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SCL 104 – Medical Surgical Nursing I Spring 2007 Session II Clinical Professor: L. Rickets LAGUARDIA COMMUNITY COLLEGE
CITY UNIVERSITY OF NEW YORK
DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM
NURSING CARE CASE STUDY
I. CLIENT-STUDENT INFORMATION

Client information
Student Practical Nurse

II. INTRODUCTION
I was randomly assigned to F.L. as my client on Thursday, July 27, 2007 by my clinical
instructor, Professor Rickets. The information during pre-conference that my clinical professor
gave me was that my client, F.L, is on telemetry, has a foley catheter, and her diagnosis is CHF
(congestive heart failure). Before obtaining more information from the chart, I introduced
myself to the client by telling her that I was her student nurse for the day. I immediately noticed
that she was on oxygen therapy, appeared tired and weak, but was responsive and alert. I also
noticed that she had some bruising over her IV site.
III. SOCIAL BACKGROUND AND PRESENT STATUS
My client is an 82 year-old Chinese woman who is married. Although her nationality is Chinese, her primary language is Cantonese. My client’s religious background is Buddhism. Although my client currently lives with her husband, her primary caregiver is her daughter and son-in-law. Her son-in-law and granddaughter were visiting at the time of my clinical experience with the client. My client’s highest level of education is unknown although, she is SCL 104 – Medical Surgical Nursing I
Spring 2007 Session II
Clinical Professor: L. Rickets
retired and living at home with her husband. This affects my client’s physical condition since
she does not work anymore, her level of physical activity is reduced. The family responsibilities
of my client involves performing a.m. care, assisting the client to the bathroom, and feeding.
According to her granddaughter, Sally, she states that my client needs help in getting out of bed,
requires assistance with feeding, and needs to repeat what she says in order for my client to
understand what she is talking about.
IV. MEDICAL AND HEALTH BACKGROUND

My client’s past medical and health history include having a cardiac stroke (ischemic), hypertension, dementia, anemia and having A-Fib four to five years ago. According to my client’s granddaughter, my client was previously hospitalized twice for a CVA at Elmhurst hospital four to six years ago. My client’s chief complaint during admission was shortness of breath. Her major diagnosis is congestive heart failure. During triage, the client arrived from home. The client arrived on a stretcher by the EMS. The client’s chief complaint quote is “She cannot breathe for 1 week” which relates to the client’s dypsnea or shortness of breath. My client’s mental status upon triage was that she was awake and her affect was calm. Additional information from the family includes that the client had a significant weight loss of about 100 lbs. within one year. According to the client’s family, the client refuses to eat which attributes to her symptoms of having fatigue, weakness, and shortness of breath. When taking the client’s vital signs, the client’s blood pressure is very low. I took the initial blood pressure with the automatic machine and it did not work. I tried several times and eventually used a manual sphygmomanometer to measure the client’s blood pressure. The client’s blood pressure is 90/60. Her temperature was 96.6 degrees Fahrenheit, respiration rate was 36, and her pulse was 48. SCL 104 – Medical Surgical Nursing I
Spring 2007 Session II
Clinical Professor: L. Rickets
V. HEALTHCARE THERAPY INCLUDING NURSING CARE
The following medications were given to the client: Lasix (furosemide), Monopril (fonisopril), Heparin, and Lopressor (Metroprolol). With the exception of Heparin, the rest of these medications were to treat the client’s congestive heart failure. According to the Davis Drug Guide, Lasix (furosemide) is given because of “edema due to CHF…it’s therapeutic effects include diuresis and subsequent mobilization of excess fluid” (Davis, 2007, p. 558). Before you administer Lasix to the client, it is important to “monitor blood pressure and pulse before and during administration” (Davis, 2007, p. 559). Checking the blood pressure is crucial because if the blood pressure is too low, you have to hold administering Lasix and inform the physician. This is what happened before administering the medications such as Lasix. Since the client’s blood pressure was 90/60, I was advised by the nurses to hold the Lasix medication and tell the physician about it, and document her blood pressure next to the medication list. Other medications for the client included Fonisopril (monopril) which is used to manage CHF (Davis, 2007). Lopressor (metroprolol) is used to “manage stable, symptomatic heart failure due to ischemic hypertensive or cardiomyopathic origin” (Davis, 2007, p. 786). Fonisopril and Lopressor were also held and not given to the client because the client’s blood pressure is too low to administer these medications. The only medication that I administered to the client with the supervision of my clinical professor was Heparin. Heparin is used in the “prevention of thrombus formation” (Davis, 2007, p. 586). When I administered Heparin to the client, I had to pinch the client’s skin to obtain enough subcutaneous tissue to inject the Heparin. I noticed that the client was thin and had poor SCL 104 – Medical Surgical Nursing I Spring 2007 Session II Clinical Professor: L. Rickets skin turgor. It was important as a nurse to assess areas where to administer the Heparin therefore, I used the abdominal site to inject the Heparin and used the 90 degree angle to insert the needle. Since the blood pressure was low and faint, I was advised by the nurses to always use the
manual sphygmomanometer. Other problems that were encountered with the client was the
client’s refusal to eat. According to the client’s granddaughter, the client usually likes to eat fish,
soup, rice, and noodles, but now eats “half of the time” and refuses to eat. This is a contributing
factor to the client’s nutritional needs because if a person does not eat enough of their daily
requirements, they become weak, tired, and deprive their body of essential nutrients to sustain
life.
VI. PSYCHOSOCIAL EFFECTS UPON CLIENT AND FAMILY:
There is a definite impact of illness upon the client and family because of the client’s
poor health condition. According to the granddaughter, she visits her grandmother nearly
everyday with her father, and also feels sad about her grandmother’s present illness. Alterations
in lifestyle include that when the client when walks, she becomes easily tired. This presents a
burden to the family that they always have to accommodate for her and care for her. It takes a
lot of responsibility and has psychosocial effects on the family and client because they are
constantly concerned.
VII. HEALTH TEACHING
As mentioned above, the needs observed for instruction in matters of health and personal hygiene include assisting the client to the bathroom, assisting the client with feeding and needs constant repetition in communicating with the client. For example, a word has to repeated several times for the client to understand what the speaker is saying. SCL 104 – Medical Surgical Nursing I Spring 2007 Session II Clinical Professor: L. Rickets The results obtained from heath teaching is making sure that the client has an
understanding and knowledge of her diet, medications, activity, knowledge of disease, and DVT
(deep vein thrombosis) prevention. It is important for the client to have an understanding of the
things related to her illness so that the client can be able to manage her illness after being
discharged from the hospital. The client’s reaction to the health teaching is that the client seems
complacent and indifferent to health teaching and education. The client does not question any
procedures being done or why they are being performed, instead the client accepts whatever
procedure is being performed. Since the granddaughter is bilingual, she is important in
communicating the needs of the client.
VIII. CONCLUSION
In conclusion, I have learned a lot from this case study with this particular client. I learned that nutrition is very important with the elderly because of the decrease in bodily functioning and to maintain a good health status. I observed that it is important to teach the client about why medications and diet are necessary in order to manage her illness. The difficulties that I have encountered in getting and analyzing information is that I could not find any lab results in her chart. The other difficulties was communicating directly with the client because the client only speaks and understands Cantonese. This presents a difficulty because you want to know how the client feels directly and not someone else’s interpretation of how the client feels. SCL 104 – Medical Surgical Nursing I
Spring 2007 Session II
Clinical Professor: L. Rickets
IX. REFERENCES
2. Relatives: Granddaughter (Sally), and son-in-law 3. Professional Staff: LPN and RN assigned to client Deglin, H. J., & Vallerand, H. A. (2007). Davis’s Drug Guide for Nurses. (10th ed.). Philadelphia, PA: F.A. Davis Company, 558, 559, 586, 786.

Source: http://www.eportfolio.lagcc.cuny.edu/scholars/doc_fa07/marie.jimenez/documents/SCL104/casestudy104.pdf