Case Study of Mrs. Eleano Hale with Pneumonia and Cardiovascular Issues

This case study discusses the medical history, symptoms, and nursing interventions for Mrs. Eleano Hale, a 56-year-old female with pneumonia and cardiovascular issues. It covers her vitals, diagnosis, and priority of care. The case study also addresses her psychosocial issues and provides recommendations for her management and follow-up.

Nursing
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This is a case study of Mrs. Eleano Hale, a 56 years old female is an admission for two days and
has been under treatment of pneumonia for two days. She has a history of Hypertension,
Ischemic Heart Disease (IHD) and beginning Peripheral Vascular Disease (PVD). She had
Coronary Artery Bypass Graft Surgery (CABG) six years ago with Saphenous Vein grafts to her
Left Anterior Descending (LAD) coronary artery and diagonal branch. She underwent a
Percutaneous Transluminal Coronary Angioplasty (PTCA) with stenting to her Right Coronary
(RCA) and Posterior Descending (PDA) arteries about two years ago. She lives alone in rented
accommodation and she is a retiree and so she is now relying on her pension as a sole source of
income. She has a history of smoking for 30 years. She currently weighs 88kg and her height is
158cm. Her BMI is 35.2 hence she is obese. She looks psychologically down.
Her vitals initially were; Temperature: 37.3ᵒC, Pulse: 74bpm, regular, volume strong,
Respiratory rate: 14/min, regular, normal depth, BP: 165/90mmHg (normal for her), SpO2: 98%
on room air. About 30 minutes later, she looks diaphoretic and has developed some slight
pressure sensation in her chest. Her vitals read; Temperature: 37.2ᵒC, Pulse: 116bpm regular and
volume is not as strong as previously, Respiratory Rate: 26/min, regular, a little shallower than
previously, BP: 105/70 mmHg, SpO2: 92% on room air. She has developed shortness of breath
and slightly cool peripherals. These are signs of an underlying condition. She is currently
experiencing unstable angina pectoris which come as pain. The etiology of the angina pectoris is
that the cardiac workload and myocardial demand for oxygen exceed the ability of the coronary
arteries to supply enough oxygenated blood to the cardiac muscles. As the myocardium becomes
ischemic, PH of coronary sinus blood falls that is why there is diaphoresis. Cellular potassium
is lost leading to loss of cardiac contractility, lactate (acid formed as a result of anaerobic

respiration) accumulates which essentially causes the pain in the muscle (Bautista-Hernandez,
et.al, 2016). If ECG is done, abnormalities appear, and both systolic and diastolic functions
deteriorate. Left ventricular (LV) diastolic pressure usually increases during angina ( Kemp, &
Conte, 2012), sometimes inducing pulmonary congestion and dyspnea that is why the patient
feels pain in the left side upper hand. Therefore, the pain comes due to oxygen deprivation of
the cardiac muscle (Cabello, et.al, 2016). The heart muscle becomes weakened due to inadequate
break down of bio-molecules to provide essential energy mainly due to a low oxygen supply. As
a result, the heart reduces its ability to maintain cardiac output hence weak but rapid pulse and
significantly reduced blood pressure. This is evidenced by the slightly raised pulse and lowered
blood pressure. The low blood pressure is due to decreased myocardial contractility with reduced
cardiac output while an increased pulse is just a compensation mechanism and the ability to
increase the capacity to transport oxygen from the lungs to the vital organs. There is also
impending cardiogenic shock as evidenced by the slightly cooled peripheries and ultimately
result in cardiac arrest if appropriate interventions are not applied. Such imbalance between the
demand and the supply happens due to the narrowed lumen of the arteries, due to reduced blood
volume in the vessels less than the capacity to carry adequate oxygen. Narrowing results from
atherosclerosis, which is a condition in which substances such as fat or smoke particles or sooth
get deposited along the walls of the arterial lumen leading to narrowing of blood vessels and
even get completely blocked with time if no interventions. For the case of Mrs. Hale, she has a
history of smoking for a duration of 30 years and more so, her body weight is clear evidence that
she is obese. She stands a high chance of having low density lipoproteins circulating together
with cholesterols. These combined together, may have gotten deposited in the arteries over time.
Smoke particles and fats play a major role in the narrowing of her blood vessels. Even though

she has had several surgical interventions to correct the stenosed vessels, like for example the
coronary artery bypass graft surgery that was done six years ago and percutaneous transluminal
coronary angioplasty with stenting to her right coronary artery and posterior descending arteries,
they are likely to have been affected too. The circulating fats smoke particles may have caused
the narrowing of these surgically fixed corrections.
The priority of care is on the airway and cardiovascular system. The respiration rate of 26 bpm,
SPO2 of 92% and dyspnea are the cluster of cues showing that there is a problem with
oxygenation. Nursing diagnoses that can be deduced are; tissue hypo-perfusion related to
reduced blood oxygen carrying capacity as evidenced by the dyspnea. Therefore, the patient has
to be first nebulized with the use of 4mg of dexamethasone and Ventolin 0.5 ml. this is done to
expand the airway and the alveoli to facilitate increased surface area for oxygen uptake in the
lungs. This will help to boost the inspiration hence increased gaseous exchanged. Also, she needs
to be administered with oxygen supplement 4 liters per minute via an oxygen mask to boost her
oxygen saturation level. This is because she is experiencing hypoxia as presented in the form of
dyspnea, which is the shortness of breath. There is increased oxygen demand due to the reduced
capacity of blood to pick oxygen from the lungs owing to its reduced volume. Therefore oxygen
supplement will increase the oxygen concentration in the lungs hence increasing surface area for
gaseous exchange. This should go on until the oxygen saturation level reaches above 95%. The
head should be propped up to facilitate oxygen intake. Tachycardia of 116 bpm and blood
pressure of 105/70 mmHg and cool peripheries are the cluster in the cardiovascular
compartments. Possible nursing diagnoses are; tachycardia related to hypoxemia as evidenced by
the heart rate of 116 bpm, a risk of hypotension related to deteriorating ventricular functions as

evidenced by reduced blood pressure from initially 160/90 mmHg to currently 105/70 mmHg.
The patient needs to be taken for ECG to rule out. Cardiogenic shock related to compromised
heart cardiac muscle as evidenced by the cool peripheries (Ukor, & Hockings, 2014). The patient
should be propped up on the chest. The patient is likely to be having left-sided heart failure and
pulmonary hypertension. First, fluid, sodium chloride 500ml should be infused intravenously
over one 30 minutes. This will help to boost the volume in the cardiovascular compartment.
Also, digoxin 25 mg should be administered per oral. The digoxin will help to boost the cardiac
contractility hence increasing cardiac output significantly (Kemp, & Conte, 2012). Administer
nitrate donors such as sodium nitroprusside. These drugs act directly on vascular smooth muscle
to produce venous and arteriolar dilatations. They reduce myocardial oxygen demand and instead
increase myocardial oxygen supply by causing coronary dilation. Also to be administered is the
calcium channel blockers for example; nifedipine 20 mg sublingually. This class of drugs will
help to; reduce myocardial oxygen consumption, dilatation of coronary artery and peripheral
vasodilatation. Pulmonary hypertension related to congestive cardiac failure as evidenced by the
patient having dyspnea. The goal here is to remove any fluid accumulation in the pulmonary to
ease the congestions. Therefore, Furosemide is supposed to be administered to lower pulmonary
hypertension (Fallah, 2015). The drug will help to facilitate the excretion of fluids that have
accumulated in the lungs and also to stabilize the pulse hence preventing tachycardia. The patient
should be administered with lipid-lowering drugs such as atorvastatin and simvastatin to reduce
the lipid levels. Blood sugar levels should also be checked regularly to ascertain that it is within
the normal ranges. There is also a risk of impaired kidney functions related to decreased blood
supply as evidenced by the diaphoresis, whereby the skin is acting as the alternative form for
excretion of excess fluids instead of the kidneys. Therefore, the cardiac functions should be done

so fast to reduce the chances of the kidney shut down. Management of the chest discomfort is
very vital in this case. The main presenting condition is angina pectoris, specifically angina
pectoris. The goal of management is to reduce pain and suppress the causes of the pains. First,
position the patient appropriately that is in a Semi-Fowler’s position to decrease the pain
aggravation and reduce oxygen demand, remove clothing, comfort and reassure. Secondly, the
patient should be administered with analgesics such as junior aspirin 150 mg per oral once in
every 24 hours. The junior aspirin will help to reduce pain by inhibition of cox pathway. Junior
aspirin also helps to prevent platelet activation and therefore reduces the incidence of myocardial
infarction and death in the patients with myocardial infarctions (Depta, et.al, 2012). Oxygen
saturation should be checked regularly to ascertain that it is within the normal levels
(Authors/Task Force Members, et.al, 2012). In case the pain persists, then administer oxygen
2L/min by nasal cannula. Anticipate for the use of intubation if respiratory distress is evidenced.
Prepare to perform CPR, defibrillation and chest compression in case the condition worsen.
Mrs. Hale has got some psychosocial issues that contributed to her current ill health condition.
She has been smoking for a duration of about 30 years and she lives alone in a rented house and
she relies only on her pension since she is already retired. She has a son who stays away and she
rarely sees him. The smoking lifestyle has caused her deleterious effects. For example, cigarette
smoking causes artherosclerosis (narrowing of blood vessels) since they deposit along the walls
of the arteries (Siasos et.al, 2014). This has resulted in her developing peripheral hypertension.
The cigarette smoking has likely to have caused her the pulmonary complications too. Her social
status of being single in the room alone has contributed significantly to her unhealthy status. She
has been sick since she has been done several surgical operations to correct the state of her

narrowed arteries. Since she needs help but there is no one, she has developed stress over time.
Stress stimulates the release of cortical hormones which causes vasoconstrictions on the
peripheral arteries (Puzserova, & Bernatova, 2016). Also, the level of work she does by herself is
too much for her as she is not in stable health to perform all the house chores and hence her
increased hypertension.
In conclusion, Mrs. Hale is such a critical patent with multiple conditions that need to be closely
monitored in an ideal set up with adequate availability of the resources. She should be kept under
cardiac monitoring as part of her management. Continue monitoring the patient also using ECG.
Manage the pain while taking and recording the pain score. Vital signs should be taken hourly
until they normalize. Also, monitor blood sugar levels to ascertain that it remains within the
normal range. Also, renal function test should be done to ascertain that the kidneys are
functioning normally (McCullough, et.al, 2013). This can be monitored by observing and
recording input and output using the appropriate fluid chart. Also important is lifestyle
education. She should be educated on the appropriate diet and exercise. Consequently, she needs
psychological counseling to alleviate her level of stress. She is also supposed to be done a close
follow up after discharge from the hospital for better prognosis by allocating her one of the
health care providers to be attending to her.

References
Authors/Task Force Members, Steg, P. G., James, S. K., Atar, D., Badano, L. P., Lundqvist, C.
B., ... & Fernandez-Aviles, F. (2012). ESC Guidelines for the management of acute
myocardial infarction in patients presenting with ST-segment elevation: The Task Force
on the management of ST-segment elevation acute myocardial infarction of the European
Society of Cardiology (ESC). European heart journal, 33(20), 2569-2619.
Bautista-Hernandez, V., Karamanlidis, G., D McCully, J., & J del Nido, P. (2016). Cellular and
molecular mechanisms of low cardiac output syndrome after pediatric cardiac
surgery. Current vascular pharmacology, 14(1), 5-13.
Cabello, J. B., Burls, A., Emparanza, J. I., Bayliss, S. E., & Quinn, T. (2016). Oxygen therapy
for acute myocardial infarction. Cochrane Database of Systematic Reviews, (12).
Campeau, L. (1976). Grading of angina pectoris. Circulation, 54(3), 522-523.
Chastre, J., & Fagon, J. Y. (2002). Ventilator-associated pneumonia. American journal of
respiratory and critical care medicine, 165(7), 867-903.
Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in
healthy people: a review and meta-analysis. The journal of alternative and
complementary medicine, 15(5), 593-600.
Depta, J. P., Fowler, J., Novak, E., Katzan, I., Bakdash, S., Kottke-Marchant, K., & Bhatt, D. L.
(2012). Clinical outcomes using a platelet function-guided approach for secondary

prevention in patients with ischemic stroke or transient ischemic attack. Stroke, 43(9),
2376-2381.
Fallah, F. (2015). Recent strategies in the treatment of pulmonary arterial hypertension, a review.
Global journal of health science, 7(4), 307.
Kemp, C. D., & Conte, J. V. (2012). The pathophysiology of heart failure. Cardiovascular
Pathology, 21(5), 365-371.
Libby, P., Ridker, P. M., & Maseri, A. (2002). Inflammation and
atherosclerosis. Circulation, 105(9), 1135-1143.
McCullough, P. A., Shaw, A. D., Haase, M., Bouchard, J., Waikar, S. S., Siew, E. D., ... &
Ronco, C. (2013). Diagnosis of acute kidney injury using functional and injury
biomarkers: workgroup statements from the tenth Acute Dialysis Quality Initiative
Consensus Conference. In ADQI Consensus on AKI Biomarkers and Cardiorenal
Syndromes (Vol. 182, pp. 13-29). Karger Publishers.
Perloff, J. K. (1973). Pediatric congenital cardiac becomes a postoperative adult: the changing
population of congenital heart disease. Circulation, 47(3), 606-619.
Puzserova, A., & Bernatova, I. (2016). Blood pressure regulation in stress: focus on nitric oxide-
dependent mechanisms. Physiological research, 65.
Siasos, G., Tsigkou, V., Kokkou, E., Oikonomou, E., Vavuranakis, M., Vlachopoulos, C., ... &
Stefanadis, C. (2014). Smoking and atherosclerosis: mechanisms of disease and new
therapeutic approaches. Current medicinal chemistry, 21(34), 3936-3948.

Ukor, I. F., & Hockings, L. E. (2014). Ischaemic cardiogenic shock. Anaesthesia & Intensive
Care Medicine, 15(2), 68-71.