University Case Study: Clinical Judgement and Reasoning - SNPG962

This case study report focuses on the clinical management of a 44-year-old male, Mr. Harry, who presented with symptoms of a heart attack. The report details his physical assessment, including cardiovascular, respiratory, gastrointestinal, and central nervous system evaluations. Diagnostic procedures like blood tests (cardiac enzymes and lipid profile) and ECG were performed, revealing elevated cardiac markers and ST-elevation. Treatment interventions included aspirin, GTN, morphine, and percutaneous coronary intervention (PCI) with stent placement. The report also highlights the importance of supplemental oxygen and continuous monitoring of vital signs. The case study provides insights into the pathophysiology, diagnostic, and curative procedures associated with myocardial infarction, along with the nursing interventions essential for patient care and management.

Running head: CLINICAL JUDGEMENT AND REASONING 1
Clinical Judgment and Reasoning
Student Name
Institutional Affiliation

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Introduction
A heart attack is one of the medical emergencies, and it occurs when the flow of blood to
the heart muscle is blocked. Blood carries oxygen to all body tissues, and hence when blood flow
is blocked, the destination is deprived of oxygen leading to anaerobic respiration that causes pain
and can lead to tissue necrosis hence3 heart attack can also be termed as myocardial infarction.
This report describes the physical assessment of a 44-year-old patient, Mr. Harry, who has
experienced a heart attack and its diagnostic tests. It will further explain the pathophysiology of
the disease, diagnostic, and curative procedures to be performed together with the management
measures of the patient. The report will also explain the nursing interventions to be implemented
during a heart attack.
Focused physical assessment
Cardiovascular system
On inspection, the patient has no scars on the chest, the skin is uniform in color, and the patient
is sweating profusely. He has no edema or ascites, and the capillary refill is<2 seconds. The
patient is pale, has a good skin turgor, and no distension on the neck veins.
On palpation, central and peripheral pulses are present, presenting with increased rate and
volume. Temperature measured and recorded to be 37.2⁰C, which is within normal ranges. The
blood pressure measured is at 167/100 mmHg, which is high compared to normal ranges.
On auscultation, the apical pulse is recorded at 120 beats/min, which is above the normal ranges
(60 -100 beats/min). The rate and rhythm are equivalent to the peripheral pulses. S1 and s2 are
heard together with a heart murmur.

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Chest pain; the pain was assessed using the pneumonic PQRST (provocation factors, quality of
pain, the region of the pain, severity, and time of onset) (Gauchan, 2019). Harry described
experiencing the pain after physical exertion experiencing stress and said the pain feels like
pressure or tightness in the chest. Chest pain occurs as a result of blockage of blood flow to a
particular segment of the cardiac muscle. Lack of enough oxygen supply leads to anaerobic
respiration in the muscle cells. This leads to the production of lactic acid that irritates the nerves
leading to pain perception (Body, Lewis, Carley, Burrows, Haves, & Cook, 2016). The patient
reports the pain to be located at his left posterior shoulder, radiating to his left arm. In
comparison to the pain severity score scale, Harry said his pain sensation to be at 9/10 hence
interpreted to be very severe since the maximum is 10/10 (Levy, Sturgess, & Mills, 2018). The
chest pain had started that day after his return from his place of work. Respiratory system
On inspection, there is a symmetrical movement of the chest with breathing. The patient reports
shortness of breath and is using accessory muscles in breathing. The respiratory rate is counted to
be at 26 breaths/min, which is higher than normal ranges (12-20) (Yonge, JBohan, Watson,
Connelly, Eastes, & Schreiber, 2018). The SpO2 measured is recorded to be at 89%, which is
lower (standard 96-100%), indicating impaired tissue perfusion.
On percussion, resonant sounds were heard indicating normal lung sounds and the absence of
excessive air.
On auscultation, crackles were heard over lung bases due to the existing heart condition.

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Gastrointestinal system
On inspection, the abdomen is round in shape with no scars or skin nodules. The abdomen moves
with respirations, and there are no signs of distension, but the patient complains of nausea. The
BMI was 29, and waist circumference 100cm.
On auscultation; bowel sounds are heard to be normal
On percussion, no abnormal sounds heard, dull, and tympanic sounds heard across the abdomen.
On palpation, no pain was reported on light and deep palpations. No organomegaly detected, no
distension, or tenderness identified in the patient.
Central nervous system
The patient was alert and conscious, and based on the neurological assessment tool, the GCs
(Glasgow coma scale), the motor, verbal, and eye-opening responses were spontaneous and
intact hence totaling the patient score to 15 indicating a neurologically stable patient.
Recommended procedures
Blood tests; blood samples are taken to determine pathology since, during a heart attack, cardiac
enzymes are leaked into the blood flow from the damaged muscle (Oliveira et al., 2018). The
result showed raised levels of cardiac troponin I and T. The levels of cholesterol were elevated to
7.2 mmol/l; low density lipoproteins were at 6.2/ and high-density lipoproteins at 0.7. These
biomarkers are a crucial consideration in myocardial infarction as they point to the risk involved
with its occurrence. Lipid profile analysis is a critical component in the diagnosis of a heart
attack and its severity (Awan, Imtiaz, Taimoor, Ahmed, & Awan, 2019). The high cholesterol

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level in the patient is a risk factor to formation plaques inside blood vessels that block blood flow
hence the occurrence of a heart attack.
ECG; results of ECG reading demonstrated an ST elevation in the V3 and V4 leads. ECG is done
to monitor the electoral conductivity of the heart muscle. A defective tissue does not send
impulse hence detected by an ECG (Coffey, Serra, Goebel, Espinoza, Castillo, & Dunford,
2018). The severity of infarction is indicated by the extent of ST-elevation and can show a
previous heart attack or an ongoing one. The report hence confirms the presence of myocardial
infarction in the patient due to the elevation in the anterior leads.
Treatment
Since myocardial infarction is a medical emergency, insertion of two large gauges IVC's
is essential to aid in the administration of medication and fluids required promptly to manage the
condition. A dose of 300mg of Aspirin was administered to Harry on arrival. Aspirin is a non-
steroidal anti-inflammatory drug that acts by inhibiting platelet aggregation. It inhibits the
formation of thromboxane A2 that facilitates platelet aggregation to form a clot (Southwell et al.,
2018). This property enables aspirin to be used in the prevention of a heart attack since a high
dose leads to breaking of clots formed in the blood vessels and prevents the formation of more
clots. Reducing the clots in blood vessels also lowers the resistance in the vessels, in turn,
reducing systolic blood pressure to normal ranges. This minimizes the risks and complications of
myocardial infarction.
Harry received a dose of sublingual GTN (glyceryl trinitrate). GTN is a nitrovasodilator.
It is broken down nitrous oxide the active form, which in turn increases the concentration of
cellular cGMP, stimulating myosin dephosphorylation leading to relaxation in the blood vessel

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smooth muscles and reduces vascular resistance (Russwurm, & Koesling, 2018). The dilation of
vessels reduces coronary artery spasms, improving the flow of blood flow through coronary
arteries hence increasing blood supply to the heart muscle. Enhanced flow of blood supplies
oxygen to the tissue leading to aerobic respiration, consequently reduced pain perception. GTN
is indicated to lower blood pressure and reduce chest pain caused by restricted blood flow to the
heart muscle (angina). GTN is a potent vasodilator hence relaxes blood vessels leading to
lowering of blood pressure (Appleton et al., 2019). It usually works by reducing systolic blood
pressure by decreasing the venous return and increasing compliance in the arterial circulation.
Intravenous morphine was to be administered PRN. Morphine is an opioid analgesic, and
it acts on the opioid receptors to manage pain. The binding of morphine on the receptors
increases the pain threshold of a patient hence reducing pain perception (Farag, Spinthakis,
Srinivasan, Sullivan, Wellsted, & Gorog, 2018). It is indicated for the management of severe
pain. The patient reports a pain score of 9/10; hence the administration of morphine will provide
relief from pain and ensure comfort.
Percutaneous coronary intervention (PCI) is used to repair narrowed coronary arteries. It
is a non-surgical intervention that involves the insertion of a catheter through a peripheral artery
(Rimac et al., 2017). Harry had a catheter inserted through his left radial artery into the coronary
artery with the insertion of two stents into his LAD. The procedure helps dilate a narrowed blood
vessel due to atheroma formation hence increasing blood supply to the heart muscle. Increased
blood supply relieves symptoms of angina.

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Further recommendations
Supplemental oxygen via nasal prongs 2l/min is essential to increase the SpO2 of oxygen
in the body. Additional oxygen will help relieve symptoms of shortness of breath, normalizing
breathing patterns. Increased availability of oxygen improves cardiac muscle nourishment hence
reduced chest pain.
Repeat ECG and vital sign monitoring have an essential role in the management of a patient with
myocardial infarction. An ECG reading will depict the presence of abnormal heart rhythms and
the severity of the infarction. Blood pressure monitoring enables to assess the effect of
vasodilator drugs to prevent cases of hypotension. The respiratory rate and pattern will help
demonstrate the nature of tissue perfusion in the body.
Conclusion
The patient suffered from a heart attack, which was facilitated by strenuous activity,
high-risk level due to a BMI of 29, high cholesterol level, and lipoproteins. Focused assessment
on the condition involved the cardiovascular, respiratory, gastrointestinal, and central nervous
system. Blood tests and ECG readings were the diagnostic tests with aspirin, GNT, and IV
morphine as the medications administered. Coronary angioplasty was performed as new
management together with supplemental oxygen and strict vital sign monitoring.

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References
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Awan, A. N., Imtiaz, H., Taimoor, A., Ahmed, M. M., & Awan, S. L. (2019). Correlation of
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