‫كلية التمريض‬

Critical care clinical

Case study writing

Student name ahmad albostanji Date…………………

Clinical area…………………………. Case name ………….

A- Write a case study according to the form

1- Demographic Date
Name:s.a.a
Age:45
Gender:meal
Smoker
Eng

2- Chief Complaint, Sign and Symptoms

Chief coplaint(chest pain)
S&s
pressure or tightness in the chest
pain in the chest, back, jaw, and other areas of the upper body that lasts more than a few minutes or that
goes away and comes back
shortness of breath
sweating
nausea
vomiting
anxiety
a cough
dizziness

3- Medical Diagnosis( myocardial infarction)

4- Medical and surgical history

Old cath
DM
5- Pathophysiology and definition of the disease
. A heart attack is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly
cut off, causing tissue damage. This is usually the result of a blockage in one or more of the
coronary arteries. A blockage can develop due to a buildup of plaque, a substance mostly made
of fat, cholesterol, and cellular waste products.
 6- Physical Exam InspectionIf heart failure ensues, elevated jugular venous pressure and
hepatojugular reflux, or swelling of the legs due to peripheral edema

Palpationincreased respiratory rate. A cool and pale skin is common and points to vasoconstriction. Some
patients have low-grade fever (38–39 °C). Blood pressure may be elevated or decreased, and the
pulse can become irregular.

Percussion……………………………………………………………………………………………………………………………………………………
……………………………

Ascultationsuch as a third and fourth heart sound, systolic murmurs, paradoxical splitting of the second
heart sound, a pericardial friction rub and rales over the lung

7- Diagnostic Test and Procedure

Lab test TROPONINS 2.LDH3.K Patient result Normal range Interpret resu
4.Na 5.cbc 6.ptt 7.pt
8.creatine kinase

Diagnostic Procedure (result)

Chest x-ray
Ecg:ST-segment elevation

8- medical management (medication, IV therapy)

Medication Classification Dose and frequency

Route Side effect Nursing consideration
 IV fluid name Type according to Rate /hour Total amount over 24
osmolarity hours

9- nursing diagnosis as priority

1…chest pain related to lack of oxygen as manifested by v/s

10- goal

1realef pain from 6 to 0 during 2 hours

11- nursing intervention

Non – pharmacological intervention Pharmacological intervention

❖ What is the fall score for your patient ……6……………………?

How you get this number ……pt said…………………………………………………………

❖ If your patient has a Pain

What is the pain score level ………………mailed…………….? pain scale that used …numearcal……………
 ❖ If your patient used O2 therapy

What’s the O2 delivery methods …………………mask…………. Flow rate …………………

Indication of uses…………………………………………………………………………………

Nursing care………………………………………………………………………………………

Clinical instructor: Mouna Hamdan