John Doe is a 65-year-old male who presented to the emergency department

Posted: June 6th, 2021

Signature case study. In order to write a case study paper, you must carefully address a number of sections in a specific order with specific information contained in each. The guideline below outlines each of those sections.

Section

Information to Include

Introduction (patient and problem)

Explain who the patient is (Age, gender, etc.)
Explain what the problem is (What was he/she diagnosed with, or what happened?)
Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology

Explain the disease (What are the symptoms? What causes it?)
History
Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment

List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments

Explain what treatments the patient is receiving because of his/her disease
Nursing Diagnosis & Patient Goal

Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions

Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation

Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
Recommendations

Explain what the patient or nurse should do in the future to continue recovery/improvement
Your paper should be 3-4 pages in length and will be graded on how well you complete each of the above sections. You will also be graded on your use of APA style and on your application of nursing journals into the treatments and interventions. For integrating nursing journals, remember the following:

Make sure to integrate citations into all of your paper
Support all claims of what the disease is, why it occurs, and how to treat it with references to the literature on this disease
Always use citations for information that you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)

John Doe is a 65-year-old male who presented to the emergency department with complaints of chest pain and shortness of breath. After evaluation, he was diagnosed with a myocardial infarction (MI), commonly known as a heart attack. As his nurse, my goal will be to safely manage his symptoms, educate him on risk factor modification post-MI, and ensure a smooth transition to outpatient management and recovery.
Pathophysiology

An MI occurs when one of the coronary arteries becomes blocked, preventing oxygenated blood from reaching a section of the heart muscle. This is usually due to a buildup of atherosclerotic plaque that ruptures, causing a blood clot (Mayo Clinic, 2022). Common symptoms include chest pain, shortness of breath, nausea, and diaphoresis. John’s risk factors for coronary artery disease include a history of smoking, hypertension, and hyperlipidemia, all of which can contribute to atherosclerotic plaque buildup (American Heart Association, 2019).
History

John has a past medical history significant for hypertension, hyperlipidemia, and a 20-pack year smoking history. His medications prior to admission included lisinopril, atorvastatin, and nicotine patches. However, he was non-adherent with his cholesterol and blood pressure medications due to cost barriers (CDC, 2021).
Nursing Physical Assessment
Vital signs upon admission were: Temperature 37°C, Blood Pressure 160/90 mmHg, Heart Rate 110 bpm, Respiratory Rate 22 breaths/min, and oxygen saturation of 90% on room air. Lung sounds were clear bilaterally with occasional wheezes. Heart sounds revealed an S4 gallop and mild mitral regurgitation murmur. Pedal edema was 2+ bilaterally (Ignatavicius & Workman, 2022). John’s pain level was 8/10 at rest (The Joint Commission, 2020).
Related Treatments

John received aspirin, clopidogrel, metoprolol, atorvastatin, enalapril, and sublingual nitroglycerin as part of his acute MI treatment plan. He underwent successful percutaneous coronary intervention (PCI) with drug-eluting stent placement to reopen the blocked left anterior descending artery (American College of Cardiology, 2019).
Nursing Diagnosis & Patient Goal
Based on John’s history and presentation, my nursing diagnosis is Acute Pain related to his myocardial infarction, as evidenced by his 8/10 chest pain at rest. My goal is for John to achieve a pain level of 4/10 or less by the end of my shift through optimal pain management.
Nursing Interventions
To accomplish this goal, I administered John’s prescribed pain medications, monitored his vital signs and pain level every 15 minutes, and encouraged deep breathing and relaxation techniques (Mayo Clinic, 2022). I also provided education on the importance of medication adherence and lifestyle changes to reduce his risk factors post-MI (American Heart Association, 2019).
Evaluation

After interventions, John reported a reduction in chest pain to a level of 3/10 at rest. His vital signs remained stable. He voiced understanding of the need to make diet, exercise, smoking cessation, and follow up with his primary care provider.
Recommendations
John will follow up with his cardiologist and primary care provider within 1 week of discharge. He has a cardiology rehab referral and will attend smoking cessation counseling. With continued risk factor modification and medication adherence, John’s prognosis is good for recovery from his MI event.