Case world: Elizabeth Green Mrs Green is a retired widow

Case world: Elizabeth Green

Mrs Green is a retired widow, living alone in her own ground floor unit. She utilises a Webster pack for medication, and employs a private cleaner once a week. She does not drive and prefers to use a taxi for transport.

Mrs Green has one daughter (Rose) and one son (James) who are very supportive and pay for the cleaner. Her son and daughter live some distance away and work full time and are only able to visit on weekends. Elizabeth has 5 grandchildren (Eloise, Bianca, Elizabeth, Matthew and Jeremy). Mrs Green’s beloved pet is Matilda who is a Terrier cross.

Mrs Green has the following health history: Former smoker (quit 5 years ago), GORD, HT, hypercholesterolemia, osteoarthritis, Type 2 Diabetes (diet controlled). She had a Hysterectomy 30 years ago.

Mrs Green’s mother had cardiac disease (deceased), Father Rheumatic Fever as a child, which contributed to long term health problems (deceased), Sister breast Ca (deceased).

Her current medication regimen comprises:

Esomeprazole 20mg nocte

Metoprolol 25mg mane

Simvastatin 20mg nocte,

Vitamin D and calcium tablet 1 daily,

Paracetamol 1g 6/24 prn no more than 4g per day

Mrs Green has had a femoral angioplasty performed. A blockage is found in Mrs Green’s Left Anterior Descending artery, which is able to be successfully stented. Other cardiac vessels viewed have 10-20% occlusion. Mrs Green is diagnosed with an anterior MI with LAD occlusion.

Mrs Green is transferred from the Angio Suite Recovery area to the Cardiac Care Ward at 1250.

Handover from Angio Suite Recovery Nursing Staff states that Mrs Green has had an unremarkable recovery post procedure.

GTN has been ceased prior to returning back to the ward. The pump with the GTN is turned off, but remains connected to the IV cannula. Cardiac monitoring to continue for 24hrs.

Mrs Green’s medical orders state that she is to remain supine for 4 hours, then sheath removal. Post sheath removal Mrs Green can sit up 30 degrees for 2 hours, and then at 45 degrees for 2 hours and then to mobilise as toleratedexample social capital, socio-economic status, stereotypes (ageism, racism, able-bodiedness).

1250 On arrival to the ward her observations are:

1300 Observations:

BP 155/90

HR 85 beats per minute

RR 26 respirations per minute

Temperature 35.8C

SpO2 99% on 6L O2

BGL: 5mmol

Pain: No reported chest pain

RIGHT foot is warm, pink with normal movement and sensation, pulse present

Puncture site soft, “5 cent size” of bleeding on dressing. No pain reported

BP 145/90

HR 85 beats per minute

RR 24 respirations per minute

Temperature 35.8C

SpO2 98% on 6L O2 via CIG

BGL: 5mmol

Pain: No reported chest pain

RIGHT foot is warm, pink with normal movement and sensation, pulse present

LEFT foot is pale, cool, with normal movement and sensation, pulse present.

Puncture site soft, bleeding on dressing noted to be a size of a “10 cent size”

Cardiac Care Ward-1400

Cardiologist Review

The cardiologist reviews Mrs Green at 1400, approximately 1hour post procedure due to Mrs Green’s Left foot being pale and cool.

Eliza attends the Cardiologists round and review of Mrs Green.

She highlights to the Cardiologist that the Left Foot remains pale and cool and that Dorsal and Pedal pulses are present.

The Cardiologist performs a Doppler ultrasound on the Left foot, and determines that there is adequate blood flow, but requests that half hourly neurovascular observations to continue for another 2 hours to monitor for any changes.

At 1400 Mrs Green’s observations are:

BP 140/80

HR 88

SaO2 99% on 6L via CIG

Pain: No reported chest pain

LEFT foot pale, cool, normal movement and sensation, pulse present

RIGHT foot is warm, pink with normal movement and sensation, pulse present

Puncture site soft, no bleeding

Cardiac Care Ward-1430

At 1430, Mrs Green asks John who has just come on for the late shift, if he could disconnect her GTN infusion as it is restricting her arm movement. John has not received handover as of yet and is relieving on the ward. Nevertheless John agrees to disconnect the GTN infusion as it appears to be turned off. Whilst disconnecting the infusion, Mrs Green states that “…the cannula is very sore and could he do something about it?”

John advises Mrs Green that he will flush her cannula. When the cannula is flushed Mrs Green shouts out to John that this is very painful, however he persists and slowly the discomfort around Mrs Greens IV cannula site eases.

1450 Mary the late shift RN introduces herself to Mrs Green. Mrs Green advises Mary that she is feeling very light headed. Mary assesses Mrs Green. 1450 Observations:

1500 Observations:

BP 100/50

HR 80 beats per minute

RR 18 breaths per minute

SaO2 99% on 4L O2 via nasal specs

Pain: No reported chest pain

LEFT foot pink, warm, normal movement and sensation, pulse present

RIGHT foot is warm, pink with normal movement and sensation, pulse present

Puncture site soft, no bleeding

BP 110/66

HR 88 beats per minute

RR 20 breaths per minute

SaO2 99% on 4L O2 via nasal specs

Pain: No reported chest pain

LEFT foot pink, warm, normal movement and sensation, pulse present

RIGHT foot is warm, pink with normal movement and sensation, pulse present

Puncture site soft, no bleeding