NURS2164 Introduction To Acute Specialty Nursing

Consider pt. situation

Mr. Anderson, aged 76 years, was admitted to the emergency department of the hospital with suspected unprovoked angina. Initial observation showed that he is suffering from fatigue, occasional palpitations and progressive bilateral lower extremity oedema (Source: Records in emergency department).

Collect cue/information

Review

Mr. Anderson reported that he is suffering from the extreme fatigue associated with occasional palpitations and progressive bilateral lower extremity oedema (as per the statement recorded by the patient).

Table: Standard Adult General Observation (SAGO) Chart of Mr. Anderson

https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/RPA-observations-policy-directive.pdf

Figure: ECG report of Mr. Anderson taken within 5 minutes upon arrival to the Emergency Department

Patient Is Having An Myocardial Infarction, S-T Elevation Mi

Can You Please Talk About That Instead Of Cholestrol

Table: Blood Test Report of Mr. Anderson done after his admission in the Emergency Department

Previous Nursing and Medical Results

On June 2016, he has been diagnosed with Gastro Oesophageal Reflux Disease (GORD). The only medication that we used to take is Nexium (Esomeprazole) 20mg once a day for 4 weeks (Source: Previous medical reports of the patient). However, after taking the medication for the 4 weeks, Mr. Anderson did not return to the doctor for further consultation (as per patient’s record). Mr. Anderson has a previous medical history of upper epigastric pain (Source: previous medical reports and prescription).

Gather new information

• Airway: Patient can talk (airway is patent) (source: emergency dept)
• Breathing: Normal (source: emergency dept)
• Circulation: 160/90 blood pressure (source: daily check up)
• Disability: None
• Exposure: NA

Recall knowledge

Don’T Worry About Writing Anything In Recall Knowledge, I Will Write About It

Process information

Interpret

Understanding of signs and symptoms

Compare normal vs abnormal

The ECG report of the patient indicated that he is having Myocardial Infarction (MI) due to ST elevation the presence of MI is leading to his unprovoked angina (Jneid et al., 2012). During his admission he complained about extreme fatigue associated with occasional palpitations and progressive bilateral lower extremity oedema. All these symptoms are indications towards MI (Thygesen et al., 2012)

Current signs and symptoms

The blood test showed that Mr. Anderson has high level of total cholesterol, common phenomenon at his age. However, extremely concentration of LDL (bad cholesterol) gives an alarming sign. LDL is bad cholesterol which remains unused and the liver fail to utilize or break this cholesterol (Tousoulis, Papageorgiou, Charakida, Siama, &Tsioufis, 2013). The unused cholesterol gets deposited in the arteries of the heart leading to the generation of arthrosclerosis (hardening of the arteries) and the outcome is angina (chest pain) (Nichols, 2013). It is due the presence of high cholesterol in blood; Mr. Anderson is suffering from extreme fatigue (Six, et al., 2013). His heart is failing to pump out adequate blood in the distant section of the body (hardening of the arteries decreases the efficiency of the heart). This lack of blood transport is decreasing the oxygen content, leading to fatigue (Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014).

Discriminate

Identify relevant and irrelevant information

The relevant information that has been recorded so far in case of Mr. Anderson is, he has high level of blood cholesterol, with extremely high level of LDL that gives the indication towards atherosclerosis, the reason behind coronary heart disease (angina) (Tousoulis, Papageorgiou, Charakida, Siama, & Tsioufis, 2013). Irrelevant information in case of Mr. Anderson is, he has low level of magnesium in blood and high levels of serum creatinine.

Recognise inconsistent information

Hypomagnesium shows that Mr. Anderson still suffers from GORD. Problem in the stomach or in the bowel interferes with the absorption of the Magnesium into the cell leading to hypomagnesium (low level of magnesium in blood and hence, electrolyte imbalance). The used magnesium is excreted out of kidneys. On the other hand, high level of creatinine in the blood serum indicated defect in renal function which may be cited as another cause of hypomagnesium(Sakaguchi, 2014).

Prioritise the most important information

Mr. Anderson has permissible level of HDL which is a positive sign as HDL takes up the unused LDL, report them to the liver. Other important information includes:

• High level of blood cholesterol
• High level of LDL
• High blood pressure

Narrowing down information

• Patient is having
• High BP
• Normal RR
• Increased fatigue
• Occasional Palpitation
• Progressive bilateral lower extremity

Gaps in the information

There are no clear indication of the prevalence of his prior GORD disease (no endoscopy has been conducted so far) and new occurrence of kidney problem (no proper kidney/liver function test)

Relation

Mr. Anderson has high level of blood cholesterol (as per the blood test report) and this high cholesterol is attributed due to high levels of LDL (Six, et al., 2013). Extra LDL is not absorbed in the kidneys and is deposited in the arteries in the form of waxy deposits, plaques. Plagues clog the arteries, disturbing the elasticity (Rapsomaniki, et al., 2014). This causes hardening of the arteries; preventing normal blood flow, impart stress in heart to pump more blood, causing chest pain or angina. Mr. Anderson is also experiencing progressive bilateral lower extremity oedema which another principal sign of heart disease of chest pain (Six, et al., 2013). Oedema is characterised as excessive accumulation of watery fluid in the tissues or the cavities of the body. Oedema also occurs due to renal malfunction due to abnormal salt retention (Shlipak, Matsushita, Ärnlöv, Inker, Katz, Polkinghorne&Levey, 2013).

Inference

The interpretation, discrimination and relation of the symptoms and the condition of Mr. Anderson analysed so far lead to the inference that, Mr. Anderson is suffering from angina arising out of increasing in the blood cholesterol level (Rapsomaniki, et al., 2014). This chest pain might be the cause of coronary heart disease or ischemic heart disease. In adverse condition, coronary heart disease may lead to heart failure or sudden cardiac arrest (Six, et al., 2013).

His previous medical complication GORD might have got cured but the low level of magnesium in the blood contradict that statement (Thrift, 2013).

Matching

Mr. Anderson with a past medical history of upper epigastric pain and GORD has been admitted in the hospital with unprovoked angina. The ECG report, high blood pressure (hypertension) and high level of total cholesterol and LDL in blood provided indication towards the arthrosclerosis leading to chest pain of Angina (Rapsomaniki, et al., 2014). His chest pain might also be due to the excessive smoking (Mr. Anderson smokes 15 cigarettes per day). A high degree of chain smoking leads to the blockage of the pulmonary arteries and vesicles which may lead to chest pain and then subsequent fatigue. Chain smoking also has a direct connection with the cardiovascular disease (Messner& Bernhard, 2014). On the other hand, progressive bilateral further proves the existence of certain cardiac problems. The evidence towards the kidney problem is reflected via high level of serum creatinine (Shlipak, Matsushita, Ärnlöv, Inker, Katz, Polkinghorne&Levey, 2013). However, Mr. Anderson has normal level of urea, something unusual with the kidney problem (Shlipak, Matsushita, Ärnlöv, Inker, Katz, Polkinghorne&Levey, 2013).

Prediction

The prediction of the clinical case study of Mr. Anderson is suffering from cardiac problems and from this, he is encountering chest pain. The cardiac problem is basically due to high levels of cholesterol in blood (Rapsomaniki, et al., 2014). This extra cholesterol is getting deposited over the cardiac arteries, leading to its hardening and then chest pain (Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014). Due to cardiac problem only, Mr. Anderson is suffering from extreme fatigue and palpitations. The body is not getting adequate oxygen in blood and hence, there occurring lack of ATP in the cells and the outcome is fatigue. The outcome o this chest pain may be coronary heart disease or ischemic heart disease that may lead to sudden heart attack and myocardial infarction (Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014).

The fluid intake of Mr. Anderson must be restricted in order to deal with the oedema because extra fluid intake might change the oedema into a fatal condition as it is in a progressive state (Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014).

Identify Problems/issues

Mr. Anderson has high cholesterol level in blood along with high blood pressure and thus might be suffering from Arthrosclerosis leading to coronary heart disease or ischemic heart disease that may cause sudden heart attack and myocardial infarction (Eckhardt, DeVon, Piano, Ryan, & Zerwic, 2014).

The most alarming and urgent issue that must be taken into consideration into an immediate basis is high concentration of LDL (bad cholesterol). LDL remains unused and the liver fails to utilize or break this cholesterol. This unused cholesterol gets deposited in the arteries of the heart causing arthrosclerosis (hardening of the arteries) and the outcome is angina (chest pain) and fatigue (Rapsomaniki, et al., 2014). The heart fails to pump out adequate blood in the distant section of the body causing decreasing the oxygen content, leading to fatigue (Eckhardt, DeVon, Piano, Ryan, & Zerwic, 2014).The ECG report showed ST-elevation which indicated MI (Jneid et al., 2012).

Establishment of Goals

In order to improve the overall condition of Mr. Anderson, I want do perfrom certain basic physiological step

1. Measure his oxygen saturation in order to know his reason of fatigue (Chen et al., 2012) (Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014)
2. Limit his water intake in order to check the progressive bilateral lower extremity oedema (Meeus, Goubert, De Backer, Struyf, Hermans, Coppieters&Calders, 2013)
3. Check is respiration rate as he is experiencing extreme fatigue and is refusing to step outside the bed (Meeus, Goubert, De Backer, Struyf, Hermans, Coppieters&Calders, 2013).

Please also mention about a time frame for goals

ECG shows he is having MI therefore; the goals would be different and vary according to that

ECO cardiogram should be done to verify if it is actually an MI

Please also talk about establishing goals regarding his cholesterol levels and blood pressureinterventions

SMART goals

• Specific: Conduct the Echo cardiogram of heart analyse the present image of heart
• Measurable: Echo cardiogram will help to identity the severity of the plaque deposition
• Achievable: Echo cardiogram will be easy to perform
• Realistic: The goal of conducting Echo cardiogram is realistic because it will help in the process of proper disease diagnosis (Rapsomaniki, et al., 2014)
• Timely: Echo cardiogram must be done in an urgent basis

Action Plan

Mr. Anderson is refusing to step outside the bed as he is complaining of extreme fatigue. It is the duty of the nurse to ring the doctor to get further advise

an order to put him under through monitor machine to get a live feed of the heart rate, respiratory rate and oxygen saturation

The attending registered nursemust also tell doctor to give orders for Echo cardiogram, endoscopy and kidney function test. Echo cardiogram will provide images of the heart via using standard two dimensional, three dimensional and Doppler ultrasound techniques (Donofrio, Moon-Grady, Hornberger, Copel, Sklansky, Abuhamad&Lacey, 2014). Endoscopy will give the actual picture of the oesophagus (Shaheen, Weinberg, Denberg, Chou, Qaseem, &Shekelle, 2012).

Evaluation

Till now there is no improvement in patient condition has he has refused to step out of the bed due to extreme fatigue. The nurse needs to keep a look at his blood pressure and urine output and respiratory rate (Gottlieb, Stebbins, Voors, Hasselblad, Ezekowitz, Califf& Hernandez, 2013).

You can also mention about keeping him on ECG monitor machine until further investigation has not been done.

Reflection on the learning process

If I encounter with this kind of similar situation again, I will definitely not have the same feeling of anxiety and apprehension. Moreover, Iwillconfirm that the echo cardiogram and kidney function test done on time. I will also keep an hourly record of the oxygen saturation, respiratory rate and urine output. Additionally, I will communicate with the patient in order to know if he/she is experiencing any level of distress or discomfort. Communication is the core to deliver the best quality nursing and at the same time, it helps in minimising initial apprehension (Riley, 2015).

References:

Boekholdt, S. M., Arsenault, B. J., Mora, S., Pedersen, T. R., LaRosa, J. C., Nestel, P. J., … & DeMicco, D. A. (2012). Association of LDL cholesterol, non–HDL cholesterol, and apolipoprotein B levels with risk of cardiovascular events among patients treated with statins: a meta-analysis. Jama, 307(12), 1302-1309.

Boutten, A., Bargnoux, A. S., Carlier, M. C., Delanaye, P., Rozet, E., Delatour, V., … & Piéroni, L. (2013). Enzymatic but not compensated Jaffe methods reach the desirable specifications of NKDEP at normal levels of creatinine. Results of the French multicentric evaluation. Clinica chimica acta, 419, 132-135.

Brisco, M. A., Coca, S. G., Chen, J., Owens, A. T., McCauley, B. D., Kimmel, S. E., & Testani, J. M. (2013). The Blood Urea Nitrogen to Creatinine Ratio Identifies a High Risk but Potentially Reversible Form of Renal Dysfunction in Patients with Decompensated Heart Failure. Circulation: Heart Failure, CIRCHEARTFAILURE-112.

Haibo, Z., Jinzhong, L., Yan, L., & Xu, M. (2012). Low-intensity international normalized ratio (INR) oral anticoagulant therapy in Chinese patients with mechanical heart valve prostheses. Cell biochemistry and biophysics, 62(1), 147-151.

Jneid, H., Anderson, J. L., Wright, R. S., Adams, C. D., Bridges, C. R., Casey, D. E., … & Peterson, E. D. (2012). 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update). Circulation, CIR-0b013e318256f1e0.

Shay, C. M., Van Horn, L., Stamler, J., Dyer, A. R., Brown, I. J., Chan, Q., … & Elliott, P. (2012). Food and nutrient intakes and their associations with lower BMI in middle-aged US adults: the International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP). The American journal of clinical nutrition, ajcn-025056.

Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., White, H. D., … & White, H. D. (2012). Third universal definition of myocardial infarction. European heart journal, 33(20), 2551-2567.