Case Study on Consider the Patient Situation

Running head: CASE STUDY
Occupational health and safety
CASE STUDY
Name of the Student
Name of the University
Author Note

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CASE STUDY
Occupational health and safety
Consider the patient situation
Banu is a 28 years old woman and has been presented in to the emergency department
with a pain in the left calf caused by tripping over the root of a tree. Banu’s vital signs at the
time of admission are as follows:-
Currently Banu’s vital signs are as follows:
Temperature- 37.3
B.P- 120/70
R- 32
O2 saturation- 98 %
Pain score- 5/10
The left of Banu is swollen and painful and the right calf is normal. A diagnosis of the L leg
DVT has been made. She had been provided with Morphine 5mg IV for the pain as needed.
Collection of cues
Currently the vital signs of Banu are as follows:
Temperature- 37.6
B.P- 140/70
R- 32
O2 saturation- 92 %
Pain score- 9/10
Banu has been complaining of chest pain, when she had been breathing. She is confused and
is gasping while talking. So, she had been subjected to a VQ scan followed by a diagnosis for

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the pulmonary embolism. Heparin has been started 5000 units IV stat and 30,000 units at
standard salinity at 42ml/hour. Protamine Sulphate is ordered.
Family history and Medical history of Banu - Banu’s father displays a medical record of
Hypertension and GERD and her mother of Transient ischemic attack (TIA, Mini-Stroke).
Both of them are under treatment.
Banu is a healthy woman, except the fact that she is only under contraceptive pill
(Drspirenone and Ethinyl Estadiol). It is necessary to assess further, Banu is coughing out
blood clots which can be common in pulmonary embolism.
Deep vein thrombosis is a vascular injury that occurs due to blood clotting a deeper
veins of the calf. DVT is the main cause of pulmonary embolism (Goldhaber & Bounameaux,
2012). DVT generally results from condition that impairs venous return, or results into
endothelial tissue injury or dysfunctioning or causes hypercoagulability (Stone et al., 2017).
The concurrent presence of the vascular pressure and the venous stasis or hypercoagulability
enhances the threat to the formation of clots. The blood clot formed in the leg can move up to
the lungs and can block a blood vessel. This can lead to low levels of oxygen in the blood (Di
Nisio, van Es & Büller, 2016). In this case Banu might have suffered from DVT due to an
injury to the vessels in the calf. The clot could have been migrated to the lungs developing
pulmonary embolism. The primary symptoms pulmonary embolism is repeated shortness
breath and pain in the chest (Li et al., 2018). Both the symptoms has been displayed by Banu,
while she was in the hospital.
Processing of information
It is evident from the literature that chest pain in Banu has been caused by pulmonary
thromboembolism. Swelling of the tissue surrounding the lungs and the chest wall or the
region of pleura might result in sharp chest pain during talking or coughing. One of symptom

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of pulmonary embolism is shortness of breath, due to lack of oxygen in the blood leading to
hypoxia. It is clearly evident from the vital signs of Banu, as previously, while Banu was
being admitted in to the hospital, her oxygen saturation level has been normal, except the
fact, that her oxygen saturation level has deteriorated with her increasing chest pain and
discomfort. Low oxygen level in the tissue might develop several complications. Low oxygen
level in the body might cause severe organ damage, if left untreated. A decrease in Spo2
signifies low level of oxygen reaching the brain cells, causing impaired neurotransmission.
The blood pressure of the Banu has increased with her increased chest pain.
Pulmonary embolism increases blood pressure. Chronic thromboembolic pulmonary
hypertension is a result of persistent thromboembolism. The clots continue to give rise to
more clots making the circulation difficult. It increases the pressure on the lungs and lungs
causing hypertension. Due to low level of oxygen in the blood, the heart has to work more to
make up to the oxygen level in the blood. Furthermore, the blood pressure in the lungs can
also increase due to damage to the lung tissues. The body temperature of the patient has
increased. Fever has been reported in several cases of PE. Acute infection in the lung
parenchyma has been found to be associated with fever in the patient. The heart rate in this
condition is also more than that of the standard value due to the increased workload of the
heart. Venous thromboembolism is a multifactorial diseases having several genetic and the
acquired risk factors. A positive family history of hypertension, increases the chance of VTE
(Eikelboom & Weitz, 2011). Furthermore, it has been revealed by studies that hypertension
can increase the risk of the occurrence of DVT. The case study reveals that both Banu’s
parents have family history of DVT (Zöller, Li, Ohlsson, Ji, Sundquist & Sundquist, 2015).
Additionally, it is also known from the case study that Banu had been under
contraceptive pills regularly. Oral contraceptives can slightly increase the risk of the
developing blood clots or DVT (de Bastos et al., 2014). Drospirenone-containing oral

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contraceptives, that is commonly available as over the counter shops, contain a
mineralocorticoid-derived progestational component. Solymoss , (2011) have added further
evidences , that women taking these types of OCPs develop a relatively higher risk of
pulmonary embolism than that of the second or the third generation contraceptives. It has
been mentioned in the case study that Banu was administered with IV 5 mg Morphine.
Pulmonary embolism is known to be accompanied with morphine therapy in individuals
exhibiting deep vein thrombosis (Lee et al., 2015). Morphine antagonize inhibition of
aggregation of the platelets by the prostaglandin E1. Morphine can exert its capability in
aggregation of platelets by joining to α2-adrenoceptors in human platelets (Lee et al., 2015).
Thus, intracellular cAMP formation is reduced and phospholipase C is activated and the
Na+/H+ exchanger is increased. Hence, morphine can facilitate DVT by promoting the
aggregation of the platelets (Lee et al., 2015). After Banu has been diagnosed with DVT, she
had been provided with Heparin, which is an anticoagulant that helps to resolve the clots (Lee
et al., 2015).
Identification of the nursing problems
The two nursing priorities that can be considered for Banu is Impaired breathing pattern and
persistent chest pain.
Goals
Short term
S-The breathing pattern of the pain will be restored
M-The effectiveness of the treatment can be measured by the continuous monitoring of the
vital signs.
A- The breathing pattern will be restored and the patient will complain of less pain.

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R- The goal is relevant as severe symptoms of pulmonary embolism might also cause death
T-This should be achieved within 2 hours
Long term
S- Banu will not display any other signs of discomfort, even after the discharge from the
hospital.
M- Daily follow up record can show whether Banu’s symptoms have resolved or not.
A-Banu’s hypertension will remain in control and she will only take oral contraceptives after
being approved by the doctor
R- Banu will be able to verbalize that there is no persistent pain in her calf muscles.
T- This will be achieved within a one year time frame.
Nursing interventions
Nursing interventions Rationale
Nursing priority- Ineffective breathing pattern
Assessment of the lung sounds , identifying
the regions of minimum ventilation and the
existence of adventitious sounds (Wilbur &
Shian, 2012).
In case of pulmonary embolism, crackles
care be heard.
It is necessary to examine the skin colour,
the nail beds and mucous membrane for any
changes in colour
Pale skin colour generally is observed as a
compensatory outcome to hypoxemia. If the
oxygen and the perfusion is not functioning
adequately, the peripheral tissue can become

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cyanotic (Streiff et al., 2016).
It is necessary to supervise and detect
alterations in the vital signs (Wilbur &
Shian, 2012).
In initial hypercapnia and hypoxia,
respiratory rate increases, blood pressure
and the heart rate. In case of complication
related to hypoxemia, the blood pressure
might drop and the heart rate tends to
increase (Streiff et al., 2016). I can include
dysrhythmias and the respirator failure
ensures that the client is unable to preserve
the rapid respiratory weight.
The client needs to be maintained on a bed
rest. Activity will only be resumed as
tolerated.
This decreases the demand of oxygen in the
body at the time of acute respiratory trouble
(Agnelli & Becattini, 2010).
The client should be positioned to facilitate
the ventilation-perfusion matching
Sitting upright assists in optimizing the
diaphragmatic excursion as well as the
perfusion of lungs. While positioning the
client in this position, the affected part
should not be dependent.
Supplemental oxygen can be provided for
maintaining adequate oxygenation and it
decrease the work of breathing and helps to
give relief from dyspnoea (Agnelli &
Becattini, 2010).
Expected Outcome:
Adequate gas exchange will be maintained. The oxygen saturation will be greater or 90 % .

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There will be no deterioration of the consciousness level and the client will display a
relaxed breathing.
Nursing priority: Chest pain
The nurses should assess the level of pain
by using the numeric pain score
Increasing the level of pain might indicate
towards increased inflammation of the lungs
(Czarnecki et al., 2012)
The patient should be positioned properly.
The patient can be positioned in the semi-
fowler position and it is the most common
position for providing comfort to the
patient.
Proper positioning of the patients will help
in lung expansion and it provides comfort to
the patients who are bed ridden (Kirsch et
al., 2017).
It is necessary for assessing for the calf
tenderness, redness and swelling and the
areas that have hardened
To assess the condition of the deep vein
thromboembolism and whether the pain in
the calf still persist (Agnelli & Becattini,
2010).
It is necessary to examine the vital signs and
symptoms of pulmonary infarction like
coughing, pleuritic pain, bronchial
breathing, hemoptysis and pleural friction
rub
If the embolus is large or consists of
multiple clots in defined regions. It can lead
to ischemic necrosis of infarction of the
region of lungs (Agnelli & Becattini, 2010).
Mild backrubs can be given to the patient as
a therapeutic backrub.
The nurses should administer the
anticoagulant only approved the physician
Mild back rubs or therapeutic touch can
help the patients to cope up with the pain
and distress (Czarnecki et al., 2012).
The doses should be approved from the
physician.

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Expected outcome: Banu will report less pain. The aim would be to make the pain score 0.
The patient will be able to show consciousness and relaxed breathing
Reflection on the learning
This method of clinical reasoning cycle have assisted me in collecting the indications
and process the information and understand the problem that the person had been facing with.
It based on this cues, that all these interventions have been planned. In order to enquire about
the pathophysiology of the symptoms, I have to brainstorm through several articles. This has
helped me to understand the relation between several factors like relation between DVT and
Pulmonary embolism or how is it related to hypertension. This assignment have also helped
me to understand the relationship between the contraceptive pills, and how it might be an
important risk factor for pulmonary thromboembolism. Presence of multiple risk factors in
this case study, have made this unique and needed more research. However, I intend to
practice more evidence based researches in order to develop my critical thinking skills. I
ensure that I will indulge in life long, learning, such that I am always updated about the
current guidelines.

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References
Agnelli, G., & Becattini, C. (2010). Acute pulmonary embolism. New England Journal of
Medicine, 363(3), 266-274. https://www.nejm.org/doi/full/10.1056/nejmra0907731
Czarnecki, M. L., Turner, H. N., Collins, P. M., Doellman, D., Wrona, S., & Reynolds, J.
(2011). Procedural pain management: A position statement with clinical practice
recommendations. Pain Management Nursing, 12(2), 95-111.
https://doi.org/10.1016/j.pmn.2011.02.003
de Bastos, M., Stegeman, B. H., Rosendaal, F. R., Vlieg, A. V. H., Helmerhorst, F. M.,
Stijnen, T., & Dekkers, O. M. (2014). Combined oral contraceptives: venous
thrombosis. Cochrane Database of Systematic Reviews, (3).
https://doi.org//10.1002/14651858.CD010813.pub2
Di Nisio, M., van Es, N., & Büller, H. R. (2016). Deep vein thrombosis and pulmonary
embolism. The Lancet, 388(10063), 3060-3073.
Eikelboom, J. W., & Weitz, J. I. (2011). Importance of family history as a risk factor for
venous thromboembolism.
Goldhaber, S. Z., & Bounameaux, H. (2012). Pulmonary embolism and deep vein
thrombosis. The Lancet, 379(9828), 1835-1846. https://doi.org/10.1016/S0140-
6736(11)61904-1
Lee, C. W. S., Muo, C. H., Liang, J. A., Sung, F. C., Kao, C. H., & Yeh, J. J. (2015).
Pulmonary embolism is associated with current morphine treatment in patients with
deep vein thrombosis. The clinical respiratory journal, 9(2), 233-237.

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Li, W., Chen, C., Chen, M., Xin, T., & Gao, P. (2018). Pulmonary embolism presenting with
itinerant chest pain and migratory pleural effusion: A case report. Medicine, 97(22),
e10944. https://doi.org/10.1097/MD.0000000000010944
on Cardiac, E. P., Kirsch, J., Brown, R. K., Henry, T. S., Javidan-Nejad, C., Jokerst, C., ... &
Panchal, K. K. (2017). ACR Appropriateness Criteria® acute chest pain—suspected
pulmonary embolism. Journal of the American College of Radiology, 14(5), S2-S12.
https://doi.org/10.1016/j.jacr.2017.02.027
Solymoss S. (2011). Risk of venous thromboembolism with oral contraceptives. CMAJ :
Canadian Medical Association journal = journal de l'Association medicale
canadienne, 183(18), E1278–E1279. https://doi.org/10.1503/cmaj.111614
Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., &
Oklu, R. (2017). Deep vein thrombosis: pathogenesis, diagnosis, and medical
management. Cardiovascular diagnosis and therapy, 7(Suppl 3), S276–S284.
https://doi.org/10.21037/cdt.2017.09.01
Streiff, M. B., Agnelli, G., Connors, J. M., Crowther, M., Eichinger, S., Lopes, R., ... &
Ansell, J. (2016). Guidance for the treatment of deep vein thrombosis and pulmonary
embolism. Journal of thrombosis and thrombolysis, 41(1), 32-67.
http://dx.doi.org/10.1007/s11239-016-1345-4.
Wilbur, J., & Shian, B. (2012). Diagnosis of deep venous thrombosis and pulmonary
embolism. American family physician, 86(10), 913-919.
https://www.aafp.org/afp/2012/1115/p913.html
Zöller, B., Li, X., Ohlsson, H., Ji, J., Sundquist, J., & Sundquist, K. (2015). Family history of
venous thromboembolism as a risk factor and genetic research tool. Thrombosis and
haemostasis, 114(11), 890-900.

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Zöller, B., Li, X., Ohlsson, H., Ji, J., Sundquist, J., & Sundquist, K. (2015). Family history of
venous thromboembolism as a risk factor and genetic research tool. Thrombosis and
haemostasis, 114(11), 890-900. DOI: 10.1160/TH15-04-0306
https://doi.org/10.1111/crj.12130