Title    Mr Marconi

Assessment Purpose

Provide evidence of underpinning knowledge to analyse health in a nursing context, by researching and answering guided questions to a complex case study.

Assessment Details
Case Study – Mr Marconi, age 76. Admitted to medical ward at 08:00 on 1/2/2013

Mr Marconi is a 76 year Italian man who has a basic understanding of English. His current health conditions include insulin dependent type II diabetes, hypertension, hyperlipidemia and congestive heart failure.

He has been residing at a nursing home for the past twelve months. He has an unmarried daughter 56 years old who stays nearby. His wife passed away a year ago and he grieves for her today Mr Marconi was admitted onto your ward after presenting to ED exhausted and in chest pain. Mr Marconi has been unwell for the past 3 days with fevers; he has been refusing to eat and drink due to feeling exhausted. He had a fall this morning whilst trying to walk to the bathroom, his left wrist is swollen.

Mr Marconi has also complained of a productive cough and pain on breathing in. He states that he has lost several kilos over the past two weeks. His vital signs include:

•    Respiratory Rate: 28 bpm (shallow with pain on inspiration)    SaPO2: 92% (2L/min)
•    Blood Pressure: 148/96                        Pulse Rate: 92 and weak
•    Temperature: 38.9                         BGL: 4.5
•    Weight: 78 kilos                            Height: 174 cms

His current medications include atenolol (beta blocker), Ramipril (angiotensin converting enzyme inhibitor) Lantus (insulin) and Lipitor (reduces cholesterol). He has no known allergies.

The doctor has noted the following in the medical record:
•    Decreased air entry and bronchial breath sounds, left lung
•    Dehydration- IV fluids commenced to 1L to run over 8 hours
•    Blood sugar 4.5, requires close monitoring.

Answer the following questions related to the case study:
1.    Describe the process of coronary artery atheroma formation. (150 words) Include the following in your answer:
a.    Factors that trigger endothelial inflammation
b.    How high and low density lipoproteins contribute to atheroma formation
c.    The role of macrophages

2.    You are asked to document Mr Jones’ neurovascular observations (left wrist) during the admission assessment. Discuss the following in relation to this assessment:
a.    List the components of this assessment and explain how you would evaluate Mr Marconi’s left wrist injury (100-150 Words)
b.    Identify the components of the assessment that evaluate vascular and nerve function.
The doctor orders a chest and left forearm X-ray. The Registered Nurse asks you to organise his transfer to the radiology department.  He is scheduled for his X-ray at 09:15
3.    Outline the preparation required to transfer Mr Marconi to the radiology department for these tests. Include the following aspects in your answer:
a.    Forms and documentation required
b.    Review the vital signs on the ADDS chart, list the abnormal signs using correct terminology  and calculate the ADDS score. (NB: evaluate the vital signs recorded immediately prior to his scheduled X-ray)
c.    Note the staff members that should accompany Mr Marconi to X-ray based on his acuity.

4.    Based on the patient history, discuss the factors that may have contributed to the cause of his fall. (75-150 words)

There is no fracture evident on the forearm X-ray, the RN bandages and elevates his arm to reduce swelling. The chest X-ray shows consolidation of fluid on his right lower lung. The doctor diagnoses right lower lobe pneumonia.
5.    Relate the diagnosis of pneumonia to the two stages of respiration- external respiration and gas transport. Include the following in your answer.
a.    Describe what occurs during external respiration and gas transport.
b.    Mr Marconi’s blood results indicate that he has a low oxygen and high carbon dioxide, relate this finding to the effects of pneumonia on external respiration and gas transport. (150 words)

6.    Relate the pathophysiology of his condition to the reason for his elevated respiratory rate.  Describe the steps involved in homeostasis of respiratory rate including the following aspects in your answer:
a)    The name of the receptor
b)    The location of the control centre
c)    Why Mr Marconi would have an increased respiratory rate. (200 words)

7.  A sputum test is ordered for culture and sensitivity. Describe what each of these tests are
evaluating and how the results relate to medication prescription. (50-100 words)

You are administering 08:00 medications to Mr Marconi, You note that the Registered Nurse in Emergency has already administered his morning Lantus. He is due for his Ramipril.
8.    Describe the steps in the renin-angiotensin pathway and how Ramipril affects this process. (100-150 words)
During the morning Mr Marconi seems quite despondent, sleeping most of the time. He is refusing to eat saying that he feels too sick and just wants to sleep. At 10:15 he suddenly becomes diaphoretic, the Enrolled Nurse records the vital signs.  His bedside glucometer test measures the blood sugar level as 3.1mmol
9.    Explain the effects of insulin on blood sugar.  (100-150 words)

10.    Review the observation chart and events leading up to his deterioration (information in the grey boxes).
•    Identify the abnormal vital signs (Review both sides of the form)
•    Identify the factors that have contributed to his  decreased AVPU scale.
•    Discuss the medication that may have caused him to deteriorate.
The Registered Nurse convinces Mr Marconi to drink orange juice and eat a sandwich and his symptoms resolve. The doctor reviews Mr Marconi and changes his insulin to a sliding scale. He is commenced on Lantus again 2 days later when he is feeling better.

Mr Marconi remains in hospital for five days.
He is treated with antibiotics and transferred back to the nursing home