Instructions:
?? Students are to choose one (1) of the case studies below and answer the associated
questions. The assignment is to be presented in a question/answer format not as an
essay (i.e. no introduction or conclusion).
?? Each answer has a word limit (1600 in total); each answer must be supported with
citations.
?? A Reference List must be provided at the end of the assignment.
?? Please refer to the marking guide available in the unit outline for further information.
** The following questions must be answered for your chosen case study **
The following questions relates to the patient within the first 24 hours:
1. Outline the causes, incidence and risk factors of the identified condition and how it can
impact on the patient and family (400 words)
2. List five (5) common signs and symptoms of the identified condition; for each provide a
link to the underlying pathophysiology (350 words)
a. This can be done in the form of a table – each point needs to be appropriately
referenced
3. Describe two (2) common classes of drugs used for patients with the identified condition
including physiological effect of each class on the body (350 words)
a. This does not mean specific drugs but rather the class that these drugs belong to.
4. Identify and explain, in order of priority the nursing care strategies you, as the registered
nurse, should use within the first 24 hours post admission for this patient (500 words).
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Case Study Question 1
Mrs Sharon McKenzie is a 77 year old female who has presented to the emergency department
with increasing shortness of breath, swollen ankles, mild nausea and dizziness. During your
assessment Mrs McKenzie reports the shortness of breath has been ongoing for the last 7 days,
and worsens when she does her gardening and goes for a walk with her husband.
On examination her blood pressure was 105/55 mmHg, HR 54 bpm, respiratory rate of 24 bpm
with inspiratory crackles at both lung bases, and Sp02 at 92% on RA. Her fingers are cool to
touch with a capillary refill of 1-2 seconds. Mrs McKenzie states that this is normal and she
always has to wear bed socks as Mr McKenzie complains about her cold feet.
Her current medications include: digoxin 250mcg daily, frusemide 40mg BD, enalapril 5mg daily,
warfarin 4mg daily.
The following blood tests were ordered: a full blood count (FBC), urea electrolytes and
creatinine (UEC), liver function tests (LFT), digoxin test, CK and Troponin. Her potassium level is
2.5mmol/L.
Mrs McKenzie also has an ECG which showed sinus bradycardia, and a chest x-ray showing
cardiac enlargement and lower-lobe infiltrates, suggesting the presence of acute exacerbation
of congestive cardiac failure.
Impression: Congestive cardiac failure with ?digoxin toxicity
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Case Study Question 2
Mrs Josie Shara is a 31 years old female, who was admitted after being referred by her GP due
to complaints of palpitations, severe fatigue and anterior neck enlargement.
Past medical history: Caesarean section x 2, Gestational Diabetes
Allergies: Nil Known
Current medications: Nil
Social History: Josie and her family migrated from Zimbabwe last year. She had a baby 7 months
ago via caesarean section and she is currently breastfeeding. She has two older children whom
she reports to be helping her with the new baby. Josie is a primary school teacher in her country
but she is currently unemployed. Her husband is working as a registered nurse in a nursing
home.
On examination: Josie is alert and orientated. She reports that over the past few months she has
increasing lethargy and sleep disturbance that she initially attributed to her recent delivery. She
has unintentional weight loss of 16 kg despite having good appetite. Josie’s husband also raised
concern that she has been unusually irritable and anxious. Last week, Josie saw the GP for what
was presumed to be viral infection as she had fever, sore throat and night sweats but was not
commenced on any medication except for paracetamol. She also noted that her neck is getting
swollen but denies any dysphagia. Josie reported that she has been experiencing more frequent
palpitations even at rest. She has nil complaints of chest pain but has slight shortness of breath.
The ECG showed sinus tachycardia.
Observations: BP: 146/58 mmHg, HR: 127 bpm, RR: 24 bpm, Temp: 36.8C, SpO2: 98% on RA,
Weight 53 kg, BGL 5.2 mmol/L
Laboratory Findings:
Result Normal Values
RBC 5.3 million/mm3 2.6 to 5.9 million/mm3
WBC 10954 /mm3 4300 to 10800/mm3
Platelets 22000 /mm3 150000 to 350000/mm3
Haemoglobin 134 g/L 120-170 g/L
Sodium 145 mEq/L 135 to 145 mEq/L
Potassium 4.4 mEq/L 3.7 to 5.5 mEq/L
Calcium 1.8 mmol/L 2.15-2.60 mmol/L
Magnesium 0.89 mmol/L 0.70-1.10 mmol/L
Troponin (cTn) 11 ng/L < 15 ng/L
Creatinine Kinase (CK) 120 U/L 30-135 U/L
TSH 0.25 mIU/L 0.4-5.0 mIU/L
T3 14 pmol/L 4.0-8.0 pmol/L
FT4 3.4 ng/dL 0.7- 1.8 ng/dL
TSI Positive
Neck Ultrasound Thyroid : Diffusely enlarged
Impression: Hyperthyroidism sec to? Subacute Thyroiditis/Graves
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Case Study Question 3
Mr Sam Smithson, is a 51 year old male who was admitted to the high dependency unit for
investigation of melaena. He has had two previous admissions for cirrhosis in the last 6 months.
He was an interstate truck driver for 15 years and is married with 4 children. Mr Smithson is a
current smoker and known to consume 5-6 bottles of beer per day. He has a history of
hypertension and mild hypercholesterolemia.
On assessment:
Mr Smithson is lethargic but orientated to time, place and person and slightly irritable. He is
slightly tachypnoeic with moderate use of accessory muscles. His wife reported that Mr
Smithson has been spitting blood stained sputum for the last few weeks with no associated
cough or shortness of breath. From the previous admission record it showed that Mr Smithson
has lost 9 kilos which he attributed simply to his lack of appetite. No changes were reported
with his urine output. On examination his sclera is mildly jaundiced and has some “unexplained”
bruises on his arms and legs. His abdomen is tight and distended and pitting oedema noted on
his ankles.
Observations: BP: 115/60mmHg, HR: 110 bpm, RR: 24 bpm, SpO2: 88% on RA, 95% on 6L via
Hudson Mask, Temp: 37.8C
Laboratory Findings:
Result Normal Values
RBC 4.0 million/mm3 2.6 to 5.9 million/mm3
WBC 3500/mm3 4300 to 10800/mm3
Platelets 75000/mm3 150000 to 350000/mm3
Serum Ammonia 110 µm/dl 35 to 65 µm/dl
Total Bilirubin 4.9 mcg/dl 0.1 to 1.0 mcg/dl
Sodium 150 mEq/L 135 to 145 mEq/L
Potassium 3.4 mEq/L 3.7 to 5.5 mEq/L
Haemoglobin 85 g/L 120-170 g/L
Albumin 24 g/L 35-50 g/L
Liver Enzymes Slightly elevated
BUN 22 mg/dl 7-18 mg/dl
Creatinine 154 ml/min 88 to 137 ml/min
Mr Smithson was ordered Vitamin K 1 mg IM and underwent urgent gastroscopy which showed
bleeding from gastric ulcer. A diagnosis of alcoholic cirrhosis with gastritis is made.
His current medications include: aldactone 25mg PO TDS, lactulose 15mls PO TDS, neomycin
sulphate 1 gram PO every 4 hours for 5 days, vitamin B12 100mg IV TDS.
Impression: Alcoholic liver disease – alcoholic cirrhosis with gastritis