Nursing Case Study: Importance of Patient History and Nursing Care Plan

This nursing case study explores the importance of patient history in providing better treatment and the development of a nursing care plan. It focuses on a patient who fell and injured her leg, leading to the diagnosis of pulmonary embolism. The study highlights the relationship between symptoms and disease process, as well as the interventions and expected outcomes.

Nursing Case Study
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Table of Contents
INTRODUCTION.......................................................................................................................................................................................3
Patient situations......................................................................................................................................................................................3
Collection of informations relevant to the patient...................................................................................................................................4
Process informations of the patient..........................................................................................................................................................6
Nursing care plan.....................................................................................................................................................................................7
Reflection.................................................................................................................................................................................................9
CONCLUSION............................................................................................................................................................................................9
REFERENCES..........................................................................................................................................................................................11
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INTRODUCTION
Nursing refers a collaborative care of people with different age. The main aim of nursing is to improve health of
people and make them healthy as well as disease free Butcher & et.al., (2018). This study is based on a case in which
patient Banu fell down from a tree root and injured her left leg. Due to this she is now suffering from the pain in her left leg.
She has overall a healthy life but takes contraceptive pills. This study is going to show importance of knowing patient
history as what she does daily, what is her family history, her medication, treatments, disease and diagnosis if happened.
By knowing all of these informations, nurses provide better treatment as per their present issue and situation. It will also
show some nursing problems as well as interventions for them Moskal, D. & et.al., (2018, p. 65).
Patient situations
In the case of Banu who fell over a tree roof stated pain in her left calf. Banu is a 28 years old lady. In the case, some
problems stated which shows her present situation.
Pathology of pulmonary embolism can be defined as a condition of sudden closure of pulmonary artery as well as
one of its branches which is mainly caused by a blood borne clot (Neto-Neves and et.al., 2017, p. 700-712).
Identification of problem: Banu is a healthy female as sudden she fell or tripped over a tree root on her daily run.
She stated that due to tree fall her left calf is swollen as well as painful. The right calf is absolutely normal. After 1-2 days
at the time of medication, she looked stressed, and she told that she is suffering from chest pain Gupta & et.al., (2018, p.
141-145). She was diagnosed with pulmonary embolism. This test is diagnosed and recommended when a patient has
pain in chest and feel like a blockage.
Medication: In the medication history, it is identified that she takes contraceptive pill as the only medicine.
Otherwise, she has a healthy lifestyle and there is no major issues Farquhar & et.al., (2017).
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Collection of informations relevant to the patient
It is important for a nurse to collect several informations relevant to her disease. It includes: her family history, her
medication, her daily routine and other. There are several reasons of having a disease in an individual as it may be
genetic as if parents of an individual have some types of disease than there are chances of having disease in patient or
their children as well. Some reasons may related to their daily life as if an individual consume alcohol, smoking and other
drugs than it may also be the reason Moskal & et.al., (2018). One of the main aim of knowing patient history and collecting
all informations is to identify the reason and give treatments accordingly. For example: If an individual has some pain in
chest, and he/she use alcohol, drugs and other things which may cause pain in chest than nurses recommend them to not
use all those things. Nurses also treat them as per the reasons Khoo & et.al., (2019, p. 348).
In the case of Banu, as a nurse it is important to collect informations and from the informations' history of patients is
identified such as:
Age: Age of Banu is 28 years.
Lifestyle: Banu lives a healthy lifestyle and that is why she found a healthy female. She rides to Holmes glen institute
most of the days when she studies allied health. From this, it can be said that she knows how important it is to being
healthy and fit as well as ways of being healthy and fits. It equates to approximate 10 km/day. She also went for a trip to
London it also shows that she likes travelling and to be happy. She also loves to read books as well as partying with her
friends.
Medication: It is stated that Banu takes contraceptive pills as the only medication. She does not take other pills because
she is healthy and fit and founded disease free. She used to drink alcohol, but she had not been drinking when she fell
Curtis & et.al., (2016, p. 1-66).
Family history: She has a happy family in which she has 3 siblings. Her father and mother. She has 1 older brother age
of 30 and 2 younger sisters age of 26 and 24. It is also stated that her mother diagnosed with TIAs. TIAs (Transient
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ischaemic attack) which is a brief episode of neurological dysfunction Dong & et.al., (2018, p. 4183-4194). One of the
main reason of this disease is loss of blood function or improper blood function in the brain, retina and spinal cord. Her
father has also a history of hypertension as well as GORD Leung & et.al., (2017). So, from this family history reason of
disease of Banu as well as treatment can be provided. It will help her out in protecting herself against TIAs, hypertension
and current problems.
Current problem: It is stated that Banu fell down from a tree root on her daily run. She is feeling pain in her left calf
Anam, Rabbani & Shumy, (2018). Her rights calf is absolutely fine and painless. After that she was kept in an observation
where her normal check up being done. In her normal check up it is identified that her blood pressure rate was 120/70
which is a normal. There is no risk of high or low blood pressure. Pain score was also identified which was 5 out of 10. It
can be considered as a normal range. Banu is kept overnight in observation in order to know other symptoms and disease
if occurs. After the night, next morning, Banu looked distressed and her blood pressure range raised and it was 140/90. It
was also stated that she hold her chest and complained pain at the time of breathing Sakhnini & Bisharat, (2019, p. 1210-
1212). From these symptoms, it can be said that she may have problem of TIAs or pulmonary embolism. Lack of oxygen
and feeling problems in breathing, air taking are some symptoms of having heart problems.
Reasons
From the symptoms and history of patients (Banu) some reasons can be identified. One of the reason of felling problem in
breathing may be genetic as her mother was diagnosed with TIAs. Her father has also a history of hyper tension. It is also
stated that she takes contraceptive pill and there may be some reasons of this disease Leung, A. A. & et.al., (2017, p.
557-576). It makes period less painful, regulates menstrual cycle, reduces risk of uterine cancer and it also relieves
symptoms of PMS and PMDD. From these reasons, it can be said that either patient has problem of irregular menstrual
cycle or having tension.
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Process informations of the patient
Pathophysiology of pulmonary embolism
After identifying some symptoms, Banu (patient) is sent for diagnosis of pulmonary embolism as she was facing
problem in breathing. Some other reasons of pulmonary embolism are: smoking, overweight, taking birth control pills or
contraceptive pills and having some types of disease like chronic, heart disease and high blood pressure. In the case of
Banu, it can be said that next morning of her observation, her blood pressure was 140/90 which was high Turetz & et.al.,
(2018, p. 92-98). So, it may be one of the reason. It is also stated from her medication that she takes contraceptive pill so,
it may be other reason of pulmonary embolism. So, she sent for diagnosis Chabbert-Buffet & et.al., (2017, P. 165-169).
The pathophysiology of pulmonary embolism is it can arise from anywhere in the body. The most identified area is
calf veins. Banu fell from tree root, and she stated that she has pain in her left calf and it is swollen. So, there are chances
of having this disease in left calf of Banu. It can also be said that in the context of pathophysiology of pulmonary embolism
is it happens when there is partial or completely occlusion of the pulmonary artery. An emboli zed clot from deep vein is
one of the main causes of it. Lipids, air tubules are also causes (Pulmonary Embolism, Pathophysiology, 2018).
Contributing factors: There are several factors which are associated with pulmonary embolism. Some common factors
include: smoking cigarette, being overweight and obese, taking birth control pills and having other chronic heart and other
disease. So, in the context of the patient (Banu) it can be said that taking contraceptive pills and drinking problem can be
main factors of this problem.
Relation with disease process and symptoms
There are strong relation between symptoms of Banu and disease process. It is identified that she has pain in her
left calf. Her left calf swollen and painful. And from the reasons of pulmonary embolism it is identified that this can arise in
any part of the body but the most common area is calf. So, one of the main disease process and sent to patient for
diagnosis of pulmonary embolism was painful and swollen calf.
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Other symptoms which identified is having problem in breathing, lack of oxygen and high blood pressure. In
reasons of pulmonary embolism, high blood pressure and breathing problem was also identified. So, it can be said that
there is a strong relationship between disease process and symptoms Nakhleh & et.al., (2017, p. 112-125)
One of the main reason of pulmonary embolism is taking birth control pill and in the history of Banu, she stated that
she takes contraceptive pill. So, it can also be the reason. So, the main reason of selecting this disease process and sent
to Banu for pulmonary embolism diagnosis are all.
It can also be said that this problem or disease of pulmonary embolism happen because of blocked artery in lungs
which may be identified by fever, excessive sweating, leg pain, dizziness. It is identified that leg pain is one of the main
symptom and problem from which Banu is suffering. So, it can be said that there is strong relation between symptoms of
this disease and process as well.
Risk factors and causes
Nursing care plan
Nursing problem Goals Interventions Evidence based
rationale
Expected outcome
Pulmonary
Embolism
Short term:
 To resolve
problem of
blood clot.
 Decrease
risk of
1. Heparin is given to the
patient. As per the
extent of the disease
and as per the extent
of disease of Banu
5000 units commenced
In the context of this
problem and
interventions, it can be
said that Banu can be
cured in a timely
manner. As the extent of
To prevent Banu or
patient from blood clot
Chamarthy, Kandathil
& Kalva, (2018, p. 208).
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hypertension.
Long term
 To decrease
the risk of
recurrence.
 To prevent
patient from
death and
amputation
of body part.
her.
2. 30, 000 units dosage in
normal saline at 42
hours of diagnosis.
3. Partial Thermoplastic
Time test.
4. Pot amine sulphate as
per the extent of the
disease.
5. Oxygen therapy as
Banu was suffering
from problem in
breathing.
the disease is not high
so, she can be cured by
providing all these
treatments Sanchez &
et.al., (2017, p. 771-
777)
Swollen and
painful left calf
Short term
 To relieve
pain.
 Preventing
blood clot
from
becoming it
larger.
Long term
1. Morphine 5 Mg.
2. Observation for at least
2 nights.
3. L DVT.
4. Massage
5. Blood thinner pills.
I believe that deep vein
thrombosis (DVT) is the
best way of solving the
problem of swollen and
painful calf which may
lead to pulmonary
embolism .Neto-Neves
& et.al., (2017). It is one
of the best medicine
To prevent patient from
developing clot bigger
and from pulmonary
embolism.
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 To prevent
patient from
pulmonary
embolism
which helps in blood
thinning and blood clot.
In addition, I can also
say that by providing all
these interventions,
nurse can cure to the
patient (Banu). DVT
does not break existing
blood clots but they
prevent clots from
getting bigger as well as
decrease risk of
developing more clots
Gill & Upadhyay, (2019,
p. A6765-A6765).
Eliminating
dizziness
Goals
Making healthy and
fit to the patient
Encouraging deep breathing
exercise and administering
oxygen if required and
indicated.
It can increase oxygen to
parts of body as it is one of
the main reason of
pulmonary embolism. By
mobilizing secretions and
improving ventilation is
the main reason of this
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intervention.
Identifying other
symptoms in a
timely manner.
Improving health of
the patient in an
effective manner.
Assessing respiratory rate and
monitor in order to know
increase in anxiety, shortness
of breath for identifying
symptoms in a timely manner.
O2 saturation of less
than 92% may detect
hypoxia and signals the
need for supplemental
oxygen.
Risk for Shock
and acute pain
Short term
 Increase
perfusion.
 Display
haemodynami
c stability.
Long term
 Report pain
relieve
 Preventing
patients
against side
effects
 Monitoring thrombolytic
therapy through PTT.
 Measuring signs of
hypoxaemia as well as
monitoring pulse
oximetry values
 Encouraging patient to
interact about feelings
and fear.
 Turning patient
frequently and
repositioning for
improving ventilation
perfusion ratio.
 Passive leg exercise.
Increased perfusion and
knowing haemodynamic
stability for relieving
patient from pain
(Intervention for Pulmonary
Embolism, 2017).
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Venous
Thromboembolic,
leg pain
Short term goal
 Relieve pain
Long term
 to remove
problem of
clot and
thickness
 Prevent patient
against heart
disease
 Early ambulation
surgery
 Passive leg exercise.
 Blood thinner pills.
 Turning and positioning
immobilized patients in
every 2 hours.
 Compression stocking
The main reason of
providing all these
treatments and
interventions to the
patient is to relieve pain
and keep blood flowing
to prevent VTE's from
forming.
In addition, some other diagnosis of Pulmonary Embolism can be ventilation perfusion scan which can help in
identifying flow of air as well as blood in lungs which can also help in identifying the extent to which disease is spread.
Chest X ray, blood test and ultrasound are some other diagnosis of this disease which can help in identifying reasons,
extent of disease. By identifying they type and extent, appropriate treatment can also be suggested to the patient.
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Reflection
From the above case of Banu, I can say that I learned several of things about the type disease and importance of
having knowledge about different types of skills related to disease. I found that having a healthy lifestyle plays an
important role as it helps an individual in healing them and protecting them against disease in a quick manner as compare
to other. In the case of Banu, I also get to know causes, symptoms as well as interventions of pulmonary embolism as it
can create several other problems. Further, I also came to know about the reason as well as importance of having all
details or patients history in a detailed manner including family background, medication, interventions current disease,
lifestyle others Matsuoka & et.al., (2018, p. 653-658).
CONCLUSION
From the above study, it has been summarized that nursing interventions played a vital role in solving problems of
patients. It has shown importance of knowing patients' history including their lifestyle, medications which they take, their
family history in order to know the reason of disease as if it occurs due to genetic reasons or not. It has also shown
importance of being polite and having ability to make a patient comfortable in order to get informations and providing them
a better health care services. Lastly, it has shown 2 main nursing problems which has both short term and long term goal
as well as different interventions. Main aim of knowing interventions and selecting the best one is improving health of
patients and getting determined results.
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REFERENCES
Books and journals
Anam, A. M., Rabbani, R., & Shumy, F. (2018). Spontaneous calf haematoma in severe dengue. Case Reports. 2018.
Butcher, H. K. & et.al., (2018). Nursing Interventions classification (NIC)-E-Book. Elsevier Health Sciences.
Chabbert-Buffet, N. & et.al., (2017). Missed pills: frequency, reasons, consequences and solutions. The European Journal of
Contraception & Reproductive Health Care. 22(3). 165-169.
Chamarthy, M. R., Kandathil, A., & Kalva, S. P. (2018). Pulmonary vascular pathophysiology. Cardiovascular diagnosis and therapy.
8(3). 208.
Curtis, K. M. & et.al., (2016). US selected practice recommendations for contraceptive use, 2016. Morbidity and Mortality Weekly
Report: Recommendations and Reports. 65(4). 1-66.
Dong, J. & et.al., (2018). Structure of tRNA-Modifying Enzyme TiaS and Motions of Its Substrate Binding Zinc Ribbon. Journal of
molecular biology. 430(21). 4183-4194.
Farquhar, C. & et.al., (2017). Oral contraceptive pill, progestogen or oestrogen pretreatment for ovarian stimulation protocols for
women undergoing assisted reproductive techniques. Cochrane Database of Systematic Reviews. (5).
Gill, K., & Upadhyay, D. (2019). An Unusual Case of a Pulmonary Vascular Filling Defect. In D55. CASE REPORTS IN
PULMONARY VASCULAR MEDICINE III (pp. A6765-A6765). American Thoracic Society.
Gupta, S. & et.al., (2018). Recurrent diabetic myonecrosis–an under-diagnosed cause of acute painful swollen limb in long standing
diabetics. Annals of medicine and surgery. 35. 141-145.
Khoo, C. S. & et.al., (2019). A rare but treatable cause of recurrent chest pain-Ictal chest pain. BMC neurology. 19(1). 348.
Leung, A. A. & et.al., (2017). Hypertension Canada's 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of
hypertension in adults. Canadian Journal of Cardiology. 33(5). 557-576.
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Matsuoka, S. & et.al., (2018). Quantitative CT evaluation of small pulmonary vessels in patients with acute pulmonary embolism.
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Sakhnini, A., & Bisharat, N. (2019). Practice behavior of emergency department physicians caring for patients with chest pain The
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22(4).; 771-777.
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interventional radiology (Vol. 35, No. 02, pp. 92-98). Thieme Medical Publishers.
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