Mr. Joe Munsie, an 80 year old aboriginal male client, was admitted to the hospital on 7/03/11 with Chronic Airways Limitation (CAL), Diabetes and the associated complications of Hypertension, Congestive Cardiac Failure (CCF) with acute exacerbation. His medical history includes coronary artery disease for the past 12 years. He had a balloon angioplasty in 2000 and a Myocardial infarction (M.I.) in 1988. His other symptoms include shortness of breath (SOB), kidney disease, impotence, peripheral neuropathy, glaucoma and repeated infections due to his poor immunity. He has had trouble passing urine at times and has had nocturia six times in the past week. He is a widower, states that for the past 3 to 4 weeks he has had increasing fatigue and shortness of breath. He visited his doctor two days ago, and his medications were changed. His preferred foods are fresh fruits and boiled vegetables. Mr. Munsie lives with one of his daughters and her family since experiencing his M.I.in 1988. He has six other children. He is a Catholic and attends church intermittently, however, since his declining health, he has been confined to his home. He smoked three packs per day x 40 years and quit in 1990. He currently sleeps on 4 pillows at night to ease breathing. He is hearing impaired and wears bilateral hearing aids. He wears glasses and reads with some difficulty. His schooling was to a Year 9 level of high school. He also has a previous history of heavy alcohol consumption for a number of years but very little now consumed.
This is his third admission for CCF since his diagnosis five years ago. Physician progress notes state: Condition improving; complaining of (c/o) increasing SOB; chest x- ray improving; serum K+ is 2.9 mmol/L, with a weight gain of 5kg in the past two months. Poor diabetic control. He has moderate respiratory distress on exertion and crackles auscultated in left lung base.
Physical exam Vital Signs: T = 37.4 oC, BP = 178/95 mm/hg, P = 110 bpm,
Ht = 176cm, Wt =120Kg, BGL = 12mmol/dl, O 2 SAT level = 90% on room air Bilateral swollen ankles evident with pitting oedema at 2+. Pedal pulses present. Complaining of increasing fatigue and severe shortness of breath (SOB) and leg pain on walking. Denies chest pain.
Digoxin 0.25 mg po daily
Lasix 40 mg po bd
Nitro Patch 25 mg Top On at 0800 and Off at 2000
Metamucil 15 ml po daily in glass of water/juice
Slow K 600mg po daily
Lantus 80 units daily
Novo rapid 25 unit’s qid
Timoptol 2 (guttae) drops daily
Diagnostic tests results
7/3/2011-Chest X Ray Mild left ventricular hypertrophy and pulmonary congestion resolving.
|Serum electrolytes:||Normal Ranges:|
|K+||2.9 mmol/L||3.8 – 4.9||mmol/L|
|Ca+||2.1 mmol/L||2.10 – 2.55 mmol/L|
|CL||102 mmol/L||95 – 110 mmol/L|
|Urea||8.6 mmol/L||3.0 – 8.0 mmol/L|
|Cr||0.6 mg/dl||0.8 – 1.4||mg/dl|
|Serum albumin 28 g/L||35 – 47||g/L|
|Serum digoxin level 2.6 ng/dl||0.6 – 2.3||nmol/L|
|Full Blood Count:|
|Hb||100 g/L||130 – 180||g/L|
|WCC||12 x 109/L||4.0 – 11.0 x 109/L|
|Platelets||125 x 109/L||150 – 400 x 109/L|
|HbA1C||10 %||4.0 – 5.5 %|
Other admitting orders
Diabetic/No added salt diet; Restricted fluids 1,200 ml/day, Monitor input & output, daily weight, activity as tolerated, Monitor bowel actions, 4th hourly observations, O 2 at 3L/min per nasal cannula.
Nursing Interview & Observations
He states, “I have a touch of the sugar and my old heart is just wearing out. I get this extra fluid every now and then. I come here to the hospital to get rid of it”. He is well oriented, however, he is a poor historian with limited understanding of medications and treatments utilized at home. He complains of frequent constipation. Skin reddened over bony prominences and has small shallow ulcers on both his shins that are inflamed and weeping. Currently requires the head of his bed elevated to assist with his breathing. Requires lift up walking frame when ambulating as he has an unsteady gait. He requires assistance with most activities of daily living.
Question 1: Identify and briefly describe three (3) of Mr Munsie’s medical conditions.
Question 2: Explain how each of the above identified medical conditions result in pathophysiological changes that impact on each body system. Also their related structures e.g. Persons with diabetes, which is a disease of the endocrine system, who have poor glycaemia control, may have resultant damage to microvascular structures leading to blindness or damage of macrovascular structures resulting in peripheral gangrene.
Question 3: Describe briefly how two (2) Medical and two (2) Pharmacological interventions act to enhance Mr Munsie’s wellbeing. E.g. Mr Munsie has Congestive cardiac failure which has led to peripheral oedema and shortness of breath. He has been placed on a diuretic medication to assist his body to excrete excessive fluid.
Question 4: Review Mr Munsie’s Physical examination, and the Diagnostic Test Results. Identify and describe briefly four (4) abnormal parameters.
Question 5: Identify the drug actions, indications and contra indications for the following medications. Digoxin, Lasix, Slow K, Nitro patch and Timoptol.
Question 6: List four 4 diagnostic investigations that could assist in the diagnosis and management of Mr Munsie’s medical conditions.
Question 7: Identify and provide a brief rationale for four (4) services that meet the psychosocial and or medical needs of Mr Munsie on discharge.
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