Essay NURS2002: Mr. Peter Stanhope Case Study – Nursing Assignment Help

Assignment Task:

The purpose of this assessment is to explore the assessment of a person with acute disruption to health and to develop an evidence based plan of care. Instructions: Refer to the case study below and complete both Part 1 and Part 2. The grading rubric for this assignment is on page 13±14 and on Blackboard.

Case Study: Background information: Mr. Peter Stanhope is a 42-year-old Caucasian male who presents to the Emergency Department with a one-day history of central chest pain.

Past Medical History: Gastro-oesophageal reflux disease (GORD) & hypercholesterolemia

Past Surgical History: L5 ± S1 vertebral laminectomy (2004), laparoscopic cholecystectomy (2006) Medications: Ranitidine 150 mg oral prn tds for reflux Lipitor 40 mg oral daily

Family History: Father deceased (age 52) – Acute Coronary Syndrome, Known family history of hypertension Social History: Married with two children and works as a financial broker. He is a tobacco smoker of 15/day for 10 years and is a social drinker (approximately 6-8 standard drinks per week) Height: 169 cm Weight: 105 Kg Results: x ECG ± Sinus Rhythm with prominent T-wave inversion in leads I, avL, V2 through V5 x Chest X-ray normal x Bloods – results pending Plan: x Admit to cardiology ward for 48 hour observation x Repeat ECG & bloods in 6 hours x Continue with regular medication You are the admitting nurse in the Cardiology Observation Unit responsible for Peter¶s care. On presentation you note Peter is having difficulty breathing with extreme shortness of breath. He looks pale; holding the palm of his left hand on his chest and is showing facial grimacing. Part 1: Describe your initial assessment of Peter including a detailed description of your systematic approach to chest pain assessment.

COURSE OUTLINE: NURS2002 – SEMESTER 1, 2020 The University of Notre Dame Australia Date of Publication to Students: 10th February 2020 Page 11 of 29 Part 2: Following your initial assessment of Peter, develop a plan of care. Your plan of care should be prioritised and include; x Short term (bedside) and long term (rehabilitation) patient centred goals, x All goals should be in the SMART format x Interventions (actions) to achieve the required goals (including multidisciplinary care) x How the goals or outcomes are measured x Rationales using current literature and evidence for each intervention to be implemented. The case study information and your knowledge of chest pain management should guide you in developing the care plan.