation and oxygenation through Auscultation of Chest. His chest was clear. I started the conversation with an open ended question. Open ended questions allow the patient to explain the problem in his own words.
Hello Mr. George, I am …………… a registered nurse. What seems to be wrong today?
You are in Emergency Room, and don’t worry everything will be alright. OK?
Patient was made to lie on resus.
I used PQRST measure scale to assess the pain level. (PQRST is an acronym and reflects a method is used to assess the level of pain assessment uses Provoking factors, Quality of pain, Region of radiation, Severity and Time or duration of pain (Hui and Bruera, 2014).)
History of Chief Complaint
When the problem started? How severe was it when it started initially?
Please tell me where it hurts?  Whether the pain radiating to another location?
For how long this problem is going on? Is it intermittent or continuous?
Are you taking any other medicines?
Past Medical History based on complaint directed review of Symptoms (ROS)
Do you have a family history of Cardiac Disease?
If there is anything else you would like to tell me that is not covered?
What kind of symptoms you are experiencing and since how long?
What is your BMI and waist circumference?
Where do you work? Does your job require stressful condition?
Do you go for any exercise or games?
What is your BMI and waist circumference?
Have you faced similar problem earlier? When?
Additional information can be collected from his wife:
Does he have any drinking or smoking habits?
Physical Assessment
BP: 174/100
Pain: 9/10
Serum Cholesterol: 7.2 mmol/L
LDL: 6.2
HDL: 0.7
Fasting Triglyceride: 5.9 mmol/L
ST Elevations in leads V3 and V4 in ECG
Elevated Troponin I and T
General Health Condition
Pale and Sweaty
Lying down on bed
Conscious
Intense pain
Able to speak but due to pain feels difficulty speak properly
Pathology related to findings
Myocardial Infarction occurs due to unexpected ischemic death of cardiac tissue (Tibaut, Mekis & Petrovic, 2016). The gradual obstruction (Atherosclerosis), Sudden reversible obstruction ( Arterial Spasm) and irreversible occlusion  due to plaque formation and thrombus,  leads to Ischaemia. This condition develops into Hypoxia leading to reduced oxygen demand. Reduced flow of oxygen causes Angina (Chest pain). With time, the angina may get unstable (due to thrombolysis) leading to permanent Thrombus and Necrosis. These symptoms result into Myocardial Infarction.
Acute Pain 
There is severe pain in posterior left shoulder and radiating to the left arm. George was reported to have pain of level 9/10 which is considerably high, unbearable intense and worst pain.

1,500 word written report ( Case study)DetailsThe objective of this assessment is to relate the process of clinical assessment to the delivery of patient care by selecting and implementing appropriate...

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