TASK 46 You are the registered nurse on the Cardiology Unit at St Luke’s Hospital, Adelaide. Ms. Kylie Weiss is a patient in your care.

Today’s date: 09/07/2017                  Patient details

Name: Ms. Kylie Weiss                     DOB: 21/05/1952

Address: 8758, pulteney Street, Adelaide, SA, 5000            

Telephone: (04)7649 5748

Date of Admission: 07/07/2017                               

Presenting complaint: BIBA – brought in by ambulance

2-hours history of intermittent discomfort in jaw and heaviness in both forearms constant discomfort-pale, clammy, nauseated         IV access in ambulance, 10mg IV. Morphine on route, Aspirin 300 mg chewed, Glytrin spray x 3                   ECG showing ST elevation

Diagnosis: Myocardial infarction Medical History               

Weigh: 85kg               Height: 10cm

Diet: Rarely cooks at home-eats muffins or pancakes for breakfast

Like eating fast foods – fries, hamburgers, sausages, lobster, onion rings, ice cream, steak

Ex-smoker-1994 Non drinker

Medical History: Mild osteoarthritis.

Mid asthma – no exacerbations within last 5 years Dyslipidaemia – (Raised cholesterol) – not treated

Medications: NIL

Family history: Brother CABG 70 years Sister MI 60 years           

Mother angina

Social history:                      

Married with one daughter

Husband-Peter Weiss, 67 years, retired, aged pensioner Daughter, Ryena Weiss, lives in London

Occupation: Works as a taxi driver,Mixed shifts

Medical treatment: Blood tests – Troponin 1 (indicative of damage to heart muscle in most instances) performed by nursing staff along with CBC- Hs TNI> 50000(N˃16 female)

ECG- ECG on arrival to ED by nurse, shows ST elevation -Leads V1, V2, V3, V4 Elevation,Anterior Mi Emergency Medication– IV Morphine, Oxygen Clexane, loading dose of Ticegralor,Emergency Angioplasty – Due to presentation of pain, ST elevation on ECG-Direct stenting proximal LAD

Echocardiogram – to indicate damage to heart muscle and treatment.Ejection fraction 35%.Pain/Discomfort – managed. Fluids encouraged to flesh dye decrease risk of AKI (Acute Kidney Injury)

Fasting blood (lipids, Diabetes TNI, CBC, Biochem) – High cholesterol levels identified

Commenced on Atorvastatin 40mg OD, Ticegralor 90 mg BD, Glytrin spray for chest pain

Nil further pain/discomfort cardiac status stable Radial site, nil ooze, swelling, pain discomfort

Pt seemed Confused regarding diagnosis, reality of near-death experience

Educated re event, MI diagnosis and modifications to risk factors (Cholesterol, wt. loss)

R/V by dietician – diet to promote weight loss and lower cholesterol levels Concerned about being unable to manage home on her husband’s pens- S/W (social worker) input required for this

09/07/2017: preparing for discharge

Discharge Medications: Commenced on Atorvastatin 40 mg OD metoprolol 23.75 mg OD

Cilazipril 0.5 mg OD, Aspirin 100 mg OD,Ticegralor 90 mg BD Glytrin spray PRN for chest pain

Discharge plan: No driving motor vehicle for 6 weeks.

Writing Tasks Using the information given in the case notes write a referral letter to Ms. Nina Gill, Cardiac Rehabilitation Nurse Specialist, Cardiac Rehabilitation- Compliance with risk factor management (wt. loss, low cholesterol diet), medications, education re about MI and its management.

Using the information in the case notes, write a referral letter to Mr. Barney Dyer, Occupational Therapist, Home Occupational Therapy services, 85 Flinders Street, Adelaide requesting him to visit Ms. Weiss at home and provide guidelines for returning to work, driving and normal daily activities.

Refer to social worker-due to inability to work for 6 weeks, 6weeks recovery from MI, assess eligibility for sickness allowance /benefits from the Australian Government Department of Human Service.

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