Nursing Assessment - Emergency Care Strategies

Nursing Assessment

Case Scenario/ Task

1. Outline the CAUSES, INCIDENCE AND RISK FACTORS of the identified condition and how it can impact on the patient and family

Cause/risks of disease needs to be focused on what the patient has presented with

The incidence of the disease needs to be as current as possible, and based in Australia. Using other stats will mean you will lose marks

Impact on family MUST be linked back to the patient you have chosen. If there is no link it is not a case study

Refrain from listing, as we are looking for you to provide a rationale for all your answers

Financial impact as evidenced by increased acuity leading to sick leave and no income etc

2. List FIVE (5) COMMON SIGNS AND SYMPTOMS of the identified condition; for each provide a link to the underlying pathophysiology

This can be done in the form of a table – each point needs to be appropriately referenced

The signs and symptoms can be taken from those listed in the case study, or you will find more relevant ones when completing your research

As long as you are able to link it back to the patho of the current patient condition and explain why you have chosen it that is fine

Pathophysiology needs to be in depth and at the cell level where possible

3. Describe TWO (2) COMMON CLASSES OF DRUGS used for patients with the identified condition including physiological effect of each class on the body

This does not mean specific drugs but rather the class that these drugs belong to.

The drug classes chosen can be from the case study or what you think may be used to manage the patient's condition

Need to include drug CLASSES, not specific drug names, or broad types

Loop diuretics - CORRECT. Diuretics - INCORRECT. Frusemide - INCORRECT. All diuretics have a different mechanism of action, so stating diuretics is not acceptable

You need to explain how each drug class works at the cell level where possible, and LINK it back to the patient in the case study. Why are these drugs indicated for the patient?

4. Identify and explain, in order of priority the NURSING CARE STRATEGIES you, as the registered nurse, should use within the first 24 hours post admission for this patient

• PRIORITISE your care - if it helps, number it
• Every nursing care priority must include a rationale as to why it needs to be done
• This includes nursing care, not medical management. For example, if you think that a patient may need thrombolytics but are not ordered this, phrase it in a way that links it back to nursing. What are your nursing considerations in this case then?
• The parameters are in the first 24 hours only which will help you narrow your care
• We prefer less considerations with more rationale, than you including a list, i.e. 8-10 would be sufficient as long as you can rationalise your care

As per the case study, Mr. Tupa has experienced acute chest pain. His ECG reports indicate that he is having ST elevated myocardial infraction (STEMI). He is also having a history of mitral valve stenosis along with stable angina. It is a serious life threatening situation which needs immediate attention without any delay. Complete occlusion of epi-cardial coronary vessel due to formation of thrombus is the main cause behind occurrence of STEMI. The main cause of STEMI is acute ischemia. Other causes could be angina, acute, mitral valve prolapse, pericarditis, neurologic events, cardiac aneurysm, early repolarization (Tikkanen, 2009). Mr. Tupa is already suffering from various cardiac problems that is the reason that chances of STEMI has increased by many folds.

The incidence rate of acute myocardial infraction has increased world widely particularly in high income countries such as Australia. The country has witnessed higher mortality rate associated with the disease. STEMI related incidence rate is 70 cases per 100,000 person years (Wong et al, 2013). MI incidence rate is significantly associated with age which means that rate increases with age. More number of cases have been noted among older age group. Gender wise analysis depicts equal incidence rate of MI (Heart Foundation, 2014).

There are two types of risk factors affecting a patient’s condition – behavioral and clinical. The behavioral risk factors include smoking, drinking, physical activity while clinical factors are obesity, blood pressure and cholesterol. Co morbid risk factors also contribute for higher mortality associated with cardiac problems. As mentioned in the case study, Mr. Tupa is a social drinker but he has quitted smoking from last six months. Vital signs show high blood pressure and obesity. All putting him at higher risk of MI.

Illness can put mental pressure on patient and care givers as well. Prolonged hospitalization disrupts daily routine of care givers. It leads for financial damage and psychological damage. Care givers involved in patient care lose their earning working hours and feel pressurized due to the patient’s health status. One important point is that care givers need proper information pertaining to medical treatment, emotional support etc. They should be given proper education so that they can comprehend the situation in the right manner. Prolonged hospital stay hampers their daily routine activities. Huge money is invested for acute care that usually lasts for couple of weeks. It negatively impact their social behavior.

2. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology

3.Describe two common classes of drugs used for patients with the identified condition including physiological effect of each class on the body (350 words)

Antiplatelet agents

This particular class of drugs has been developed to treat congestive heart failure problems. These drugs have become the preferred choice for treatment of MI. Antiplatelet drugs can be classified into various types depending upon their mechanism of action such as COX-1 inhibitors, ADP antagonists, phosphodiestherase etc. The mechanism of action of this particular drug is quite complex comparatively. Antiplatelet agents show antithrombotic activity and are used to prevent cardiovascular events. These agents are involved in inhibition of pathway leading for platelet activation. Antiplatelet agents affects arachidonate–thromboxane A₂ and adenosine diphosphate (ADP) pathways. Platelet cyclooxygenase is a key enzyme for generation of thromboxane A2 which is responsible for activation of platelets. Antiplatelet agents directly disrupt function of platelet cyclooxygenase and further prevent generation of arachidonate–thromboxane A_2. These agents also prevent activity of cyclic GMP phosphodiesterase and inhibit adenosine uptake. Antiplatelet agents can sometime cause allergy, hypersensitivity, bleeding, and hypertension if not given under strict observation.

Antiplatelet agents could be quite effective for Mr. Tupa who is experiencing acute chest pain along with high BP, elevated cholesterol and irregular heartbeat. Patient is having history of angina and mitral valve stenosis. ECG results depict ST elevated MI which needs immediate care and medication. Mr. Tupa has been administered with sublingual glyceryl followed by morphine to control chest pain. Looking at the vital signs, antiplatelet agents could provide instant relief and can reduce complications at larger extent (Wright et al, 2011).

Beta blockers

Beta blockers stimulate adrenergic receptors which are involved in cardiac action. These are responsible to reduce BP, treatment of angina, controlling heart beat etc. Beta blockers are known as beta adrenergic blocking agents. Theses blockers bind to beta adrenoceptors and prevent binding of epinephrine and norepinephrine. The process happens within cardiac nodal tissue region. Beta adrenoceptors are linked with Gs proteins which in turn increase heart rate. Gs proteins activates formation of c-AMP from ATP by stimulating adenylyl cyclase enzyme.

Beta blockers can be adopted as an important therapy line for the patient as it is able to control heart rate, BP, relaxation rate etc. It is a good alternative to reduce the chances of mortality which is very common with ST elevated MI. Mr. Tupa can be recommended one of the drugs related to this category. Associated risk factors have increased the seriousness of the disease so these agents can fight against effectively (Kezerashvilli, Marzo & Leon, 2012).

Nitrates

Nitrates are responsible for dilation of coronary vessels which increase the oxygen supply to heart muscles. They are also known as nitro vasodilator. This particular class has a direct impact on vascular smooth muscles. They have also an effect on central nervous system but few studies are available to find out the actual reason behind the phenomenon. Nitrates provide NO by undergoing a reduction reaction. NO stimulates guanylate cyclase within cardiac smooth muscle cells. This enzyme converts GTP into c-GMP that activates cyclic nucleotide dependent protein. This protein activates other protein involved in decreasing calcium concentration which leads for muscle relaxation and widening of blood vessels (Ferreira & Mochly-Rosen, 2012).

4. Identify and explain, in order of priority the nursing care strategies you, as the registered nurse, should use within the first 24 hours post admission for this patient (500 words).

Nursing strategies within first 24 hours could be divided as per the following –

• High priority strategy
• Medium priority strategy
• Low priority strategy

Patient positioning- The nursing care of plan will include about the patient positioning which is very important to manage. They will adhere to the following tasks- keep patient’s neck slightly in extended position, provide oxygen therapy immediately etc. (McMurray, Pfeffer, 2011). It can be rationalized by stating that the above strategy would assist to reduce the acute pain and manage the situation effectively within 24 hours. Hence it would be considered as high priority nursing care. Extended position is important for proper blood supply (Gabriel et al, 2012).

Assessment of vital signs – Nurses will assess all the vital signs to decide about the therapy line. They will report to the medical team to get approval for the effective therapy such as thrombolytics treatment.

Drug monitoring - Patient is experiencing acute chest pain that could be the reason behind shortness of breath. Hence morphine treatment is essential and required for pain management. So nurses will ensure that the patient has been administered the medicines on time without any hindrance. They will also monitor for any sign and symptom after the administration. If in case of any adverse reaction, nurses will immediately report to the medical personnel involved in care and treatment. This will become high priority for the management team because alveoli are collapsing due to shortness of breath (Gabriel et al, 2012).

Pulse monitoring - Restoration of normal health condition by maintaining quality of life would be at high priority followed by prevention of further serious complications. The nursing plan of care would include continuous monitoring of pulse through oximetry and use of nasal cannula if shortness of breathing continues for few hours.

Rational – The above strategy would be counted as high priority because managing longer refill time is an abnormal sign for more complex cardiac problem and condition worsens if not treated on time. Nursing staff on duty will do regular follow up for next few couple of hours by measuring oxygen supply, administration of medications, and other supplies (Gabriel et al, 2012).

As such there is no difference between medium and low priority level strategy but patient would be monitored and observed for any bleeding if happens at any point of time. This would be considered as medium priority strategy as this does not give rise to life threatening situation (McManus et al, 2010).

Fluid requirement and glucose monitoring - Nursing plan would include continuous support and observation for any requirement, for example – thirst, urination, stress, anxiety etc.

Rational - This would be conducted as medium priority strategy as this does not cause any harmful effect (McManus et al, 2010). Overall, the mentioned factors are important to take care of as stress could hamper the treatment process. Drugs are not effective if patient is under heavy stress which is quite natural under such circumstances. Another medium priority strategy is to keep a track of blood glucose level regularly as it can worsen the situation further. This could an important aspect of care for those who are suffering from high blood glucose level. So for diabetic patient it would become a medium to high priority nursing strategy (McManus et al, 2010).

Providing supportive environment to the patient and his family members would be an important nursing strategy. Nurses are responsible to motivate the patient to take medications properly. This will assist to produce positive outcome of the current treatment. Care givers also require proper information and want to know about the patient’s health condition. Hence a nurse will analyze the medical report and share it with them in their language.