CASE STUDY: PULMONARY EMBOLISM It is Thursday

CASE STUDY: PULMONARY EMBOLISM It is Thursday morning (Time 0845), and you are working in a busy Emergency Department. History of Present Illness: You are caring for Giles, a 70-year-old male. He arrived at the emergency department with his spouse, Mary Lou. He complains of shortness of breath which started yesterday and has gotten worse today as well as lethargy. He also reports sudden chest discomfort which started one-hour prior. He is afebrile and appears apprehensive. Social History: (from Giles) Giles is a retired electrician for GE. He has an active lifestyle and often “fixes” things around the house for pleasure. His wife describes him as a handyman. He eats mostly meat and potatoes and drinks alcohol on occasion. He previously smoked cigarettes but quit 20 years ago. His BMI is 32. He is compliant with yearly exams but sometimes “forgets” to take his blood pressure medications. He does not have a home blood pressure monitor. He denies any recent injures or fractures. Medical History: CHF, obesity, hypertension. Subjective History: Giles was born on a farm and grew up working the land with his 10 brothers and sisters. He has always worked hard his entire life. He retired last year and has continued his hobby of fixing old appliances and gardening. He has only been hospitalized once when newly diagnosed with CHF. Since then he has not had any exacerbations or issues. He lives in 1-story house with his wife. His 5 children live close. Medication Dose Last dose taken Coreg (carvedilol) 3.125 mg BID 0800 Lasix (furosemide) 20 mg BID Not yet taken today CASE STUDY QUESTIONS 1. Now that you have gathered initial information from the patient and analyzed its clinical significance and/or impact your next step is to assess your patient. What assessment data would you gather, and why is it important why? HINT: It would be a focused assessment Assessment Importance 1. 2. 3. 4. GENERAL APPERANCE: Giles looks apprehensive. He is sitting up in bed and is clean and well groomed. His spouse is at bedside. He complains of shortness of breath and chest discomfort. VITAL SIGNS: Temp: 36.8°C (98.24°F) BP:120/80 mmHg MAP 93 HR: 118 bpm RR: 30 SpO2: 90% on RA NEURO: Alert and oriented to person/place/time/situation. GCS 15. PERRLA. Anxious CARDIAC: Mucous membranes are pink. Capillary refill <3 seconds. Apical HR tachycardic. Peripheral pulses palpable and weak x4 at +1. No edema. No murmur RESP: Lung sounds clear in RUL, LUL, RML and basilar crackles in RLL and LLL. No stridor. Respirations are symmetrical and labored GI: Abdomen obese. Soft, non-tender. NABS x4. Last BM was today. Negative for nausea and vomiting. GU: Voids painlessly and without hesitation. Clear, yellow urine. UA normal. MUSCOLOSKELETAL: Moves all extremities with no overt deficits. Ambulates unassisted but is slow paced. Equal grip strength bilaterally. INTEGUMENTARY: Skin is warm, dry, and intact. No bruises or wounds noted. PSYCHOSOCIAL: Broad affect, apprehensive. Wife at bedside for support. 2) What data from Giles' assessment and recent clinical history is significant? References: Pulmonary Embolism Nursing Care and Management: Study Guide (nurseslabs.com) https://nurseslabs.com/pulmonary-embolism/ Pulmonary Embolism Nursing Diagnosis (nursestudy.net) https://nursestudy.net/pulmonary-embolism-nursing-diagnosis/ SCIENCE HEALTH SCIENCE NURSING NUR 3755L

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