Case Study: Clinical Reasoning Cycle and Pharmacokinetics

This case study examines the case of Mr. Gordon Deltori, a 68-year-old taxi driver admitted to the emergency department with severe chest pain. The paper begins with an overview of his condition, including his medical history of hypertension, diabetes, osteoarthritis, and atrial fibrillation, as well as his unhealthy lifestyle choices. The study then delves into the pathophysiological issues related to his chest pain, which is described as dull and achy, radiating to his back, and not alleviated by his medication. The analysis identifies nursing care priorities using the clinical reasoning cycle, focusing on the use of echocardiogram and administration of nitroglycerin. The paper also provides a detailed explanation of the pharmacokinetics of two of Mr. Deltori's medications: Metformin and Anginine, discussing their absorption, metabolism, and excretion processes. This case study presents the patient's condition, presents the nursing care plan, and the pharmacokinetics of the medications used by the patient.

Running Head: CLINICAL REASONING CYCLE
Case Study Assessment: Clinical Reasoning Cycle
Name of the Student
Name of the University
Author’s Note

1CLINICAL REASONING CYCLE
Table of Contents
Pathophysiological issues................................................................................................................2
Clinical Reasoning Cycle................................................................................................................3
Pharmacokinetics.............................................................................................................................5
References........................................................................................................................................7

2CLINICAL REASONING CYCLE
Case Study Assessment: Clinical Reasoning Cycle
This case study is on Gordon Deltori who is a male taxi driver of 68 years of age. He was
admitted to the emergency ward after he went through a severe chest pain that began at the odd
hours of the night. His pain was achy and dull pain that was radiating to his back. When he was
going to sleep he felt a tight sensation in his chest and when he woke up he felt a chest pain.
According to him, his pain was worse when compared to the pain at night and he had to use his
anginine for the 3rd time in the last 5 months. He complained that this time his medication was
not working and he was worried that how will he look after his family if something happens to
him. Gordon’s wife is also distressed due to his condition and shares that he has an unhealthy
lifestyle were he only eats fast food and rarely exercises (Hussain et al., 2014). He refuses to take
medication and is a chain smoker since he was 14 years old. He has a medical history of
hypertension for the past 10 years, diabetes for the past 5 years, osteoarthritis, and atrial
fibrillation.
The purpose of this paper is to analyse the case and give care plans after using the clinical
reasoning cycle including the pharmacokinetics of two medicines used by him.
Pathophysiological issues
The pathophysiological issues related to his presenting problems will be discussed. As it
is evident from the case study that Mr Gordon is suffering from severe chest pain, which can be
critical if not treated or monitored. He has complains of dull and achy pain that radiates to the
back. He rated his first pain as 4/10 and later it increased to a 6/10. This shows that his pain is
not decreasing and instead it is elevating after every hour (Zeller et al., 2014). He even used his
anginine but that was of no use. His medical history sheds a light on his current
pathophysiological issues because he is a patient of diabetes mellitus and hypertension including

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atrial fibrillation. All these previous complications are linked to his current issue of intense chest
pain. His medications are comprised of anginine, perindopril, metformin, vitamin D and epixban.
After he was admitted he was unable to remember his medications, he was confused if he should
keep taking them and he was not sure if it was doing him any good (Hambrecht, Berra & Calfas,
2013).
His examination data showed that he was alert, anxious, well-groomed, diaphoretic, and
cooperative but he looked older than his age. The vital signs after observation indicated that his
temperature was 37.1 C, heart rate was 120 bpm that was regular, and blood pressure was 169/90
mm Hg and respiratory rate was 24. The peripheral pulses showed that his pulses were palpable,
dorsalis pedis was bilateral, apical impulse was 120 bpm that is strong and regular, and his S1
and S2 were without murmurs. Thoracic heave with pulsation was observed. When he was in
supine position his pulsation and jugular distension was noted. His skin was dry and warm
without cyanosis and had an even hair distribution. His pitting oedema was noted bilaterally
without the presence of lesions (Tarkin, & Kaski, 2013). The pathophysiological issues might be
related to his heart health and he has tendencies of stroke and angina or myocardial infarction
that can lead to cardiac arrest according to his current complications. His constant and severe
chest pain indicates that it is something life threatening and he needs to be monitored including
the implementation of serious medical interventions. It is also seen that he is unable to remember
anything about his medications and he is unaware about the requirement of the medicines
prescribed to him. His lifestyle has no discipline and he has no control over his diet, which is
another reason for his current state. Gordon and his wife is tensed because he is the sole bread
earner of the family and that is a stressing issue for both of them (Moattari et al., 2014).

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Clinical Reasoning Cycle
The nurses should be careful in treating a patient with Angina as it is a critical issue,
which happens due to blockage in heart that can lead to cardiac arrest or death. The nursing care
plan should be used by them for efficient patient care and safety. The identified care plans for
Mr. Gordon included investigation about the location of pain, reducing his anxiety in the medical
department, implementing ways to prevent his angina by making the patient sit in semi-Fowler’s
position after stopping every activity. The patient should be administered with nitroglycerin
sublingually (Asress et al., 2017). After identifying the pain scale and the level of activity that
caused the pain, the nurses should use medications and injections that can prevent his pain
according to his condition. Most importantly, the demand of the oxygen should be decreased by
keeping the patient at rest and at a comfortable position. Mr. Gordon is complaining of a tight
chest pain that radiates to his back so he should be given optimum care and attention so that his
condition improves (YUSEFZADEH et al., 2014). The initial care plan will include rest and
stability so that he is less vulnerable to more complications. His blood pressure should be
monitored including his echocardiogram that will give a clear idea about his heart condition.
Some of the medications to be included is morphine, nitro-glycerine and aspirin, which is
prescribed by doctors in certain cardiovascular diseases including angina and myocardial
infarction (Boland, Jiang & Fenning, 2019).
According to the cycle of clinical reasoning, the nursing care priorities will be critically
analysed. In this cycle the patient situation is considered, cues and information are collected,
processing of information is done, issues/problems are identified, establishment of goals, action
is taken, outcomes are evaluated and finally the reflection is done on the process and new
learning. The first two nursing care plans prioritized according to the clinical reflection cycle is

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echocardiogram and administration of nitro-glycerine. His current information was considered
while choosing these two as a priority care plan. He showed symptoms of angina and cardiac
arrest, which needs to be monitored by echocardiogram test and the treatment will be proceeded
with the help of nitro-glycerine that it used to prevent chest pain or angina (Divakaran &
Loscalzo, 2017). Usually chest pain occurs when the heart is unable to receive blood and it
happens when the arteries are blocked. They are also known as nitrates that widens the arteries
and reduces the workload of the heart through easy flow of blood. In the future, it also helps to
reduce the number of heart attacks in a person who is vulnerable to cardiovascular diseases.
Echocardiogram is another care plan that will be used to monitor Mr. Gordon’s heart rate, which
will help in understanding the stability of his heart. As angina is a critical issue it needs to be
monitored so that the same incident does not occur again. As per the critical analysis, these two
care plans will be beneficial for the patient because it has been proved efficient and is used by
many experts (Biering-Sørensen et al., 2014).
Pharmacokinetics
Pharmacokinetics is the branch of study in pharmacology that deals with the movement
of a specific drug in the body.
Metformin: It is also known as biguanide metformin (dimethylbiguanide) and is used as an oral
antihyperglycaemic drug used in the treatment of non-insulin dependent diabetes mellitus. High
performance liquid chromatography is used to determine the metformin through biological
fluids. The disposition of metformin is only affected when other oral formulations are taken for
diabetic treatment. This medicine has the bioavailability of 40-60% and the gastrointestinal
absorption takes 6 hours to ingest this drug. This drug is rapidly absorbed and it does not bind to
the plasma proteins. The renal excretion of this medicine takes 4-8.7 hours after oral

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administration but it can be obstructed if the patient is suffering from renal impairment or has
creatinine clearance issues (Duong et al., 2013).
Anginine: It is also known as glyceryl trinitrate that is easily absorbed through the buccal
mucosa and it is instantly metabolized. The increasing rate of metabolism guarantees fast
duration of action. When this drug is administered sublingually then the peak plasma levels
become visible after every four minutes. It is absorbed by the vascular smooth muscle cells and
the volume of distribution in the body is 3 L/kg. It undergoes hydrolysis inside the plasma and it
is instantly hydrolysed by glutathione-organic nitrate reductase to mononitrates and dinitrates in
the liver. It is excreted from the blood in 1-3 minutes (Zacharias et al., 2017).

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References
Asrress, K. N., Williams, R., Lockie, T., Khawaja, M. Z., De Silva, K., Lumley, M., ... &
Guilcher, A. (2017). Physiology of angina and its alleviation with nitroglycerin: insights
from invasive catheter laboratory measurements during exercise. Circulation, 136(1), 24-
34.
Biering-Sørensen, T., Hoffmann, S., Mogelvang, R., Zeeberg Iversen, A., Galatius, S., Fritz-
Hansen, T., ... & Jensen, J. S. (2014). Myocardial strain analysis by 2-dimensional
speckle tracking echocardiography improves diagnostics of coronary artery stenosis in
stable angina pectoris. Circulation: Cardiovascular Imaging, 7(1), 58-65.
Boland, J. E., Jiang, F., & Fenning, A. (2019). Drug therapy in the cardiac catheterisation
laboratory: A guide to commonly used drugs. Interventional Cardiology and Cardiac
Catheterisation: The Essential Guide.
Divakaran, S., & Loscalzo, J. (2017). The role of nitroglycerin and other nitrogen oxides in
cardiovascular therapeutics. Journal of the American College of Cardiology, 70(19),
2393-2410.
Duong, J. K., Kumar, S. S., Kirkpatrick, C. M., Greenup, L. C., Arora, M., Lee, T. C., ... &
Williams, K. M. (2013). Population pharmacokinetics of metformin in healthy subjects
and patients with type 2 diabetes mellitus: simulation of doses according to renal
function. Clinical pharmacokinetics, 52(5), 373-384.
Hambrecht, R., Berra, K., & Calfas, K. J. (2013). Managing Your Angina Symptoms With
Nitroglycerin: What About Exercise?. Circulation, 127(22), e642-e645.

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Hussain, M., Khan, N., Uddin, M., & Al Nozha, M. M. (2014). Chest pain, coronary artery
disease and risk factors: a global snapshot. Journal of the Dow University of Health
Sciences (JDUHS), 8(2).
Moattari, M., Adib, F., Kojuri, J., & Tabatabaee, S. H. R. (2014). Angina self-management plan
and quality of life, anxiety and depression in post coronary angioplasty patients. Iranian
Red Crescent Medical Journal, 16(11).
Tarkin, J. M., & Kaski, J. C. (2013). Pharmacological treatment of chronic stable angina
pectoris. Clinical medicine, 13(1), 63.
YUSEFZADEH, E., Akbarzadeh, R., KHADEMOLHOSEINI, S. M., & Akrami, R. (2015). The
effect of implementing evidence-based guidelines on the quality of nursing care provided
to patients with angina pectoris.
Zacharias, K., Ahmed, A., Shah, B. N., Gurunathan, S., Young, G., Acosta, D., & Senior, R.
(2017). Relative clinical and economic impact of exercise echocardiography vs. exercise
electrocardiography, as first line investigation in patients without known coronary artery
disease and new stable angina: a randomized prospective study. European Heart
Journal-Cardiovascular Imaging, 18(2), 195-202.
Zeller, T., Keller, T., Ojeda, F., Reichlin, T., Twerenbold, R., Tzikas, S., ... & Munzel, T. (2014).
Assessment of microRNAs in patients with unstable angina pectoris. European heart
journal, 35(31), 2106-2114.