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Grand Case Presentation (MI, COPD and BPH)

Grand Case Presentation (MI, COPD and BPH)

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Published by Sarah Lim

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Published by: Sarah Lim on Mar 08, 2010
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08/06/2014

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i. INTRODUCTION
Acute myocardial infarction (AMI or MI), commonly known as a heart attack, is adisease state that occurs when the blood supply to a part of the heart is interrupted. Theresulting ischemia or oxygen shortage causes damage and potential death of hearttissue. It is a medical emergency, and the leading cause of death for both men andwomen all over the world.
 
Important risk factors are a previous history of vascular disease such as atherosclerotic coronary heart disease and/or angina, a previous heartattack or stroke, any previous episodes of abnormal heart rhythms or syncope, older age—especially men over 40 and women over 50, smoking, excessive alcoholconsumption, the abuse of certain illicit drugs, high triglyceride levels, high LDL ("Low-density lipoprotein") and low HDL ("High density lipoprotein"), diabetes, high bloodpressure, obesity, and chronically high levels of stress in certain persons.Heart diseases constitute the second most common cause of death. Coronaryheart disease death rates have shown consistent declines over the past 15 years, withmen having almost twice the death rates of women. The difference in rates hasremained constant over the years. In 2008, the age-standardized death rate for menwas 105 per 100 000 resident population, compared with 56 for women. The incidenceof acute myocardial infarction events among adults has generally decreased since1990. The incidence rate for men is about twice that for women; in 2007, the age-standardized incidence rate for men was 179 per 100 000 resident population,compared with 79 for women.
Myocardial infarction is a leading cause of morbidity and mortality in the United States.Approximately 1.3 million cases of nonfatal MI are reported each year, for an annual incidencerate of approximately 600 cases per 100,000 people. The proportion of patients diagnosed withNSTEMI compared with STEMI has progressively increased. MI continues to be a significantproblem in industrialized countries and is becoming an increasingly significant problem indeveloping countries.
This is a case of patient FT, 89 years old, male, Roman Catholic, from Talakag,Bukidnon; admitted at MRH on Feb. 3, 2010 with chief complaints of facial asymmetryassociated with slurring of speech and chest pain. His previous diagnosis from last
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hospitalization includes CAD, AF with RVR (AF with CVR); CHF Class IV (Clan I, StageC); Stress Hyperglycemia; and BPH.In organizing patient care, the group utilized Primary Nursing, also known as
relationship-based nursing 
. The group viewed themselves as the primary nurses. Theywere the ones who assessed and established the nursing care plans which were thenclearly communicated to the student nurses directly assigned to the patient when thegroup was not present. Feedback was then sought from them with regards to theevaluation and progress of the client’s condition.
A. GENERAL OBJECTIVES:
This case presentation seeks to enhance the students’ knowledge withregards to the patient’s general health and disease condition, its pathophysiology,possible complications, treatment plan and medical regimen. This also seeks toassimilate the student’s skills through application of several nursing interventions andmedical management. Furthermore, this case presentation intends to improve thestudentsattitude by conveying open-mindedness and utilizing therapeuticcommunication all throughout the activity.
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PhysicianClinicalInstructor Health careOrganizationResourcesPrimaryStudentNurseAssociateLevel 3StudentNurseChargeNurseStaff NurseStaff Nurse
 
B. SPECIFIC OBJECTIVES:
The student nurses aim to achieve the following objectives in 1 hour of casepresentation:1.Accurately present a thorough general health assessment of the client whichincludes physical assessment and family history taking.2.Effectively discuss and elaborate actual signs and symptoms of disease exhibitedby the client3.Thoroughly discuss, explain, and elaborate the nature of the disease process4.Efficiently provide appropriate and proper nursing diagnosis in line with the client’smedical condition5.Skillfully formulate nursing care plans for the different problems identified6.Appropriately provide nursing interventions according to the standards of nursingpractice7.Effectively apply the learned concepts and theories of disease8.Efficiently appraise the effectiveness and efficacy of nursing interventionsrendered to the client9.Impart the outcome of the rendered nursing interventions10.Convey the significance of client’s response to the rendered nursing interventions11.Correctly provide concise and concrete information to the audience with regards tothe patient’s disease condition.12.Appropriately provide appropriate environment for learning for the audience
C. SCOPE AND LIMITATION
The data presented in this case was primarily obtained from student nurse-patient interaction as well as with the significant other who partly served as informant.Further information is based on the patient’s chart. The student nurses were only able torender care to the patient during the assessment on February 4, 7, and 10, 2010 sincethe former’s clinical exposure at MRH already ended during that period. Additionally,subsequent assessments after the 3
rd
visit were not done because the patient was thendischarged. The Nursing Care Plans presented herein were implemented at a verylimited time but were endorsed and continued by the student nurse assigned to thepatient. Nevertheless, the evaluation bears the nursing outcome observed uponassessing the patient
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