Seventy-six year old female found collapsed at home. Known hypertensive treated with Losartan 50mg, took double her normal dose of Losartan yesterday by mistake. Not feeling well since yesterday dizzy and finding it difficult to find her words in normal conversation. Paramedics noted a Glasgow Coma Scale score of 8 and BM of 6.5, patient was sweaty. Had a thirty second self terminating clonic type seizure in the ambulance. The doctor’s initial diagnosis was stroke and haemorrhage with ride sided hemiparesis; this was revised to include probable aspiration pneumonia. Noted to be Hyponatraemic - cause?
Treatment commenced included Intravenous fluids + nil orally, IV antibiotics, insertion of urinary catheter reason for catheterisation not stated. Made an unremarkable recovery her Hyponatraemia thought to be secondary to her pneumonia.
Nursing care for this patient related to care of the unconscious patient, observations including neurological, monitoring of the Intravenous fluids, management of the indwelling urinary catheter, pressure area care, communication with the son & daughter on the seriousness of their mothers condition.
Other professionals involved with the patients care included Speech & language Therapist and Physiotherapy.
The lady progressed well and was well enough to sit out of bed by day three. IV and catheter were removed on day four and the lady was discharged to her home with family support on day five following admission.
Profile of Adult Patient Case 01-015
Seventy six year old female, admitted to the ward via Accident and Emergency Department with a history of collapse and loss of consciousness. This patient had suffered with similar episodes of collapsing over a period of three months prior to admission. Found on the floor by her friend, where she had been for several hours throughout the night. Reported to have had a poor appetite for 6 weeks prior to admission associated with weight loss and reduced mobility.
Past medical history included Hypertension, Type 2 Diabetes Mellitus, and Hypothyroidism. This patient also had a stoma, and had a diabetic ulcer to her right leg. Prior to this admission into hospital, she lived alone in a bungalow with the District Nurses regularly attending to dress the leg ulcer and to check her blood glucose levels. The patient was awaiting Lava treatment to the leg ulcer although the Primary Care Trust could not fund this.
Whilst in hospital she developed multiple complications and it is unclear what caused the complications. Having been initially diagnosed with fast Atrial Fibrillation and Postural Hypotension, for which she was treated with medication and discontinued from some of her normal medication. Throughout the period of her stay she was found to be having episodes of fast Atrial Fibrillation with episodes of Ventricular Tachycardia. Abnormal blood results indicated impaired renal function that again was treated with medication. Episodes of haematuria and blood clots were also reported and it was believed that this was due to a urine infection for which she was treated with antibiotics. Further investigations revealed stones in the urinary tract. Whilst in hospital, the patient complained of having difficulty when swallowing and had several episodes of nausea. Although an Endoscopy was arranged this procedure was not performed. Nursing management included input from the dietician, the coordinator for the elderly, tissue viability nurses and diabetic nurses.
Unfortunately this lady’s condition deteriorated throughout the period of hospitalisation. Following multiple medical complications she was diagnosed with metabolic acidosis and septic shock, the prognosis was poor. Discussions were held with the doctors and the patient’s family in relation to her prognosis. A decision was made that the patient should not be resuscitated or ventilated in the event of Cardiac Arrest. The family requested that the patient be made comfortable.
The patient’s condition continued to deteriorate despite treatment and she died peacefully following a forty-day stay in hospital. May she rest in peace.
Profile of Adult Patient Case 01-016
Acute admission with central “crushing” type chest pains and shortness of breath. Patient was discharged from hospital on the previous day to this admission following treatment for intermittent chest pains. Chest pains worse on exertion.
Diagnosed with unstable angina, cholesterol noted to be raised. Treated with medication, investigations were undertaken and she was commenced on a heart monitor. The patient had several episodes of chest pain whilst on the ward. On day 8 the patient reported that she ‘felt out of sorts’, he was seen by doctor who thought it was indigestion, she was known to have reflux oesophagitis. The patient was found to be in complete heart block on Day 12. Following insertion of a urinary catheter, she was transferred to the Coronary Care Unit for close monitoring. Seven days later it was agreed by the medical staff that the patient required a Permanent Pacemaker. The patient was consented and the pacemaker was successfully inserted. Seen by the physiotherapist on several occasions in the days following the procedure, patient was assessed on walking up the stairs. She managed this assessment although she became short of breath, despite her observations being stable. The patient requested that her bed at home be moved downstairs as she did not want to walk upstairs. Discharged home on day 26.
Profile of Adult Patient Case 01-017
This eighty-three year old lady was admitted via her GP with a history of falls and a reduced appetite. Known to have Osteoarthritis to her right hip, she also has a history of breast cancer, Chronic Obstructive Pulmonary Disease (COPD), Cor Pulmonale and Hypertension. She was admitted into hospital as she was unable to manage at home.
This lady was previously assessed for a left hip replacement although this was not performed as she had some other problems at the time. Reviewed by the Orthopaedic surgeon on the ward and agrees to the operation despite the risks involved. However there are some concerns expressed by the consultant in relation to her chronic chest condition. Following an assessment by the anaesthetist a decision is taken that she is not fit to undergo surgery due to her chronic chest condition. She is later referred to the Pain clinic to be assessed for pain relief. The nursing management of this patient consists of a referral to the Occupational Therapist, Physiotherapist and Social Worker. This lady is discharged home following a twenty day stay in hospital with home support.