Nursing

Mrs Dorothy (Dotty) Beecham is 74 years old, and has been admitted with community-acquired pneumonia (CAP) and query Deep Vein Thrombosis (DVT). Mrs Beecham arrived in the emergency department, concerned about her increasing shortness of breath, high temperature, fatigue, ‘strange’ coloured sputum as well as pain and swelling in her right calf. Her clinical manifestations on admission were dyspnoea, fever, and chills. Mrs Beecham’s current medical history includes Chronic Obstructive Pulmonary Disease (COPD), Myocardial infarction 2012, osteoarthritis (poor mobility and awaiting a Total Knee replacement), hypertension, hypercholesterolaemia, type 2 diabetes mellitus, varicose veins and 4 episodes of DVT in the last 2 years. Mrs Beecham states that she has been smoking upto 5 cigarettes/day since 2012 and prior to this 20 per day for 25 years despite knowing about her emphysema, heart disease and risks for further DVT’s. Her alcohol intake is limited to the1 small glass of port per day. Mrs Beecham is a retired machinist, who lives alone since her husband’s death 2 months ago. Her two children live in Qld and visit infrequently. She has one sister Ruby who brought her to the emergency department.

Mrs Beecham’s observations on arrival to the ward are:
Temperature: 37.9°C
Pulse: 92 beats per minute
Respirations: 28 breaths per minute
BP: 135/75 mmHg
Weight: 85 kg
Height: 174 cm
Random blood glucose 9.6 mmol/L

The following Blood tests were taken within 24 hours of admission to hospital and the following results were found:

Clinical Examination Result Units Reference Range
Fasting Glucose 7.8 mmol/L (3.9–6.4)
Cholesterol 7.1 mmol/L (desired < 5.2)
Triglycerides 3.2 g/L (0.4–1.5)
HDL 0.79 mmol/L (0.80–2.05)
LDL 5.3 mmol/L (1.55–4.65)
Thyroxine 55 mmol/L (58–154)
Sodium: 136 mmol/L (135-145)
Potassium: 4.1 mmol/L (3.5-5)
Chloride: 97 mmol/L (95-105)
Bicarbonate: 27 mmol/L (22-31)
Creatinine: 78 umol/L (60-110)

Haemoglobin: 12 g/dL (12-15 women)
Haematocrit 38 % (36%-47% women)
GlycosylatedHaemoglobin 5 % (4%-6%)
Red blood cell count 3.5 x 1012/L (3.8-4.8 for adult females)
Haematocrit 38 % (36-46 % for adult females).
Mean corpuscular volume (MCV): 91 fL (80-100)
Mean corpuscular hemoglobin (MCH): 29 pg (27-32)
MCH concentration (MCHC): 34 g/dL (32-36)

White blood cells (WBC) 13 x 109/L (4-11)
Neutrophils: 7.9 x 109/L (2-8)
Lymphocytes: 3.8 x 109/L (1-4)
Monocytes: 0.8 x 109/L (0.0-1.0)
Eosinophils: 0.4 < 0.5 x 109/L
Platelets: 235 x 109/L (150-450)

Creatine kinase: 32 U/L (25-200)
Creatine kinase MB (CKMB): 0 ng/mL (0-4)
Troponin 0 ng/mL: (0-0.4)

C-reactive protein: 9.2 < 5 mg/L
D-dimer: 126 < 500 ng/mL
Her arterial blood gas results on admission were as follows:
Result Normal ranges
pH: 7.27 pH: 7.35-7.45
PCO2: 56 mmHg Partial pressure of carbon dioxide (pCO2): 35-45 mm Hg
PO2: 70 mmHg Partial pressure of oxygen (pO2): 75-100 mm Hg
HCO3: 25 mmol/L Bicarbonate (HCO3): 22-26 mmol/L
SaO2: 89% Oxygen saturation: 96%-100%

Doppler Ultrasound on her right calf has confirmed a Deep Vein thrombosis A chest x-ray taken when she was in the emergency department shows right lower lobe consolidation. A sputum specimen has been sent to the pathology department for gram stain, and culture and sensitivity. In the interim, Mrs Beecham has been commenced on intravenous antibiotics Azithromycin and Ceftriaxone. Additionally a Heparin infusion has been commenced

Mrs Beecham has been placed on oxygen via a mask at 6litres

Medication regimen for Mrs Elsa Beecham:

As per usual at home medication regime:

Salbutamol 5 mg nebule by nebuliser 3-4 hourly PRN
Fluticasone 250 mcg / salmeterol 50 mcg (Seretide) 2 inhalations by inhaler (MDI) bd
Tiotropium 1 capsule (18 mcg) daily by Handihaler
Lisinopril 5 mg per orally daily
Gliclazide (Diamicron MR) 30 mg mane per orally
Metformin (Diabex XR) 500 mg mane per orally
Frusemide 40 mg mane per orally
Simvastatin 40 mg nocte per orally
Oxycodone Hydrochloride controlled release 10 mg per orally daily when required.

Commenced since admission to hospital
Azithromycin 500 mg IVI daily
Ceftriaxone 1 g IVI daily
Heparin infusion IV bolus dose of 5,000 units of heparin, followed by an infusion of 1,000 units per hour. 25,000 units of Heparin have been added to a 500mls Bag of Normal Saline

The following Blood tests were taken:

Clinical Examination Result Units Reference Range
Fasting Glucose 7.8 mmol/L (3.9–6.4)
Cholesterol 7.1 mmol/L (desired < 5.2)
Triglycerides 3.2 g/L (0.4–1.5)
HDL 0.79 mmol/L (0.80–2.05)
LDL 5.3 mmol/L (1.55–4.65)
Thyroxine 55 mmol/L (58–154)
Sodium: 136 mmol/L (135-145)
Potassium: 4.1 mmol/L (3.5-5)
Chloride: 97 mmol/L (95-105)
Bicarbonate: 27 mmol/L (22-31)
Creatinine: 78 umol/L (60-110)

Haemoglobin: 12 g/dL (12-15 women)
Haematocrit 38 % (36%-47% women)
GlycosylatedHaemoglobin 5 % (4%-6%)
Red blood cell count 3.5 x 1012/L (3.8-4.8 for adult females)
Haematocrit 38 % (36-46 % for adult females).
Mean corpuscular volume (MCV): 91 fL (80-100)
Mean corpuscular hemoglobin (MCH): 29 pg (27-32)
MCH concentration (MCHC): 34 g/dL (32-36)

White blood cells (WBC) 13 x 109/L (4-11)
Neutrophils: 7.9 x 109/L (2-8)
Lymphocytes: 3.8 x 109/L (1-4)
Monocytes: 0.8 x 109/L (0.0-1.0)
Eosinophils: 0.4 < 0.5 x 109/L
Platelets: 235 x 109/L (150-450)

Creatine kinase: 32 U/L (25-200)
Creatine kinase MB (CKMB): 0 ng/mL (0-4)
Troponin 0 ng/mL: (0-0.4)

C-reactive protein: 9.2 < 5 mg/L
D-dimer: 126 < 500 ng/mL

Case Study Written Assignment

THE QUESTION :

1. Mrs Beecham has a history of cardiovascular and respiratory disease where smoking is a clear risk factor. Using the current literature and pathophysiology explain the risk that smoking poses to her future health. Identify the challenges and reasons why some patients are reluctant to quit and evidenced based strategies that could assist Mrs Beecham to address this. Outline how you would explain the risks and potential outcomes to Mrs Beecham.
Instruction :

• The word count for this written assignment will be 1650 words.
• You will be expected to use research or evidence-based journal articles (a minimum of five), textbooks and appropriate authoritative web sites (not Better Health Channel, Virtual Hospital, etc.), and all references used are to be no older than five years.
• All referencing is to be formatted intext and final list using the APA 6th Edn referencing style.
• A Table of Contents is required if headings are used in your assignment.
• provide an excellent introduction to your submission, and clearly explain how you intend to answer the topic question with Excellent paragraph structure.
• Professional language used throughout, with well-defined terms.
• Your conclusion provides a high quality summary of the major points covered in your
• You effectively linked quality research based evidence to justify each of your rationales.

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