Mrs. James Admit: Case Study Nursing Assessment

You are a newly graduated registered nurse working on the medical ward as part of your graduate year rotation. You are commencing an afternoon shift and have received a handover on a Mrs Wendy James. Mrs James is a 83 year old female (DOB: 15/09/1939), who has been admitted with exacerbation of her heart failure. Mrs James was admitted last evening from her GP after presenting yesterday with 1 week of increased shortness of breath, increased weight gain and peripheral oedema. She presented via the emergency department (ED) and is admitted under cardiology for ongoing management of her heart failure.

Social history: she lives with her elderly husband. They have 2 adult children and 5 grandchildren who are very supportive and help with house maintenance. They receive meals-on-wheels and some other council services such as house cleaning once per fortnight. They are also part of the local lawn bowls club.

Past medical history:

• Hypertension
• High cholesterol
• Atrial fibrillation
• Ischaemic heart disease with *2 stents (LAD and RCA)
• Heart failure

Student response (100 marks)

In preparing your student response, please ensure that you respond to the following questions:

Question 1:

You need to complete a full assessment of Mrs James. Describe and rationalise two (2) systems assessment (eg. cardiovascular, respiratory, renal etc.) that you would focus your assessment on in relation to her hospital presentation (450 words).

We do not want a description of how you would assess the system. What is expected of you is that you need to explain why you have chosen that particular system in relation to her hospital presentation, what you could potentially find and why would you find that in heart failure and discuss the pathophysiology behind this.

Question 2:

Heart failure is a complex condition that may require a range of medications Review Mrs James’s medication chart and choose two (2) of the followin medications. Discuss the indications of its use and the related pharmacodynamics in relation to Mrs James. Indicate in your response the nursing considerations for each of the chosen medications. (400 words)

Choose two (2) medications:

• Bisoprolol
• Ramipril
• Frusemide

Question 3:

Create a concept map, to link the relevant nursing care considerations that should be implemented to ensure safe, person-centred care during Wendy's admission. Start your concept map using the concepts listed below and expand your ideas, linking all key factors and justifying your nursing care with a brief explanation: (200 words)

• Education / support

In this question, you are to discuss all her medications and why she is on them, what education/support she will need to ensure a safe discharge home, and think about what else she might need (ie referrals and why) to ensure a safe discharge home

Question 4:

Outline, with clear rationales, your plan of care of Wendy for the remainder of your shift focusing on vital signs, fluid management, diet and patient education. (600 words)

Why are you doing these, what are you looking for , how will this help Mrs James and the care she receives?

You need to be really specific when addressing this (eg. maintain hourly bp as the patient has a history of…. Escalate to doctor if bp is higher than… or lower than… this is because….

Structure:

Heading: vital signs (discussion)
Heading: fluid management (discussion)
Heading: diet (discussion)
Heading: patient education (discussion)