In Class

CONSIDER THE PATIENT:

Michael Bryant, 59-year-old Aboriginal male

  • Chest pain (recent onset, after travel)

  • Significant PMHx: Hypertension (HPT), Hyperlipidaemia, Type II Diabetes Mellitus (T2DM)

  • Smoker (1 pack/day), Obese (BMI ≈ 35)

  • Social drinker (2-3 standard drinks nightly)

  • Recent long-haul travel (USA), now feeling unwell

  • Currently under cardiology team for Chest Pain for Investigation (CP FI)

COLLECT CUES:

Subjective Cues:

  • Chest pain episodes

  • Feels “sick” post-travel

  • Poor diet and random meal times

  • Recent travel history (DVT/PE risk)

Objective Cues:

  • HR: 80 irregular

  • BP: 150/85 (elevated)

  • RR: 20 (normal)

  • SaO₂: 97% (normal on room air)

  • Temp: 37°C (normal)

  • Obesity (105kg, 173cm)

  • Smoker

  • Pending bloods and ECG

INTERPRET INFORMATION:

  • Irregular HR → possible arrhythmia (e.g., Atrial Fibrillation)

  • Elevated BP → poorly controlled hypertension

  • Recent immobilization + obesity + smoking → high risk for Pulmonary Embolism and acute coronary syndrome (ACS)

  • Poor diabetes management → increased cardiovascular risk

  • Chest pain → urgent assessment for myocardial ischemia or infarction

  • Social factors (single, poor diet) impact recovery and chronic disease management

Five Priority NURSING PROBLEMS:

1. Risk of Decreased Cardiac Perfusion

  • GOAL: Michael will maintain adequate cardiac output without worsening chest pain.

  • ACTIONS:

    • Immediate 12-lead ECG

    • Notify cardiology/medical team

    • Monitor chest pain using PQRST (Provocation, Quality, Region, Severity, Time)

    • Administer oxygen if SpO₂ drops below 94%

  • OUTCOMES:

    • ECG reviewed by RMO.

    • Chest pain controlled without infarction progression.

2. Risk of Arrhythmia (due to irregular HR)

  • GOAL: Detect arrhythmia early and prevent complications.

  • ACTIONS:

    • Continuous cardiac monitoring

    • Record and report any rhythm changes

    • Prepare for potential antiarrhythmic medication administration

  • OUTCOMES:

    • Early identification and treatment of abnormal rhythms.

3. Risk of DVT/PE (recent travel, obesity, smoking)

  • GOAL: Prevent venous thromboembolism.

  • ACTIONS:

    • Early mobilization (as tolerated)

    • Apply compression stockings if ordered

    • Encourage hydration

    • Monitor for signs of DVT (leg swelling, pain) and PE (sudden SOB, chest pain)

  • OUTCOMES:

    • No clinical signs of DVT or PE develop.

4. Risk of Poor Blood Glucose Control

  • GOAL: Maintain blood glucose within target range.

  • ACTIONS:

    • Monitor BGLs (before meals and bedtime)

    • Follow diabetic diet plan

    • Administer insulin/oral hypoglycemics as prescribed

  • OUTCOMES:

    • Blood glucose levels stable within normal limits.

5. Risk of Non-Compliance with Lifestyle Modifications

  • GOAL: Improve understanding of risk factors and promote lifestyle change.

  • ACTIONS:

    • Provide education on cardiac health, smoking cessation, and diet

    • Arrange dietician and diabetes educator reviews

    • Explore Michael's readiness to change (Motivational Interviewing techniques)

  • OUTCOMES:

    • Michael verbalizes understanding of lifestyle modifications needed.

REFLECTION:

  • Clinical Priorities: Michael’s presentation with chest pain and cardiovascular risk factors required urgent cardiac assessment, monitoring, and collaboration with the medical team.

  • Learning: Early cue recognition and rapid response (ECG, pain assessment, vital signs monitoring) are critical in preventing myocardial damage.

  • Areas for improvement: Continue developing skills in cardiac rhythm interpretation and patient education about chronic disease management.

  • Cultural Considerations: Providing culturally safe care for Michael as an Aboriginal patient, acknowledging historical health disparities and building trust.

✅ What is happening to Michael?

Michael is now showing signs of a Deep Vein Thrombosis (DVT) in his left leg.

✅ Evidence:

  • Pain, redness, warmth, and swelling in one leg are classic signs of DVT.

  • D-Dimer and ultrasound are correctly ordered to confirm a clot.

  • Recent immobility, cardiac issues (AFib), and hospitalization all increase VTE risk.

✅ Why is this happening (pathophysiology)?

  • Atrial fibrillation already increases clot risk due to blood pooling in the atria.

  • Hospitalization often leads to reduced mobility, causing venous stasis.

  • His heart condition and low cardiac output (low BP, ashen colour) suggest overall poor circulation, further predisposing him to thrombus formation.

  • Virchow’s Triad (stasis, endothelial injury, hypercoagulability) is at play.

✅ What are the risks if DVT is confirmed?

  • The clot can break off and travel to the lungs → Pulmonary Embolism (PE), which can be life-threatening.

  • He already had one MET call and unstable vitals before — a PE would greatly worsen his cardiac function.

✅ What needs to happen next?

  • Urgent ultrasound to confirm DVT.

  • D-Dimer blood test results to support diagnosis.

  • Start anticoagulation therapy (e.g., heparin, enoxaparin) to prevent clot extension or embolism.

  • Monitor for signs of PE (shortness of breath, chest pain, hypoxia).

  • Keep Michael monitored even after diagnosis — DVT/PE are dangerous in patients with cardiac problems.

✅ Summary:
Michael likely has developed a DVT due to immobility, AFib-related clot risk, and poor circulation.
Immediate anticoagulation and close monitoring are critical to prevent serious complications like pulmonary embolism.