Nursing Case Study: Analysis of Mr. Dury's Cardiovascular Event

This case study report analyzes the nursing care plan for Mr. Dury, a 58-year-old male with ischemic heart disease admitted to Sisters of Mercy Memorial Hospital for a coronary angiogram. The report begins with an introduction to Mr. Dury's medical history, including diabetes, hypercholesterolae...Read More

Case study
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Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY..................................................................................................................................3
Primary admission Diagnosis......................................................................................................3
Nursing Problems........................................................................................................................4
Nursing Management...................................................................................................................5
Discharge Planning......................................................................................................................7
CONCLUSION................................................................................................................................8
REFERENCES................................................................................................................................9
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INTRODUCTION
The report is based on the case study about the patients who are suffering from particular disease
therefore, different medical professional will provide the health care service to client. According
to case study, Mr. Dury is an 58 years old who has been diagnosed with ischemic heart disease
known as coronary heart disease. He is having problem of chest pain and is planning to do
surgery of coronary anigiogram with iodinated radiocontrast. He is a male who lives in south
Australia and his wife has died 18 months ago with cervical cancer. During his medical treatment
he said that sometime he forget to remember meditation. Also, he does not want to take fluid
medicines. However, there are many other problems which he faced such as pitting in both legs.
Also, he gets breathless on exertion and uses GTN spray 4 times a day. Besides that, Mr. Dury
has not spoken to his son regarding admitted to hospital (Chow, and Chok, 2019).
The report will describe about primary admission diagnosis for Mr. Dury. Furthermore, it will be
explained about nursing problems which may arise during it. Also, nursing interventions and role
of registered nurse will be discussed. At last, discharge planning of patient will be mentioned.
MAIN BODY
Primary admission Diagnosis
As per investigation, it has found that Dury is a client, which mainly faced health issue or
problem in regarding of chest pain (Shahif, Idris and Rahman, 2019 ). That’s why, he was
planned to the admitted in memorial hospital for reason behind investigation of chest pain. Other
medical professional also suggested to diagnose with long history of Ischemic heart disease
otherwise, it become dangerous in future for increasing the health issue or problem (Thyrian. and
et.al., 2017).
The primary diagnosis of Mr Dury that can identify the current health status, condition.
Afterwards, medical professionals have decided to provide, what kind of treatment. Initially,
doctors have a responsible for occasioning the admission of patient within hospital for purpose of
special care services (Ayaz-Alkaya and Terzi, 2019).
Furthermore, medical professionals are investigation on the pathophysiology of the disease,
which mainly describing the condition at the time of diseases. Sometimes, it can be identified as
abnormal condition which directly affecting the functionality of human body (Ma and et.al.,
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2020). Moreover, it has been diagnosis as both process of classification or pre-existing set of
multiple categories upon by medical profession.
As per case scenario, when doctors has performed the diagnosis pathophysiology of coronary
artery disease but it will require to consider the pre-medical history of Mr. Dury. In order to find
out the various issues such as diabetes mellitus, Coronary Artery Bypass 5 years ago,
Hypercholesterolaemia and so on. These type of problem has already occurred in the pre-medical
history (Bottle and et.al., 2019). In this way, it is important for consider these assumption and
then provide the treatment according to them. It would prefer to handle the complication while
easily diagnosis the pathophysiology of the disease.
Nursing Problems
By using the knowledge about the pathophysiology and clinical manifestation of Mr. Dury. The
medical diagnosis has made by physician and other health care practitioners (Oksman, Linna and
Talja, 2017). it is mainly deals with the disease, medical and pathological state of Mr. Dury.
Moreover, experience and well-known expert can be provided the better treatment.
Nursing Diagnosis help for identifying that how client responds to the potential health and life
processes (Kammersgaard and et.al., 2019). During primary care, it should be increased the
problem in the diagnosis process.
As per case study, it has been identified the nursing problem when professionals following the
coronary angiogram, which are undertaken to diagnose coronary artery disease. in this way, Mr
Dury that faced the difficulty remembering when to take his own medication. this situation has
been occurred due to lack of collaboration problem between nurses and patient.
Problem: 1 Heart Failure
It is consider one the potential problem which has decreasing the fluid output. Sometimes, it has
been occurred when heart muscles does not pump blood as well as. In this way, it has more
chances to increase high blood pressure, gradually leave heat too weak. Afterwards, it should be
considered physical prescribe intervention as well as independent. This type of problem or
condition may occurred during primary diagnosis (Bahadori-Chinibelagh, Fathollahi-Fard, and
Hajiaghaei-Keshteli, 2019). A lack of collaboration with client which may increase complex
situation and also difficult for understanding the initial cause of disease.
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This type of problem will be increasing because nurse’s diagnosis directed towards patient and
his physiological or psychological response (Ayaz-Alkaya and Terzi, 2019). But at that time, it
should not consider the initial response of Mr. Dury towards treatment process. In this way, it
has been increased the situation or condition.
Problem: 2 Kidney related problem
Kidney is also another problem that has been occurred and Mr.Dury faced the problem. In this
way, it has reduced the urine output although occasionally urine output become remain normal.
Also finding another causes shortness of breathiness.
According to case study, the individual client such as Mr. Dury is more susceptible to develop
the kidney and heart failure issue or problem during diagnosis process (Konttila and et.al., 2019),
Also identified that difficulties in breathing, walking.
After examine the heart and kidney problems within Mr. Dury. Generally, medical professional
will give the Aspirin, Hydrochlorothiazide, diuretic tablets, Atenolol, which help for reduced
blood pressure, excessive fluid, Fluid restrictions In order to help for kidney get rid of more
water and salts. In additional, it provide the better intervention therapies to control the current
heath condition in proper manner.
Nursing Management
It is based on the process or method that mainly consists of performance and efficiency of
leadership function within hospit-als.it may include the common processes for management such
as planning, organising, directing and controlling (O’Connor, O’Callaghan and Salim, 2019).
The nursing management is concept that must focus on the inpatient nursing assessment,
intervention and role of registered nurse in related to medication management.
The registered Nurses have performed the significant role in term of medication and also helping
for improve the hospital environment. As per case study, memorial hospital are accomplished the
significant task of improving patient health condition or situation. However, nurses are involved
in different stage of patient’s care such as prescribing, dispensing, monitoring and documenting
(Horner, Daddona and Wurcel, 2019 ). These will help for resolving the nursing problem which
mainly identified at the time of diagnosis. The registered nurses that have not participate as
prescription authority but it plays essential role in term of prescribing. It means that nurse
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conduct accurate interpreting and also understanding the prescription. Through case study, it
might be included significant role in medication while checking the patient health status. In
additional, registered nurses have more responsibility to evaluate, prevent and report the
particular drug and their side effects. Before giving the treatment, it should be considered the
medical history of patient. Therefore, it can easily understand the specific need or requirement of
patient.
Manage heart failure and kidney problems
As per given study, it has focused on the different nursing problem that usually occurred at the
time of primary diagnosis process. As considered the potential physiological complication that
nurses monitor to detect the onset changes in patient’s status due to heart failure (Zueger and
et.al., 2019). It is important for nurse to give positive response and quickly diagnosis the problem
such as breathing pattern and chronic heart pain.
Both health care provider are helping Mr Dury achieve their own optimal state of health
condition. in order to improve the health problem when they are participating in the medical
session (Konttila and et.al., 2019). On the other hand, Nurses are completely establish the
effectively interact with Mr Dury and also identifying their specific need or requirement. At that
point, it can resolve the collaborative nursing problem.
In additional, medical professionals such as nurses that help for following the procedure of
coronary angiogram, Also performing the different test in regards of blood and check
functionality of kidney. In order to demonstrate the fall in eGFR.
Manage effectiveness
(John and etal., 2020). There is no well-manner record to identify the best treatment that’s why,
it will increase the problem during primary diagnosis process. According to case study, it has
considered the better way to manage or eliminate heart and kidney diseases (Alam and et.al.,
2017). The nurses have changing the documentation that come from different sources such as
hospital records, researcher’s and nurses themselves. Through case study, Sisters of Mercy
Memorial Hospital that simplified a set of complex form and enable nurse to spend more time
caring for patient or client (Mr Dury).
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Furthermore, it will be using the educational interventions which mainly designed to improve the
documentation record of patient. In order to provide the best quality of health care service of Mr.
Dury. The involvement of intervention that have nurses apply a theory of case to other plan.
Sometimes, it also promoting the more patient focused documentation.
As per discussion, it has identified the two different nursing problems which may be resolved for
considering the effective intervention procedures. In order to control or manage the problem, if it
has occurred the complex situation and condition (Carlson and et.al., 2020). According to case
study, memorial hospital also focused on the nurse care planning. The documentation records are
intended to facilitate information flow, especially when conceptualizes the care planning process
in the form of coordination communication that will generate accurate result or outcome.
Discharge Planning
It is based on the process which mainly involving the transition of patient’s care from one level
to another. The major participation of health care professionals towards the patient’s in term of
treatment service. It is important to do discharge planning so that patient is discharged in
effective way (Konttila and et.al., 2019). Here, aim is to it is to reduce length of stay in hospital
and unplanned re admission in it. also, to enhance services of discharge and coordination
between patient and care workers. Here, it must be ensured that each patient leaves hospital
within time (Kimura, 2018). The planning is done differently for patient depending on their
situation. However, multi disciplinary approach enable in offering evidence based care to patient.
In this there are health professional and nurses that work together. So, with team work and
integrated practices care services are delivered. It has become way to work with various health
professionals (Martins, Silva and Lopes, 2019).
Furthermore, it has found that registered nurse plays vital role in this approach. He communicate
regularly with patient and identify needs. Also, by interacting with doctors they provide care
services to them. Similarly, in case of Mr. Dury. Nurse will interact with patient and analyse
his health condition. Moreover, as per schedule nurse will provide him all facility to fulfill needs.
Besides that , nurse will ensure that fluid balance remain maintained after surgery done. So, in
this way all are roles which will be performed by registered nurse. (Nigro and Merlano,, 2017).
Doctor- their role will be checking report and doing planning for discharge.
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Health professionals- they will provide treatment to Mr. Dury by discussion it with doctor and
checking medical data as well.
Nurse- his role will be to ready paper of discharge and provide primary care services to patient
CONCLUSION
From above discussion, it has been concluded that Mr. Dury has decided to go for surgery of
coronary anigiogram with iodinated radiocontrast. He is been admitted to hospital and having
some serious past medical history. it has summarized that medical professional and nurses that
should consider the intervention interventions, performed the significant role play by registered
nurse in the hospital. As per identified the nurses problem but it can be implementing the
effective management procedure to improve the complex situation or condition. it help for
recognizing the issue or problem before performing diagnosis process. However, The report has
described the discharge planning, which is based on the process that should include all essential
multidisciplinary approach.
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REFERENCES
Book and Journals
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Bottle, A. and et.al., 2019. Frailty and co-morbidity predict first hospitalisation after heart failure
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Nigro, C.L. and Merlano, M., 2017. Head and neck cancer: improving outcomes with a
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O’Connor, R., O’Callaghan, C. and Salim, U., 2019. An audit of discharge summaries from
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Oksman, E., Linna, M. and Talja, M., 2017. Cost-effectiveness analysis for a tele-based health
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Shahif, S., Idris, D.R. and Rahman, H.A., 2019. Knowledge and attitude towards mental illness
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Thyrian, J.R. and et.al., 2017. Effectiveness and safety of dementia care management in primary
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Zueger, P.M. and et.al., 2019. Older medicare beneficiaries frequently continue medications
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