Complex nursing care Assignment PDF

Running head: COMPLEX NURSING CARE
Complex nursing care
Name of thee Student
Name of the University
Author Note

1COMPLEX NURSING CARE
Table of Contents
Background..........................................................................................................................2
Patient health problems........................................................................................................3
1. Chest pain........................................................................................................................3
Assessment data...................................................................................................................3
Interventions........................................................................................................................4
Evaluation............................................................................................................................5
2. Breathing..........................................................................................................................5
Assessment data...................................................................................................................5
Intervention..........................................................................................................................6
Evaluation............................................................................................................................7
References............................................................................................................................9

2COMPLEX NURSING CARE
CASE STUDY
Background
Mr Anthony Khoury, 67(M) presented at emergency department of the UTS hospital.
Complain includes shortness of breath and chest pain. The patient was reported by the eldest
daughter at 1000 hrs. On collection of the medical history, the patient was found to be diagnosed
with type 2 diabetes 12 years ago. The patient was administered with oral medication. The
diabetes complications of the patient include symptomatic neuropathy and Peripheral vascular
diseases. The patient underwent coronary angioplasty and stents for myocardial infarction. He is
also under regular cardiology care. Other medical history also involves hypertension,
dyslipidaemia, and Angina also managed by oral medication. Recently the hypertension has
exacerbated. The person is non-drinker but previously was involved in smoking. No allergies
were reported in the patient. He was administered perindopril for hypertension and Atarvostatin
for hyperlipidemia.
On admission Mr Khoury was observed with the following-
HR 130
tachycardia
BP Sitting: 152/92
standing: 130/64
Resp. 28
non-productive cough;
speaks in short phrases
auscultation- coarse crackles
Reports-orthopnoea
fatigue with exercise
O2 Sat. 91% RA
Elevated to 95% with O2 (6L/min)
Temp. 36.5oC
LOC Alert
orientated to person
slight confusion with time and place (GCS 14/15)

3COMPLEX NURSING CARE
feels light headed after quick wake up
Pupils Equal
reactive to light
Pain 4/10
focused upper chest area (left)
Decreased with O2 suppky
Airway Patent
Peripheries oedema in both ankles
BGL 7 mmols/l
Patient health problems
1. Chest pain
Assessment data
Mr Khoury while arguing with his sons experienced sudden chest pain and
breathlessness. His pain is exacerbating due to high level of anxiety and stress. His cardiac
condition is weak with history of the Angina and Myocardial infarction. Chest pain together with
shortness of breath is risk factor blockage in blood vessels and reduces supply of oxygen to the
heart muscles, characteristics of the coronary artery disease. It is the condition of the inactive
tissue perfusion and activity intolerance (Miller et al., 2015). There is a risk of coronary heart
failure as the patient has high fluid accumulation in ankles, tachycardia, high anxiety, state of
confusion and orthopnea. Orthopnea is the symptom of the left ventricular heart failure or and
pulmonary edema (Gazewood & Turner, 2017). The patient was observed with fatigue. It is
caused by decreased cardiac output and impaired skeletal muscle blood supply, which is causing