Scenario
History of Present Problem:
Joyce Johnson is a 58-year-old woman with a history of atrial fibrillation, COPD, and depression. A friend who had not
heard from her for two days became concerned and went to her
...
Scenario
History of Present Problem:
Joyce Johnson is a 58-year-old woman with a history of atrial fibrillation, COPD, and depression. A friend who had not
heard from her for two days became concerned and went to her home. She found Joyce unresponsive on the floor of her
living room. She had a large left middle cerebral artery (MCA) ischemic stroke. She is intubated and has remained in ICU
since she was admitted to the hospital five days ago. She is also in acute renal failure as a result of rhabdomyolysis and
requires daily dialysis.
Personal/Social History:
Joyce is divorced, and has one adult daughter. She is estranged from her siblings and has not spoken to her daughter in
five years. She is on disability for severe depression. Depending on how she feels, Joyce inconsistently takesscheduled
medications including warfarin.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
1) Patient has History of atrial fibrillation,
COPD, and depression
Patient had a large left middle cerebral artery
ischemic stroke and was found on the floor in
the living room by her friend that got concerned
because she hadn’t heard from her and went
and checked to make sure she was ok and found
her unresponsive
They intubated her and sent to the hospital was
admitted to the ICU been there 5 days
She ended up getting rhabdomyolysis and
because of that she went into acute renal failure
which now requires her to get dialysis to help
her stay alive
1) The patient past diagnosis is important to the nurse because knowing
the patients past can help why she eventually got the stroke. Atrial
fibrillation as a correlation with strokes because blood may not be properly
pumped out of the heart, which may cause it to pool and form a clot.
Which then can travel to the brain and block the blood flow to the brain.
Knowing her meds also helps like warfarin because she was probably
taking this to prevent blood clots and, on this medication, it has to be takin
daily and have labs draws as well. Has a nurse we know she wasn’t takin it
as scheduled which didn’t help her situation and could have been some of
the reason why. Patient also had breathing problems COPD and sometimes
with that you could get upper respiratory infection can cause the lung
arteries to narrow or become blocked called pulmonary hypertension and
that can lead to Afib as well.
Patient being intubated means she is critically ill and needs to let her body
rest and recuperate itself. Only time will tell. It’s only been 5 days so they
don’t know how long she will be intubated for or if she will remain
intubated long term. It’s a day to day process
Another significant thing that the nurse would look at how she got
rhabdomyolysis. Rhabdomyolysis is a breakdown of muscle tissue that
releases a damaging protein called myoglobin into the blood. The
myoglobin is what can damage the kidneys. Usually this happens to a
person when they are immobile and stay in the same spot without
movement for a very long time they say anybody that doesn’t have
movement in half a day 12 hours and this patient we don’t know how long
she was immobile for but we do know she was not heard from for two days
by her friend and was found unresponsive probably stayed in the same spot
and position for more than 12 hours which then caused her rhabdomyolysis
which then damaged her kidney and the reason why she needs dialysis and
the stroke was not due to her getting rhabdomyolysis it was her staying in
the same position for a long time
RELEVANT Data from Social History: Clinical Significance:
Patient has a daughter she hasn’t talk to in five
years, Patient has siblings that she been distant
from and doesn’t have contact with them and
does not have a husband is divorced
Patient has severe depression and is on
disability because of it. Patient does take meds
but is not consistent with mediation ritual like
she should be. One of the medications that’s
included in her meds is warfarin
As a nurse this is a concern seeing she has no support system really affects
her treatment and future cares. This is probably why she is depressed and
doesn’t put effort to taking her meds. She doesn’t have help or a good
support system around her. Someone encouraging her to take her meds or
giving them to her for her to take sometimes that makes a great difference.
She probably feels what’s the point. Even her being educated on the risks
of not taking certain meds might have been useful for her to have as
knowledge. She has COPD and gets tired easily which can be another
health concern and why she is not compliant with her meds maybe she
doesn’t have the energy nor the motivation to get them or take them
because of that her not taking her warfarin as scheduled is what probably
the cause of her having the stroke. Just seeing how this patient health issue
and also psychiatric concerns both a part of her had getting a stroke due to
her not wanting to be compliant with meds cause of her depression and her
health issues. This shows you how both areas have a part in a persons
health its not always o...........................CONTINUED
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