NRS277 Clinical Reasoning in Nursing - Assessment 3: Case Study

Martin Stevenson, 48 years old, arrived at the emergency department this morning accompanied by his wife. Martin was visibly distressed and clutching his chest. He described his severe chest pain as "9 out of 10 and as if an elephant has been sitting on my chest for over an hour now", which began shortly after taking the full wheelie bin out to the street from their side gate. Martin also described the pain as a sharp, crushing sensation at the center of his chest, radiating to his jaw. He mentioned experiencing indigestion-like symptoms over the past couple of nights that woke him up, but they eventually subsided. He added that he couldn't walk as far as before without feeling tired and short of breath.

Triage Observations

Airway: Patent, own, RR: 30 Sp02: 96% on Room Air (RA)

BP: 160/95

HR: 125, regular

T: 37.1

Pain 9/10.  The patient reports “feels as if an elephant has been sitting on my chest for over an hour”. Sharp, crushing sensation at the center of his chest, radiating to his jaw.

GCS 15

BSL: 8 mmol/L

Medical History

Nil known allergies

Not on regular medication

Denies drinking alcohol Independent with activities of daily living.

ED Investigations

CXR: Pending

ECG: Non-ST elevated myocardial infarction (NSTEMI) with widespread T wave inversion most prominent in the lateral leads

Troponin: 1500ng/L (Normal value for Males < 26 ng/L )

FBC, UEC, Lipid profile: Results pending

In the ED, the patient was commenced on Pathway for Acute Coronary Syndrome (PACSA) for high-risk NSTEMI. Martin received aspirin 300mg PO, a glyceryl trinitrate (GTN) sublingual tablet of 300 micrograms, and enoxaparin 100mg via subcutaneous injection. Martin has been admitted to the medical ward for cardiac monitoring via telemetry and has been added to the cardiac catheterisation list this evening for an angiogram.

You are the registered nurse (RN) in the medical ward, and you assume care of Martin during this afternoon shift. Martin appears anxious and is rubbing his chest. You approach Martin to introduce yourself and proceed to conduct your primary and secondary assessment.