course material

1. Discipline of Nursing & Midwifery
RMIT UniversitySchool of Health SciencesDiscipline of Nursing & MidwiferyBachelor of
NursingNURS2100 Acute Care Nursing 1 2014Case Study Assignment (30%)The case
studies:Each of the case study assignment topics relate to one (1) of the case studies
provided in the first three lecture modules for this course (Cardiovascular, Vascular and
Respiratory); so please read each case study carefully as part of your preparation for
selecting your topic and in completing your written assignment.Choose one (1) of the
following assignment topics:1. In relation to Mrs Melissa Jones (Case Study 1) and with
emphasis on current research, discuss the effectiveness of stent insertion in preventing
further cardiac events.2. With reference to Mrs Clara O’ Donnell (Case Study 2), discuss
the pathophysiological development of aortic aneurysms, and the roles that genetics and
lifestyle play in aortic aneurysm development.3. Discuss how the pathophysiological
changes that occur in Chronic Obstructive Pulmonary Disease (COPD) impact on the
respiratory function of people such as Mrs Maria Santini (Case Study 3), and increase their
susceptibility of contracting pneumonia.Due date of assignment submission:• The
assignment must be submitted at the beginning of Week 8 of semester by or on the due date
of Monday 28 April 2014 at 1700 hours.• The word count for this written assignment will
be 1500-1700 words.• You will be expected to use research or evidence-based journal
articles (a minimum of seven), textbooks and appropriate authoritative web sites (not
Better Health Channel, Virtual Hospital, etc.), and all references used should reflect
contemporary practice.• All referencing is to be formatted using the APA referencing
style.• You are required to submit an electronic copy (Word Document) of the completed
case study uploaded into the Assignment Folder on the course Blackboard site. This folder is
connected to Turnitin, so you only submit your assignment into one place.• Students are
able to submit their assignment multiple times before the due date through the Turnitin
submission site, in order to achieve an Originality Report of no more than 10-15%. The
report takes 24 hours to be processed from assignment submission, so students wanting to
review this should factor this in to their submission date.• The marking rubric and
submission guidelines will be provided on the course Blackboard site.• Each student is to
also have read the Assessment Declaration and Statement of Authorship on this site before
submission of their assignment, and must include the RMIT electronic submission of work
for assessment statement at the bottom of the title page.Case Study1: CardiovascularMrs
Melissa Jones is a 48 year old lady 175 cm tall, 98 kgs, and BMI 28; was admitted with
severe substernal squeezing pain that radiated to her left arm and jaw. She also complained

2. of nausea. After receiving Aspirin 300mg, Sublingual Nitroglycerine Spray 400mcg,
Morphine Sulphate 5mg IV and Streptokinase 1.5 million units IV over 30-60 minutes in the
emergency department; Melissa was transferred to the Coronary Care Unit (CCU) where she
was monitored. Once in the CCU, Melissa is commenced on Ramipril 2.5mg daily. Melissa is
scheduled to have an angiogram.Melissa is a high school teacher, married with two
secondary school aged children. Prior to admission to hospital she smoked one packet of
cigarettes per day, drank 2-4 glasses of gin and tonic per night. She stated that her diet
consisted of mainly high fat take away foods, particularly in the last 6 months as her
teenagers had numerous extra curricula activities after school. As such the family rarely ate
together with a home cooked meal. Melissa’ s father died of an MI aged 50 following a
history of hypertension and type II diabetes.Although Melissa was physically fit in the past,
in the last 2 years family commitments have overtaken her own leisure and fitness regime.
Melissa states that this has significantly increased her stress levels and she is rarely home
before 8pm most evenings with her children’ s activities.Blood tests on admission showed:
Haematology Result Units Reference RangeSerum
Cholesterol 9.3 mmol/L <4HDL 0.8 mmol/L 0.9– 2.0LDL 5.5 mmol/L 2– 3.
4CK MB 1.8% < 5% of total CK activityTroponin I 0.0 µg/L 04 hours later once
thrombolysis completed Haematology Result Units Reference RangeCK MB 36% <
5% of total CK activityTroponin I 5.2 µg/L 0Following thrombolytic therapy
Melissa’ s ECG shows resolved ST changes. The following day she has an Angiogram and
Percutaneous Coronary Intervention (PCI) which resulted in her having a stent inserted
into her Right Coronary Artery (RCA). Her post procedural management was uneventful.
One day later following a cardiac rehabilitation referral and no complications she is
discharged on:Aspirin 100mg daily, Metoprolol 100mg daily, Simvastatin 40mg nocte,
Ramipril 2.5mg daily, Nitrate patch 5mg, and prn Sublingual Nitroglycerine Spray
400mcg.Case Study 2: VascularMrs Clara O’ Donnell is a 75-year-old woman admitted to a
private hospital following a visit to her local GP. She has a one month history of fatigue,
abdominal and back pain unrelieved by non steroidal anti inflammatory medication.
Routine Xray showed a 6-7cm mediastinal silhouette and calcification in the wall of the
abdominal aorta. Clara has smoked for the last 25 years half – one pack of low level nicotine
/ day. She states that she gave up one month ago when they became too expensive to
purchase. She does not exercise due to pain in her feet. Her meals consist mostly of fast
food, soups and sandwiches since her husband died 4 years earlier. Clara’ s past medical
history includes type II diabetes, hypothyroidism and hypertension. She weighs 96 kgs and
165 cm tall. BP 155/90, random blood glucose 9.6 mmol/L. Family history includes: father
died of MI aged 49, mother died at aged 79 from aortic dissection.Biochemistry
Results: Reference Range:Fasting Glucose 7.8 mmol/L (3.9– 6.4)Cholesterol 8.1
mmol/L (desired < 5.2)Triglycerides 3.2 g/L (0.4– 1.5)HDL 0.79
mmol/L (0.80– 2.05)LDL 5.3 mmol/L (1.55– 4.65)Thyroxine 55
mmol/L (58– 154)Clara is on metformin for her diabetes, lisinopril for her hypertension,
and thyroxine for her hypothyroidism. She has been referred to the dietician and diabetic
educator for comprehensive education.Clara has been seen by the vascular surgeon who
wants to send her for an elective surgical repair of her 6cm aortic aneurysm in two

3. days.Following Clara’ s surgical repair of her aortic aneurysm she is cared for in the ICU.
She is fully monitored via a Central Venous Catheter and arterial line and careful attention is
given to ensuring there is adequate blood pressure to ensure graft patency. Periods of
hypotension result in a risk of thrombosis due to a decreased level of blood flow (Wipke-
Tevis et al., 2012). However hypertension may lead to pressure on the arterial anastomoses,
so caring for Clara requires a delicate balance of her level of hydration and
hypertension.Following two days of ICU management, Clara is transferred to the medical
surgical unit to continue her recovery and prepare for discharge. Clara is reluctant to
participate in her activities of daily living (ADLs). Although her PCA (patient controlled
analgesia) has been removed, she continues to fear movement and links this with surgical
site pain. Clara also expresses fear about returning home as she doesn’ t have family
support. Her anxiety about pain and fear about sense of independence have led to a
reluctance to mobilise and perform ADLs; leaving Clara at risk of developing Deep Vein
Thrombosis.Case Study 3: RespiratoryMrs Maria Santini is 72 years old, and has been
admitted with community-acquired pneumonia (CAP). Mrs Santini arrived in the emergency
department, concerned about her increasing shortness of breath, high temperature, fatigue,
and ‘ strange’ coloured sputum. Her clinical manifestations on admission were dyspnoea,
fever, and chills. Mrs Santini’ s current medical history includes Chronic Obstructive
Pulmonary Disease (COPD), hypertension, hypercholesterolaemia, and type 2 diabetes
mellitus. Mrs Santini states that she is still a smoker despite knowing about her
emphysema; but has cut down to five cigarettes per day. Her alcohol intake is limited to the
occasional wine. Mrs Santini is a retired retail assistant, who lives with her husband in
South Morang. Her daughter and son-in-law visit her regularly as they live close by.Mrs
Santini’ s observations on arrival to the ward are:Temperature: 37.9°CPulse: 92 beats per
minuteRespirations: 28 breaths per minuteBP: 110/75 mmHgWeight: 75 kgHeight: 164
cmHer arterial blood gas results on admission were as follows:pH: 7.27PCO2: 56
mmHgPO2: 70 mmHgHCO3: 25 mmol/LSaO2: 89%Blood tests have been taken, for a
complete blood count and urea and electrolytes. A chest x-ray taken when she was in the
emergency department shows right lower lobe consolidation. A sputum specimen has been
sent to the pathology department for gram stain, and culture and sensitivity. In the interim,
Mrs Santini has been commenced on intravenous antibiotics Azithromycin and
Ceftriaxone.Mrs Santini has been placed on oxygen via a mask at 40%. AIDitional
medications include salbutamol 3-4 hourly PRN by nebuliser, and her regular medications
of fluticasone/salmeterol (Seretide), tiotropium, lisinopril, gliclazide, metformin, frusemide,
and simvastatin.Medication regimen for Mrs Maria Santini:Azithromycin 500 mg IVI
dailyCeftriaxone 1 g IVI dailySalbutamol 5 mg nebule by nebuliser 3-4 hourly
PRNFluticasone 250 mcg / salmeterol 50 mcg (Seretide) 2 inhalations by inhaler (MDI)
bdTiotropium 1 capsule (18 mcg) daily by HandihalerLisinopril 5 mg per orally
dailyGliclazide (Diamicron MR) 30 mg mane per orallyMetformin (Diabex XR) 500 mg mane
per orallyFrusemide 40 mg mane per orallySimvastatin 40 mg nocte per orallyTest results
to date:Sputum micro and culture indicated the causative organism to be Streptococcus
Pneumoniae.Haemoglobin – 115 d/LUrea – 8.8 mmol/LCreatinine – 64 µmol/LNa – 130
mmol/LK+ – 4.1 mmol/LFEV1 3 months ago – 65%Since admission, Mrs Santini has been

4. having the salbutamol every six hours, which helps her for a time. Her antibiotics have not
been changed.