Nursing Case Study

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Patient RW is a 72-year old male that came into the hospital by ambulance from an assisted living facility in the Des Moines area. Patient RW has lived fulltime in an assisted living facility since 2013. His daughters come and visit him daily and are also by his side in the evening while he is staying in the hospital. His support system is small, but is very involved in his cares within the living facility and the hospital. He was admitted to 7 South for chest pain and is on continuous telemonitoring and on four liters of oxygen. According to his daughters, he is an average Christian, with no religious or culture aspects that would affect the health care that needs to be given. Though, no religion or culture is affecting care, his past…show more content…
He is also on medications for his hypertension and to manage the pain he is experiencing. These medications are given at his assisted living and within the hospital, so teaching has been done, but the nurse was able to briefly explain the medications to his daughters as each one is administered so that the patient was aware of what is being given each time. He is taking 40 mg by mouth at bedtime of Atorvastatin as a primary prevention for cardiovascular disease and lowering the risk of a heart attack (MI) or stroke. It is a lipid-lowering agent, HMG-CoA reductase inhibitor. This medication requires a nursing assessment to be done involving monitoring the patient’s serum cholesterol and triglyceride levels before starting this medication and to monitor the liver function throughout the drug therapy. If the patient develops muscle tenderness, the nurse will need to assess CK levels in the patient (Deglin, Vallerand and Sanoski, 2014, p. 642). 75 mg by mouth at bedtime of Clopidogrel, which is an antiplatelet agent, is being used to reduce atherosclerotic events. When giving this medication, the nurse needs to assess for symptoms of stroke, PVD, or MI periodically during treatment. Also, the nurse needs to monitor for signs of forming blood clots and monitor bleeding (Deglin, 2014, p. 327-328). Metoprolol 25 mg daily is a…show more content…
It is not the reason he is admitted to the hospital at this time, but it is crucial in the way he receives care because he is no longer able to speak or hear. Though he is alert, and can respond appropriately, he does suffer with forgetfulness from time to time, and that comes with both age and his injury. “A traumatic brain injury (TBI) is damage to the brain from an external mechanical force and not caused by neurodegenerative or congenital conditions” (Ignatavicius, Workman, Blair, Rebar and Winkelman, 2015, p. 946). In RW’s case, his TBI was caused by a car accident. TBIs can be temporary or permanent and lead to numerous impairments, whether it is cognitively, physically, and/or psychosocially. He is currently hospitalized for chest pain, and with a stress test and angiogram, doctors found there to be a mild case of cardiomegaly and atherosclerosis within 3 vessels of the heart. Cardiomegaly is an enlargement of the heart, but atherosclerosis is what the doctors really want to treat and prevent. “Atherosclerosis is a type of arteriosclerosis, which is a thickening or hardening, of the atrial wall, often associated with age. With atherosclerosis, plaque is formed within the arterial wall and is the leading risk factor for cardiovascular disease” (Ignatavicius, 2015, p. 706). The exact pathophysiology is unknown, but is said to occur from blood vessel damage, causing inflammation. Populations at

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