NURS 3046 Nursing Project
Question:
1. Demonstrate an understanding of the ‘deteriorating patient’ and patients being cared forin the critical care nursing environments of emergency department, coronary care unit,high dependency and intensive care, including related anatomy and physiology, pathophysiology, diagnostics, pharmacokinetics, pharmodynamics, the quality use ofmedicines and complementary therapies;
2. Apply comprehensive assessment and evidence based clinical reasoning with initiativeand judgement in theoretical, clinical and simulated environments related to critical carenursing
3. Demonstrate the capacity to analyse, integrate and apply principles of ethical and legalpractice to person centred care in the critical care environment;
4. Apply effective practice and intra- and interprofessional communication strategies tofacilitate the delivery of safe, quality care to people in diverse settings; and
5. Further develop an understanding of health professions’ roles and responsibilities whencaring for the ‘deteriorating patient’ in the acute care setting and develop anunderstanding of health professional roles and interventions in critical careenvironments.
Answer:
Elements of deterioration
The patient, Mr. Lee was admitted with myocardial infarction with associated symptoms of shortness of breath, lightheadedness and angina or chest pain. Early interventions and diagnosis of the condition was done through performing electrocardiogram, which enabled initial management of the cardiac discomfort. The patient was given nitroglycerin in sublingual form in successive dosages along with morphine. This drug treatment, intended to improve the condition, however, further resulted in deterioration of the patient’s condition with reduction of blood rate, hypotension and reduced preload of myocardial oxygen demand followed by lethargy. A review of the patient’s clinical condition confirmed that increased heart rate (HR 133), decreased blood pressure (BP 87/53) and reduced level of myocardial oxygen saturation (SPO2 88%) are mainly the elements of deterioration in the patient’s condition. According to NSW Health Between the Flags, indication of these elements of deterioration require a clinical review by nursing officials to assess the root of deterioration of clinical treatment (Hughes et al., 2014). Based on clinical review in the given case study, an increased requirement of myocardial oxygen is required to improve the hypoxic condition. The nursing assessment of the Mr. Lee needs to be performed to identify whether the deterioration has occurred due to drug overdose or any new clinical symptom. If these clinical review and identification of deteriorating causes do not result in improved patient condition in the following one hour, then a rapid response team would be required to handle the situation (Chen et al., 2014). In the given case study of Mr. Lee, frequent assessment by nurses is essential for the following one hour post clinical review.
ISBAR communication
I (Identity) |
Health nurse attending Mr. Lee post drug treatment in Coronary care unit. |
S (Situation) |
The patient, Mr. Jae Kwang Lee, a 65-year old man has admitted with severity of conditions; He reported that he felt an increasing chest heaviness which moved to his left arm. He was constantly rubbing both his chest and arm, trying to get some relief from the discomfort. On further questioning, shortness of breath and mild dizziness were also reported with lightheadedness. He was immediately admitted in the emergency section and electrocardiogram was performed which confirmed that he had been suffering from myocardial infarction. He had been given nitroglycerin in sublingual form followed by morphine administration as the first line of treatment. Nitroglycerin showed no effect after administration, whereas morphine showed a number of responses. ECG before drug treatment confirmed blood pressure of 108/73 and a myocardial oxygen demand of 95%. |
B (Background) |
Mr. Lee reported that he had been having a continuous chest pain for last few months and that he had never experienced such severity of the pain before. This pain had been continuing since the day before, which caused him to seek medical help. |
A (Assessment) |
5mg of morphine administration appreciably reduced the chest pain; on the contrary, heart rate is increased and blood pressure is reduced. The patient became hypotensive and lethargic. Verbal responses are proper. |
R (Recommendation) |
Proper knowledge needs to be gathered on the role of morphine in relieving chest pain, taking concern that no aggravating side-effects result. More rapid response teams need to be employed to have a proper management upon drug treatment. A concrete intervention plan needs to be designed to eliminate the deterioration upon drug treatment. |
Pathophysiology of deleterious condition
Myocardial infarction, particularly Non-ST-elevation myocardial infarction is a form of coronary artery disease, which is less predominant among humans as compared to the ST-elevation myocardial infarction (STEMI). Electrocardiogram is performed as an initial diagnosis in both the forms of heart attack. In non-ST elevation myocardial infarction, the electrocardiogram does not show any alteration in the ST segment, which indicates that the patient is suffering from temporary or partial blockages of coronary arteries and is unlikely to be serious as compared to the ST-elevation myocardial infarction. Chest discomfort or ischemic pain which is not localized is a common symptom as have been reported in the given case study. Shortness of breath, mental dizziness, lightheadedness are commonly noted during the pathological condition. Chest discomfort and shortness of breath continues for a while; therefore relieving the chest discomfort or angina is the primary concern in treating myocardial infarction. High blood pressure or bradycardia is observed which causes discomfort to the patient. Initial diagnosis involves performing an electrocardiogram (ECG) which shows the severity of the condition, depending on which medications are prescribed.
The patient, Mr. Lee has been administered with short term dosage of nitroglycerine in the form of sublingual tablet or spray of GTN in order to relieve the chest pain the patient was suffering from. However, the nitroglycerin produced no noticeable effect in ameliorating the patient’s symptoms. After two doses of sublingual GTN, Mr. Lee was administered with 5mg of morphine. Nitroglycerine alone or in combination with morphine is the first line of therapy in myocardial infarction (Bellandi et al., 2016). Morphine showed considerable effects in the patient’s level of discomfort within 2 hours of administration. Morphine is administered to reduce the chest pain or angina, which is achieved in the reported case of Mr. Lee. However, the patient Mr. Lee suffers from cardiogenic shock after drug treatment as confirmed through assessment post drug administration. A deterioration of the patient condition has been observed; bradycardia which is reduced blood pressure, hypotensive nature and a reduced myocardial demand of oxygen with pO2 being 88% are concerning signs of cardiogenic shock. Cardiogenic shock in myocardial infarction occurs as a result of cardiac dysfunction involving both systolic and diastolic dysfunction. In myocardial infarction, the left ventricular diastole shows an increased pressure. Myocardial perfusion continues during diastolic event and is dependent on the pressure difference between aortic diastole and left ventricle (Heusch & Gersh, 2016). As a result of myocardial infarction, coronary perfusion shows a decreasing trend due to decreased pressure in aortic diastole and subsequent increase in left ventricular pressure. This is associated with a progressive event of ischemia. In response to decreased coronary perfusion, the heart rate increases in order to increase the myocardial demand of oxygen (Cooper & Panza, 2013). In relation to Mr. Lee’s condition, increased heart rate (HR 133) occurs to increase the oxygen demand in the hypoxic condition. Increased heart rate, in turn directly affects coronary perfusion. Dilation of coronary blood vessels reduces the blood pressure (bradycardia) (Kubica et al., 2015). In relation to the given case study, lower blood pressure reduces the cardiac preload of oxygen, minimizing the pO2 at 88% as observed in Mr. Lee. The time of diastolic event increases with the increase in heart rate. Therefore, the time of tissue perfusion dramatically decreases leading to further manifestation of ischemia of inner membrane of the heart. Hypoxic condition and lethargy in Mr. Lee are the resultant of the pathophysiological cycle of cardiogenic shock.
References
Bellandi, B., Zocchi, C., Xanthopoulou, I., Scudiero, F., Valenti, R., Migliorini, A.,. & Parodi, G. (2016). Morphine use and myocardial reperfusion in patients with acute myocardial infarction treated with primary PCI. International journal of cardiology, 221, 567-571.
Chen, J., Ou, L., Hillman, K., Flabouris, A., Bellomo, R., Hollis, S. J., & Assareh, H. (2014). The impact of implementing a rapid response system: a comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia. Resuscitation, 85(9), 1275-1281.
Cooper, H. A., & Panza, J. A. (2013). Cardiogenic shock. Cardiology clinics, 31(4), 567-580.
Heusch, G., & Gersh, B. J. (2016). The pathophysiology of acute myocardial infarction and strategies of protection beyond reperfusion: a continual challenge. European heart journal, 38(11), 774-784.
Hughes, C., Pain, C., Braithwaite, J., & Hillman, K. (2014). ‘Between the flags’: implementing a rapid response system at scale. BMJ Qual Saf, bmjqs-2014.
Kubica, J., Adamski, P., Ostrowska, M., Sikora, J., Kubica, J. M., Sroka, W. D., & Siller-Matula, J. M. (2015). Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial. European heart journal, 37(3), 245-252.
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