SNPG962: Clinical Judgement and Reasoning
SCHOOL OF NURSING
FACULTY OF SCIENCE, MEDICINE & HEALTH
|Assessment 2||Case study video and report|
|Type of Collaboration||Individual Assessment|
|Length||10 minute video AND a 1,500 word written report|
|The objective of this assessment is to relate the process of clinical assessment to the|
delivery of patient care by selecting and implementing appropriate assessment techniques and demonstrating clinical judgment.
You will need to record yourself carry out a 10 minute focused health assessment of your case study patient. A focused health assessment concentrates on a specific area of concern, for example if a patient is breathless, then your assessment should include a respiratory/cardiovascular assessment.
Your case study outline will include a number of findings and a health history that will assist you in further discussing your case study patient and responding to the questions listed below. You will need to refer to literature to support findings, nursing interventions and further recommendations.
Your case study submission should include the following:
|Style and format||Case study report|
|Subject Learning Outcomes|
1. Demonstrate clinical judgment through the overt association connecting health history, assessment and nursing care
Relate the processes of clinical assessment to the delivery of patient care, by selecting and implementing appropriate assessment techniques
Analysis of Findings
Mr. George seems to be a clear case of acute myocardial infarction that is a common cause of death in Australia. The majority of patients that die get medical attention much after they have developed ventricular fibrillation. This makes it necessary to look and report acute signs of myocardial infarction immediately and provide proper medical attention to prevent sudden death of the patient. Here the triage nurse and nursing practitioner play a key role in initial diagnosis and start of proper treatment for reducing the size of myocardial infarct focused on drug therapy as well as timely tests and checks through physical assessment, blood pathology testing, ECG, etc (Frangogiannis, 2015).
It is to be noted that acute myocardial infarction (MI) is commonly known as a “heart attack” resulting in death of heart muscle. It results out of a complete or partial blockage of a coronary artery that reduces the supply of blood to the heart cells supplied by the blocked or necrotic coronary artery (Sweis, 2018). It is the amount of blockage in the artery that identifies the extent of the cardiac damage.
Triage nurse is responsible for taking a brief, targeted and initial history while making and assessment of current or past history of any coronary bypass graft CCABG), PCI, Coronary Artery Disease (CAD), angina on effort or MI. the nurse is also responsible for check for any risk factors like smoking, hypertension, diabetes mellitus etc. while making a physical examination to confirm the condition (Frangogiannis, 2015). The regular and recent medications used should be checked and the signs of radiating pain in neck, jaw, shoulder, back, or 1 or both arms are considered and identified while conducting a physical examination of George. The radiating pain along with the intensity of 9/10 that is being reported since long indicates towards acute MI (Malik et al., 2013)
Further, the initial physical examination should be focused on looking for the severity of chest pain or epigastric pain to sense is its non-traumatic in origin, with components typical of myocardial ischemia or AMI. The patients need to be checked of any dyspnea, nausea or vomiting and associated diaphoresis. Such signs or symptoms become the key reason of obtaining vital signs and a stat ECG for further diagnosis of the condition (Scruth et al., 2012).
Considering the required areas of check it is clear that George has a history of high blood pressure and high cholesterol and fasting triglycerides. The suggestions made by the GP for lifestyle changes along with George being overweight are alarming for his heart condition. Furthermore, the complaints of nausea and pain and other symptoms like anxiety, palpitation, and weakness are clear signs of clinical manifestations associated with a heart attack.
There are certain principles or steps to be considered while giving immediate treatment for suspected acute myocardial infarction that includes aspirin, oxygen, and sublingual glycerol trinitrate (GTN). The rationale of pharmacological treatment of myocardial infarction is to improve myocardial oxygen/supply demand ratio, management of pain, control of heart rhythm and inhibit cardiac remodelling (Sweis, 2018). The nursing practitioner is responsible for improving the oxygen supply/demand ration and managing pain along with continuous monitoring and management of the case.
While planning and giving the immediate treatment certain tests should also be conducted that is properly undertaken by the RN. Laboratory tests are also called cardiac biomarkers focused on diagnosis of AMI including creatine kinase- MB or CK-MB, myoglobin and Troponin T or I (Scruth et al., 2012). These are necessary to understand the exact situation and define future course of medication and care for the patient.
Along with these immediate medications, certain pain reliefs are also required that should be given through IV and muscle injections must be avoided. It is to be noted that pain management is a key consideration as pain is directly associated with anxiety that can prove to be deleterious to the heart. However, morphine also has a beneficial effect of working as a vasodilator (Frangogiannis, 2015).
Such initial action aims to decrease the degree of myocardial damage by reducing the consumption of myocardial oxygen and dissolution of the thrombus for restoration of the coronary blood flow (Edwards, 2002). The focus of such a treatment is on early relief while ensuring that the patient is in an atmosphere of possible defibrillation and decreasing the size of the possible infarct by re-opening of the occluded coronary artery (Deatin et al., 2017).
As the initial treatment to patients with a suspected myocardial infarction, aspirin should be given as a powerful antiplatelet drug effecting in a rapid manner thereby reducing the mortality by 20% (Sweis, 2018). The nursing practitioner was right in advising the patient to take aspirin and in such a case there is no need to wait for ECG.
Another key step is to focus on pain relief for the patient during administration of thrombolytic therapy or any other drugs. Here, intravenous morphine titrated slowly will help Mr. George in getting adequate relief. Also it is important to monitor the effect of morphine on BP and respiratory rate to understand the cardiovascular response to the drug.
The role of sublingual GTN is to reduce the myocardial oxygen consumption by lowering the heart rate, blood pressure and cardiac filling pressures. So it was immediately required for George to ensure initial relief and prevent loss of life. The successful management of the condition depends on proper care and timely shifting of patient to cardiac catheterization (cath) lab for undergoing PCI on an emergency basis. This is procedure where coronary arteries are reopened mechanically using a balloon and the placement of a stent in the blocked arteries (Scruth et al., 2012 and Edwards, 2002). The patients with symptoms of acute myocardial infarction are given PCI as the first line of therapy.
However, as Mr. George’s ECH showed ST elevation in leads V3 and V4 and pathology results also showed moderately raised troponin I and T, he must be given the fibrinolysis therapy, i.e. clot-busting drugs where three options of on-going patient management can be followed including rescue PCI, pharmacoinvasive PCI or other PCI.
The RN then shifted the patient to coronary catheter laboratory for a primary PCI, where he proceeded to have coronary angioplasty. The therapy is effective in securing and maintaining coronary artery patency for avoiding the risk of bleeding fibrinolysis (Deaton et al., 2017). The importance and success of primary angioplasty for infarction patients is universally accepted and therefore George received the appropriate treatment in a timely manner due to proper steps taken by the RN and adhering to the nurse intervention protocols associated with the condition.
Proper nursing support can reduce the risk of a new cardiac event and ensure proper rehabilitation of the patient through education, support, supervision and reinforcement. It is important to focus on patient care and support to improve their satisfaction, lower levels of anxiety and depression, ensuring high compliance level for treatment and improve the overall quality of life of the patient as well as their family members (Deaton et al., 2017).
Post treatment care should be focused on management of specific in-hospital complications like deep vein thrombosis and pulmonary embolism, interaventricular thrombus and pericarditis. Any such condition should be reported immediately and this is possible through continuous monitoring and regular check-ups based on risk factors (Deaton et al., 2017). Adhering to clinical frameworks defining pre and post hospitalization care is necessary to ensure early and healthy discharge of the patient without any further complications.
Also RN is responsible for rehabilitation care aiming to restore the patient to as full a life as possible. Here the focus should be on managing physical, psychological and socio-economic factors taking care of to start the process soon after the recovery and continued in the succeeding weeks (Edwards, 2002). Here lifestyle changes and advice related to healthy diet, weight control and exercise should be suggested to George. Moreover, it is important to control anxiety of patients as well as their family members making it important to help George and his wife to be more aware of the situation and adopt healthy lifestyle, proper medication and regular check-ups to avoid any frequent occurrence of depression and irritability after return home. It is also to be considered that denial is common in such acute cases and RN is responsible to ensure that there is no influence of the situation or treatment on the personality of the patient thereby reducing any emotional distress through rehabilitation programme.
Apart from this, George and his wife needs to be educated about keeping a check of any reoccurrence symptoms like chest pain, shoulder pain, vomiting, nausea or any other discomfort that should be reported immediately to the RN. Therefore, it is important that nurse practitioners deliver qualitative care to patients by considering evidence-based standards of care right from the patient’s reporting of any discomfort or pain that can be an early sign of acute myocardial infarction.