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Running head: CLIENT CASE STUDY
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Client Case Study
Annie Kownack
Old Dominion University
CLIENT CASE STUDY
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Client Case Study
D.F is a 68-year-old male with a history of myocardial infarction and mechanical
aortic/mitral valve replacement. He also has a long medical history of cardiac issues including
cardiomyopathy, valvular heart disease, coronary artery disease, and chronic congestive heart
failure. He is a full code with no known drug allergies. He was on vacation in the outer banks
when he suddenly fell out of a recliner and hit his head. The emergency medical squad found
him apneic and pulseless with ventricular fibrillation. He was defibrillated 3 times and given 3
doses of epinephrine with 300 milligrams of amiodarone. He was flown into Norfolk Sentara
after being intubated in the field with possible aspiration pneumonia and reintubated upon
arriving at the emergency room. His blood levels were drawn in the emergency room showing
a Troponin level of 0.26 indicating that he had heart muscle damage. His chest x-ray revealed
heavy infiltrates in bilateral lung fields and interstitial edema. He was admitted to the ICU and is
currently on hospital day 28 in the PVSU.
His condition is relatively stable now and his prognosis looks good. He was cardioverted
from atrial fibrillation and tolerated it well. His cardiac catheterization showed normal coronaries
and normal prosthetic valve function. He is on telemetry and in sinus bradycardia with 58 beats
per minute. He is conscious, oriented times four, and does not have any focal weakness. He
showed signs of acute respiratory failure so he was kept on the vent for two weeks and now has a
tracheostomy, which he is being weaned off of. He has been coughing up blood and blood has
also been coming out of his tracheostomy, but it is believed that this is because of his heparin
drip. His breath sounds are clear to coarse. He completed his bedside swallow test so his NG
tube was removed and he is now on a puree diet. He failed his voiding trial so he still has a foley
catheter in with good output. He has full range of motion but is very weak symmetrically. He
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requires maximum assistance and does not have any restraints. His skin is intact but he does have
some scrotum swelling and bruising on his lower legs. He is on isolation for stenotrophomonas
moro in his sputum. His daughter and wife are constantly at the bedside and have been staying
onsite. He is a little depressed and anxious about his health and hospital stay. He is being
consulted by internal medicine, speech, cardiology, and pulmonary/critical care doctors. Once he
is able to tolerate it, an internal cardiac defibrillator will be surgically placed in his heart to fix
any arrhythmias or irregular heart rates he may experience after being discharged. He is most
likely going to be discharged sometime in the next week and will require follow up care
afterwards.
The scope of this paper will include medical diagnosis, nursing diagnosis, outcomes,
interventions, evaluations, and nursing research that apply to this patient.
Medical Diagnosis
D.F was admitted to the ICU because he was in acute respiratory failure after his
myocardial infarction and could not be taken off the ventilator. His admitting diagnosis was
acute respiratory failure related to a cardiac arrest. “A heart attack happens if the flow of oxygenrich blood to a section of heart muscle suddenly becomes blocked and the heart can't get oxygen”
(Gibbons, 2013, p. 5). This could be related to the fact that D.F already had coronary artery
disease and congestive heart failure. He also had valvular disease with mechanical aortic/mitral
valve replacement, which put him at risk. The most likely cause of his heart attack was his
coronary artery disease. “Coronary artery disease is when plaque builds up in the coronary
arteries that usually supply oxygen rich blood to the heart” (Gibbons, 2013, p. 7). If the plaque
buildup is too severe it can clot and cause a blockage and the oxygenated blood cannot be
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circulated. If the blockage isn’t fixed quickly the heart tissue will start to die and will cause a
heart attack or myocardial infarction, which is what D.F experienced.
The most common signs and symptoms that are related to having a heart attack include
chest pain or discomfort, upper body discomfort in your shoulders, jaw, neck, back, or arms, and
shortness of breath. Other symptoms include diaphoresis, feeling unusually tired, nausea,
lightheadedness, and dizziness. These symptoms can develop slowly over weeks or hit you hard
at once. Diagnosing a heart attack includes looking on an EKG for T wave inversion, ST
elevation, or Q waves. These signify cardiac ischemia, injury, and infarction. Troponin levels are
drawn to check for cardiac muscle injury. An elevated troponin level signifies that cardiac
muscle has been injured and means you have had or are having a heart attack. The treatment for
a heart attack consists of aspirin to prevent clotting, nitroglycerin to dilate the blood vessels,
oxygen, and morphine for pain. The only way to completely get the blockage out is by going in
through cardiac catheterization and removing the clot to restore blood flow. If the heart attack
has already occurred and the patient is unconscious like D.F was found, cardiopulmonary
resuscitation can be performed to stimulate the heart. If the patient is in ventricular fibrillation a
defibrillator may also be used to provide a shock that will hopefully correct the arrhythmia.
D.F was having a left bundle branch block heart attack with ventricular fibrillation. When
the emergency medical squad got to him he was unconscious, pulseless, and apneic. They
performed cardiopulmonary resuscitation on him and defibrillated him to get his heart beating in
normal rhythm again. Prolonged resuscitation can cause damage to the body and having a heart
attack takes a huge toll on the body so he was admitted to the ICU for follow-up and further care.
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Nursing Diagnosis
There are multiple nursing diagnoses that go along with D.F and his post myocardial
infarction care and recovery. Inadequate tissue perfusion is huge since his body was not able to
get oxygen while his heart was not pumping. Another nursing diagnosis is impaired gas
exchange. His blood was not oxygenated and wasn’t being pumped through his body. Therefore
his lungs were also suffering from lack of oxygen and tissue perfusion. This is why he was
intubated for so long and now requires a tracheostomy to help him get adequate oxygenation.
Activity intolerance evidenced by generalized weakness is expected from being in bed resting
and intubated for so long. He does not have much strength and it is difficult for him to even sit
up on his own or lift his hand to his mouth to eat food. He is also experiencing some anxiety and
depression related to a change in his health status and not being able to perform his regular day
activities. This is evidenced by him expressing verbal concern about his outcomes, crying, and
his uncertainty about if he is getting better or not. His family and him have been referred to
chaplain services in order to discuss their feelings and beliefs on the rough situation they are
going through. He is originally form New York and talks a lot about how he just wants to go
home. Lastly, he is at risk for excess fluid volume from decreased organ perfusion and urine
retention. This is evidenced by him failing his voiding trial, plus two edema in his extremities,
and pulmonary edema.
The priority nursing diagnosis for D.F is that he has inadequate tissue perfusion. In order
for him to perform day-to-day activities and to survive his body needs to be oxygenated. A
nursing theory that goes with this is Orem’s theory of self-care deficit. This theory states that
human beings have varying abilities to care for themselves during illness and nurses use different
approaches based on the patient’s ability to care for themselves. A key concept of this theory is
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that activities an individual performs themselves contributes to their continuing health and well
being. If D.F is weak and tired from his blood not being perfused correctly then he will have
difficulty in performing self care. It is important that the nurse works to promote his self-care
and well being to aid him in his recovery. The nurse can do this by allowing him to assist her in
his activities of daily living like brushing his teeth, bathing him, taking his medications himself,
and feeding himself. In order to help him not feel weak or tired the nurse can spread these
activities out and gradually increase the amount of active time he has.
Outcomes
The top priority nursing diagnoses for D.F include inadequate tissue perfusion and
activity intolerance. It is important for his tissues to be perfused and for him to be able to
perform daily tasks. Appropriate outcomes for tissue perfusion include being able to demonstrate
adequate perfusion. For example his skin should be warm and dry, peripheral pulses should be
able to be palpated and strong, and his vital signs should be within his normal limits. He should
also have a balanced input and output. Lastly he should not have edema and should be free of
pain or discomfort. These should all be attained before the patient is discharged.
Activity intolerance can be occurring because of an imbalance between his myocardial
oxygen supply and demand or because of ischemic myocardial tissues that make it harder for
him to complete daily tasks without tiring out. D.F exemplifies this because he is too weak to do
anything and he requires maximum assistance. An outcome for him includes demonstrating an
increase in tolerance for activities by his heart rate, rhythm, and blood pressure not increasing
when he exerts himself. Another outcome would be no complaints of pain or angina with
activity. A good outcome would be for him to be able to pull himself up in bed and sit up without
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help within a week. Now that he is able to eat food orally he should be regaining more energy
and will be able to perform more tasks without tiring.
Interventions
In order to achieve these outcomes, interventions must take place to aid the patient in
progressing forward. For activity intolerance documentation of vital signs before, during, and
after activity can help mark trends in the patient’s response to the activity and can indicate if the
patient needs to take a break or decrease the activity level. Rest should be encouraged so that the
patient does not overexert themselves and be at risk for another myocardial infarction. The
patient should increase his activity gradually by sitting up in bed, feeding himself, walking to a
chair to sit in it, walking around his room, and walking around the unit. Progressive activity
provides a controlled demand on the heart, increasing strength and preventing overexertion.
According to the AACN standard for interventions, they should be delivered in a manner that
minimizes complications to the patient. Therefore, it is important for the activities to be
progressive to not overexert the patient too much. The patient may need to be referred to a
rehabilitation program after discharge where he can regain his strength and be able to perform
even more activities. This continued support will help him return to baseline quicker and
promote his wellness. The family and patient need to be taught about possible signs and
symptoms of overexertion and possible oncoming heart attack so they are prepared in such a
circumstance. D.F is a bigger, Italian man who loves to eat and has personally stated that his
culture loves to eat and does not exercise as regularly as they should. He should be encouraged to
go on walks everyday once he is able to tolerate it and to eat a healthier diet. All of these
interventions should help improve his activity tolerance.
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There are also many interventions that could help D.F reach his outcomes for his
inadequate tissue perfusion. The patient should be assessed for changes in mental status that
could indicate his cerebral perfusion is not adequate. This could be as a result from decreased
cardiac output so it is important to look out for. The patient should also be assessed for pallor,
cyanosis, skin temperature, and peripheral pulses. Making sure the skin is warm and that the
patient has strong pulses bilaterally proves that the patient is being perfused well. Monitor intake
and outtake to make sure the patient is still making urine. If the patient has a decreased urine
output it could be a sign that his kidneys are not getting a good amount of blood flow. The
patient should perform leg exercises to enhance his venous return and decrease his risk for
getting a clot. Medications can also be administered if needed to reduce the risk of clots forming
and blocking oxygenated blood flow. D.F is on a heparin drip which is an anticoagulant used to
reduce the risk of getting a blood clot. There are specific policies and standards for patients on
heparin drips that he needs to be informed of because it puts him at an increased risk for bleeding
and he will bruise more easily. D.F is also getting an internal cardiac defibrillator so if he is
having an arrhythmia and the blood is not being perfused, the device will shock him and
hopefully fix the rhythm so that blood will be pumped correctly. According to AACN standards
of practice, the patient and family participate in implementing the plan according to their level of
participation and decision-making capabilities. In order for these interventions to work, the
patient and family must actively participate to perform the actions. All of these interventions will
help D.F with his tissue perfusion and promote his well-being.
It is clear that adequate tissue perfusion is very important for patients after having a
myocardial infarction and D.F needs to have it in order to recover. The nursing journal
“Reperfusion Therapy for ST Elevation Acute Myocardial Infarction in Europe” is interesting
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because it talks about patient access to reperfusion therapy and primary percutaneous coronary
intervention in European countries. The journal showed a lack of organized PCI networks in
countries there but most European countries use it. It was interesting to read about the way they
handle myocardial infarctions in a different country.
The article “Impaired Microcirculation Predicts Poor Outcome of Patients with Acute
Myocardial Infarction Complicated by Cardiogenic Shock” talks about a study done to test the
relationship of perfused capillary density to measure tissue perfusion in patients after a heart
attack. The study revealed that decreased perfused capillary density is related to poor outcomes
in these patients including multiple organ failure. This is relevant to D.F since he suffered a heart
attack and one of his priority diagnoses is about tissue perfusion. It would be good to measure
this in him to predict possible decreased perfusion to his organs and prevent organ failure.
Another article called “Physical activity levels, ownership of goods promoting sedentary
behavior and risk of myocardial infarction” discusses the relationship between physical activity
and the risk of having a myocardial infarction. The results of the study revealed that mild-tomoderate physical activity was associated with a reduced risk but not heavy physical labor. Since
D.F has activity intolerance at the moment, this will have to be something he works up to when
he is able to tolerate activities more. It is important for him to prevent future attacks in any way
possible.
Evaluation
It is important to evaluate D.F’s progress towards his outcomes to make sure that he is
achieving them. “Evaluation is systemic and ongoing using evidence-based techniques and
instruments” (Bell, 2008, p. 564). His activity tolerance can be evaluated by his increased ability
to handle activities. He should be progressing and be able to sit up by himself in a chair by the
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end of the week. Evaluating his vitals, respirations, pain level, and muscle strength are good
indicators of if he is tolerating the activity well. His heart rate and respirations should not
dramatically increase with activity and his pain level should not rise either. If he is not able to
tolerate the activities then an additional plan could be to refer him to a rehabilitation center.
D.F also needs to be evaluated to make sure his tissue perfusion is adequate. His progress
can be evaluated by checking for increases in pain. He did not complain of any pain throughout
my evaluation. He has a foley catheter in and his input/output ratio are good so this shows his
kidneys are getting perfused. His peripheral pulses were present and strong, his skin was warm
and dry, and his capillary refill was less than three seconds showing that his skin was being
perfused. All of the evaluation results are documented so any change in the patient’s state can be
seen. If the evaluation were to show that he was not being perfused well then a change in
medication may be needed. It is also possible he could need a stent or balloon to keep his vessels
open so that blood can flow through them more freely. Currently his perfusion is adequate and
all of the results are within normal limits.
Conclusion
The assessment and care of this patient has helped educate me on cardiac health and the
effects a heart attack can have on a patient and their family. It is interesting to me how the heart
has such an effect on every single organ in the body, which is why D.F started having issues with
breathing after having a myocardial infarction. When the heart isn’t pumping correctly, no
organs can get the right amount of oxygenated blood and the whole body suffers. I learned about
different treatment options for patients who have had heart attacks and different prevention
factors that can be done so another heart attack does not occur. I would love to learn more about
the internal cardiac defibrillator and how it works to correct the arrhythmias the heart can
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experience. Overall, my experience with this patient completely broadened my knowledge on
cardiac and critical care and I am thankful to have been a part of his recovery.
References
Bell, L. (Ed.). (2008). AACN Scope and Standards For Acute and Critical Care Nursing Process.
American Association of Critical Care Nurses.
Gibbons, G. What Causes a Heart Attack? (2013, December 17). Retrieved October 4, 2015,
from http://www.nhlbi.nih.gov/health/healthtopics/topics/heartattack/causes
Luscher, T. (n.d.). European Heart Journal. Retrieved October 4, 2015, from
http://eurheartj.oxfordjournals.org/content/31/8/943.short
Impaired Microcirculation Predicts Poor Outcome of Patients with Acute Myocardial Infarction
Complicated by Cariogenic Shock. (2010). Retrieved October 3, 2015, from
eurheartj.oxfordjournals.org/content/31/24/3032.short
Physical Activity Levels, Ownership of Goods Promoting Sedentary Behaviour and Risk of
Myocardial Infarction. (2012). http://dx.doi.org/10.1093/eurheartj/ehr432
Vera, M. (2014, February 27). 7 Myocardial Infarction (Heart Attack) Nursing Care Plans –
Nurseslabs. Retrieved October 4, 2015
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NURS 451 Client Case Study
Grading Criteria
Student:
__________________________
Score:
__________
Grading Criteria
Points
Faculty Comments
Introduction
Pt. Overview
Scope of paper
2
1
Medical Diagnosis
Dx for ICU adm.
Patho
Related S/S
2
4
4
Nursing Diagnosis
5 NANDA (1+ psych/soc)
Priority with theorist support
5
10
Outcomes for top 2 NDX
Appropriate for NDX
Attainable within timeframe
#1 #2
2.5 2.5
2.5 2.5
Interventions for top 2 NDX
Interventions with rationale
SOP /Clinical Path
Patient/family teaching
Critical Thinking
Cultural Considerations
#1
6
2
2
2
Evaluation
Progress toward outcomes
#1 #2
5 5
3
#2
6
2
2
2
Points
Awarded
CLIENT CASE STUDY
Additional/alternative plan
Conclusion
Review of learning
13
1
1
3
CLIENT CASE STUDY
Grading Criteria
Sources
5+ sources
3+ primary nursing research
Study results
reviewed/applied
Study poorly
reviewed/applied
Research omitted
14
Points
1
3 3 3
1 1 1
0 0 0
APA Format (Cover page,
headings, margins, type size)
Format conforms to APA Format
Format includes 1-3 APA errors
Format includes 4-6 APA errors
Format includes >6 errors
APA- References/Reference
Page
Conform to APA Format
Include 1-3 APA errors
Include 4-6 APA errors
Include >6 APA errors
Do not conform to APA format
3
2
1
0
4
3
2
1
0
Writing Style (Grammar,
spelling, punctuation, language)
Logical, organized, without
errors
Logical, organized minor errors
(<5)
Lacks logic/organization OR
major spelling/grammar/errors
(>5)
Lacks logic / organization AND
major spelling / grammar /
errors (>5)
3
2
1
0
Faculty Comments
Points
Awarded
CLIENT CASE STUDY
Comments:
15