Patient Data: Male – Aged 76 years. Weight 70kg. Height 170cm
Prior medical history:
According to his medical record Mr Anderson has a history of upper epigastric pain and was diagnosed with gastroesophageal reflux disease (GORD) in June 2016.
He was admitted to the hospital with suspected unprovoked angina. Prior to this admission, the only medication he has been prescribed was Nexium (esomeprazole) 20mg once a day for 4 weeks. After taking the medication for the 4 weeks Mrs Anderson did not return to the doctor for further consultation.
He has also been complaining of increased fatigue, occasional palpitations and progressive bilateral lower extremity oedema. He has no known allergies and is smoking 15 cigarettes a day.
BP – 160/90, HR – 88, RR – 22, SaO2 – 95%, T – 36.7
Total cholesterol 7.1 mmol/L
Low-density lipoprotein (LDL) cholesterol. 5.2 mmol/L
High-density lipoprotein (HDL) cholesterol. 1.0 mmol/L
Magnesium 0.66 mmol/L
Potassium 2.7 mmol/L
Sodium 135 mmo/L
Toponin T <0.03
Urea 2.6 mmol/L
ECG taken with 5 minutes of arrival to ED (according to hospital protocol) – see below
Recent medical history:
Today Mr. Anderson has refused to get out of bed due to increased fatigue.
Using the above case study apply the clinical reasoning framework
Clinical reasoning framework: Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia. Page 5-9 to plan the nursing care for this patient.
Consider the pt. situation
Process the information
Reflect on process and new learning’s