Nur 103 : Clinical Judgment Assessment Answers

Answer:

Sequencing of proposed structure:

In order to complete a research and answer the research questions it is important to identify the appropriate method. There are various qualitative and quantitative study method that are helpful to complete a research effectively. Research based on social element such as health is most important in nursing profession as it helps to find out the pathophysiology of various diseases, clinical manifestation, health assessment and relevant strategies regarding prevention and treatment (Ritchie et al., 2013). In this regards the qualitative method such as case study has been found to be one of the most applicable study method as it play significant role in order to process various social research. It helps to describe a specific situation and helps to introduce proper investigation and in-depth research related to the clinical incident (Lewis, 2015). Thus, the assignment aims to elaborate clinical ideas based on cardiac issues provided by a case study. It will provide focus on the significant clinical areas, pathophysiology, assessment and nursing interventions related to the health condition of the patient in the case study.

The case study is about a 64 years old women, Rainey who was married and had two daughters. She had a family history of cardiac issues such as heart attack and stroke. She had been living sedentary lifestyle and her diet was full of fat and sugar. At first the client was presented to the GP due to the occurrence of the symptoms of flu. Only high BP was identified by the GP thus, she was not provided any antibiotics and recommended for further tests to identify main issue.  After few days, further test for BP and cholesterol was done and the GP had recommended to modify her lifestyle. After 3 months, Rainey was found to be lying on the lawn and she was complaining chest pain radiating to neck and jaw, thus she was hospitalized and admitted to the emergency department. Different assessment such as PORST, vital sign and pain assessment. She had reported that her pain was provoked by exercise which rated 9 in the pain scale and it was lasted for more than 5 minutes. Further tests such as ECG and blood test for serum markers had been recommended and she was given oxygen therapy, IV cannulas and effective medication. She was diagnosed with ST segment elevation myocardial infarction. However, due to the uncertainty of onset time of symptoms she was not provided fibrinolytic therapy. She was provided coronary balloon angioplasty and stent was inserted through the puncture of right groin. After that she was transferred to medical ward and further assessment and monitoring had been provided for faster recovery.

Coronary syndromes are classified based on the presence and absence of ST elevation in the ECG report during hospitalization. ST segment is defined as the isoelectric section in the ECG between the end of S wave and Starting of T wave. The presence of ST elevation indicates the interval between the depolarization and repolarization of ventricles. In case of elevation or depression of the ST segment leads to the consequence of myocardial infraction or ischaemia (O'Gara et al., 2013). The risk factors include pericarditis, acute cardiac issues, age, smoking, obesity, improper diet and psychological distress as well. The symptoms include chest pain, pain radiating to the neck, jaw, shoulder and arms and clenching over sternum. Other common symptoms include nausea, sweating, fainting, shortness of breath, pulmonary edema, palpitation and in severe cases it may lead to death (Lin et al., 2013). More than 30% people have been found to suffer from the symptoms of myocardial infraction across the world (Durak, Kudaiberdieva & Gorenek, 2015). Thus it has become a major concern for health system. Hence, it is important to identify the cause, diagnosis, prevention and treatment of the illness in order to improve the health outcomes in an effective manner. In this regards the paper will provide information about some specific pathophysiology, health assessment and treatment of cardiac issue such as myocardial infraction via discussing the clinical situation in the case study.

Questions asked to identify the health history and complete the proposed assessment:

Identify and understand the health history of the patient is one of the main purpose in order to carry out the proposed assessment. The method of taking health history has been introduced in order to recognize the important factors and determinants that have contributed to the development of health complications of the patient. The major elements of health history consist information about present and past health issues, social factors, psychological factors, physical factors, medication and family health history as well. Identification of such factors help to introduce effective nursing interventions in order to address such factors to help the patient to recover faster (Pappas et al., 2017). In case of Rainey, the clinical manifestation regarding ST elevated myocardial infraction had been identified by the health care team, thus, it is required to gather information about health history in order to identify the contributing factors of the health complication. The following paper will elaborate the questions that are important to ask to the patient in order to collect data regarding health history and complete the proposed assessment.

Baseline data:

Name of the patient.
Contact number and address of the patient.
Age of the patient.
The marital status of the patient.
Occupation of the patient.

The base line data collection regarding the general information about the patient is important as it helps to collect personal information of the patient and keep the record in the hospital record book for further use during the time of need (Pappas et al., 2017).

Data for present health condition:

• What kind of health issues you are facing?
• What is the onset time of the symptoms?
• How long you are suffering from such symptoms?
• Do you suffering from fever?
• Do you have sweating, nausea and vomiting?
• How long you are suffering from chest pain?
• Do you have pain in other body parts?
• How long the pain lasts?

Such information collected through the questions could help to recognize the current health issues of the patient and identify the priority areas of care for the patient. Through identifying the current health issues the health professional could initiate adequate treatment in order to address the issues and help the patient to achieve desired health outcomes (Forbes & Watt, 2015).

Data of past health history:

• Did you suffer from flu in past?
• If yes, what was the onset time?
• Do you have history of cardiac issue?
• If yes, do you admitted to hospital for cardiac issue?
• Do you have history of other chronic diseases?
• Do you have diabetes?
• Do you ever suffer from any health complication during exercise or due to exercise?

Such questions could help the health professional to identify if there is any past health issue that have contributed to the development of current health complications (Pappas et al., 2017).

Data regarding medical history:

• What medication do you take for the suffering from flu?
• Do you administer any antibiotics during flu?
• Do you administer any medication to relief your pain?
• Do you have allergy to any drug or food?
• If yes, what adverse reaction occurs?

Such data regarding the medication could help the health professional to recognize whether the current clinical situation is influenced by any improper medication and information regarding the allergy against food and drugs could help the health professional to avoid such drugs and food element during the treatment session to avoid adverse drug reaction or medication error (Brown,  Sandhu & Herrmann, 2015).

Data regarding social history:

• Are you addicted to any substance?
• What is your dietary habit?
• Are you vegetarian or non-vegetarian?
• Do you maintain healthy diet such as proper amount of carbohydrate, fat, proteins, vitamins and minerals?
• Do you perform physical activities?
• What exercise do you perform daily?
• Have you exposed to people suffering from flu?

Information regarding such social history could help the health professional to identify the social factors that have contributed to the development of current health complications. Furthermore, the health professional could recognize that if the chest pain or pain in other body parts has occurred due to improper exercise or physical activities (Forbes & Watt, 2015).

Data regarding family history:

• There are how many members in your family?
• Is there any family history of cardiac issue such as heart attack or stroke?
• Have anyone from your family died due to cardiac issue?

Such health history regarding the family members of the patient could help the health professionals to recognize the contribution of genetic factors in the development of current health issues of the patient (Pappas et al., 2017).

Data from health assessment:

• BP: 165/100
• BMI: 31 kg/ m²
• Serum cholesterol: 7.2 mmol/L
• LDL: 6.2
• HDL: 0.7
• Fasting triglyceride: 5.9mmol/L
• Pain rate- 9/10
• ECG- ST elevation
• Serum cardiac marker: slightly depressed creatine kinase, elevated troponin.
• Diagnosed: ST elevated myocardial infraction.

Health and clinical assessment and relation with path physiology:

In this case study, Rainey who is 64 years women of Maori descent admitted to the hospital due to severe chest pain. In such situation, when chest pain reported by the patient, the most popular health assessments that were performed by the physician was the assessment of vital signs and performing the PQRST method. P refers the provoking factor or position where the pain was detected whereas Q refers to the quality of the pain (Hoffman et al., 2016). On the other hand, R refers to the areas where pain radiates where as S refers to the severity of the pain and T refers to the time. In this case study, the provoking factor observed was exercise and pain radiate further in neck and jaw. Moreover, the severity of the pain scored 9 out of 10 and it lasted for 15 minutes. . In this case study, the assessment of blood pressure was done by nurses which indicate the elevated level of blood pressure. Other tests that were performed involve serum, cholesterol level, fasting triglyceride level. Serum cholesterol level was estimated for detecting the plaque buildup in the heart. On the other hand, fasting triglyceride tests generally performed for determining the occurrence of atherosclerosis (Bittencourt et al., 2016). Assessment that should be performed when the patient reported chest pain is an electrocardiogram, blood tests, Chest, and computerized tomography. Electrocardiogram used for indication of heart. Injured heart muscle generally does not give the estimation of heart attack, ECG indicates the probability of heart attack or previously occurred heart attack. Her ECG showed the elevation level of serum troponin and depressed the creatinine kinases along with the elevated level of troponin I and troponin T. Blood tests provide the estimation of leaked protein or fat in the heart. Chest x-ray allows the physician to check the condition of lungs and size, shape of heart along with the status of blood vessels. Computerized tomography helps to spot any blood clot in the centre. Since the patient has developed acute coronary syndrome, the decision was taken by a physician for undertaking a coronary balloon angioplasty.

Findings related to path physiology:

In this case study, the patient was admitted to the hospital due to severe chest pain. Her assessment report showed that she had high BP which is 160/100 and a few days later the Bp elevated to 165/ 100. The elevation level indicates that coronary arteries severing heart become narrow down due to building up fat. Her diet was mostly rich in high fat and sugar, and she was obese which further increase the risk of cardiovascular disease. Her serum cholesterol level was 7.2 mmol/l, which indicate that a higher level of serum cholesterol level than average.Moreover, her LDL level and HLD level were also abnormal as compared to the normal LDL and HDL level. She had the family history of heart attack, stock, and her parents died in the heart attack which further confirms the risk of heart attack. She complained that she felt chest pain which radiates to neck and jaw and she was experiencing ear pain for the past three months. These symptoms increase the occurrence of severe cardiac diseases.  Moreover, her ECG report confirms that slightly depressed creatine kinase. Creatine kinase may found as the consequences of diminished efflux of heart muscle into serum, and it subsequently reduced physical activity (Fordyce, Newby & Douglas, 2016). Gross level of troponin I and T indicate the occurrence of myocardial infarction since it released from the heart after the heart inflammation. An increased level of cardiac protein troponin circulates in the blood when heart muscle injured and released into the blood after nay severe heart injury (Dewey et al., 2016). Her ischemic was not immediately revised so she had a restriction of blood supply in to tissues causing the shortage of oxygen in the blood. All of the symptoms and assessment report together indicate the occurrence of myocardial infarction. The prime reason behind the development of myocardial infarction is that high level of fat and sugar was incorporated in her diet. That, in turn, increases the cholesterol level, LDL and HDL level in the heart. Moreover, she was obese in nature and cholesterol blocked the oxygen supply in her heart. Her ischemic was not revised, so she developed acute coronary syndrome and admitted to the hospital. In this severe heart condition, coronary balloon angioplasty was the choice of treatment for the patient. The balloon in coronary balloon angioplasty opens the narrowed coronary artery in the heart (Mäkikallio et al., 2016). Consequently, it will further reduce the occurrence of myocardial infarction and chest pain.

Nursing interventions:

Nursing interventions for management of chest pain in cardiac arrest involves the independent interventions which involves instructing the patient to notify the nurse at once when such pain starts. This is required since the chest pain might lead to decreased cardiac output. This in turn might play a role in stimulating the sympathetic nervous system to release excessive amounts of norepinephrine. This is responsible for elevating the aggregation of platelets in addition to the release of thromboxane A2 (Barley et al., 2014). This is a potent vasoconstrictor that is responsible for causing coronary artery spasm. This has the ability to precipitate as well as complicate, or to prolong an anginal attack. The next intervention should involve proper accession of the documents in addition to the proper documentation of the response of the patients along with effect of the medications. This process will help to provide adequate information regarding the progression of the disease. This will also help in investigation of the interventions that are being accrued out. It might also aid in pointing out the need for change in regimen of the medications. The interventions also require to identify the event of precipitation in terms of frequency, duration, along with the intensity and location of pain. This identification is significant as it helps to distinguish between the chest pain along with assessing the progression to unstable angina. The nursing interventions also require to make observations of the symptoms which are associated along with the prevailing condition like dyspnea, nausea and vomiting in addition to dizziness or palpitations. In cases of reduced cardiac output, there is a stimulation of the
sympathetic and the parasympathetic nervous system. This is responsible for causing a variety of vague sensations which for the patient might not be identified as being related to anginal episode (Foy, Liu, Davidson, Sciamanna & Leslie, 2015).

The nursing interventions are also required to evaluate the reports regarding the presence of the pain in the neck, the jaw, shoulder, arm, or hand especially on the left side of the body. In cases of cardiac arrest there are high chances that the chest pain might radiate that is the pain in most of the cases referred to be present in more superficial sites as is served by the same spinal cord nerve level. The interventions also should involve placing the patient in a state complete rest especially during the prevalence of the angina episodes. Complete rest will help to reduce the myocardial oxygen demand, which in turn will help to minimize risk of tissue injury or in case necrosis. The intervention should also involve the patient’s head to be elevated in case the patient is running short of breath. This action will help to facilitate the exchange of the gases and in turn will help reduce hypoxia which results in shortness of breath. It is also required to constantly monitor the heart rate of the patient along with monitoring the rhythm of heart beat. The patients who are suffering from an unstable angina have a tendency of increased risk of acute life-threatening dysrhythmias. This is which occur in response to ischemic changes and due to presence of excess stress. Finally the interventions must ensure to monitor the major vital signs after every 5 minutes during the occurrence of the initial heart attack. This is very important since the blood pressure might rise initially due to the sympathetic stimulation. The blood pressure again might fall in case the cardiac output is compromised. There is also a high chance of development of Tachycardia, which occurs in response to sympathetic stimulation. However this might be sustained as a compensatory response in case the cardiac output falls (Fihn et al.,  2014).

The evidence-based interventions that needs to be carried out in such conditions involve primarily making an accurate chest pain assessment. This involves using the popular method of ‘PQRST’ pain assessment. This includes assessment of the position or provoking factors, quality, radiation, severity or symptoms and finally time (Gelinas, Arbour, Michaud, Robar & Côté, 2013). This should be followed by a goal directed oxygen therapy. This is required for the patients suffering from hypoxia with less SpO2. Use of coronary vasodilators like Glyceryl Trinitrate can also be applied. The nurses might also provide the patient with anti-platelet aggregators like Aspirin. This helps to reduce the risk of thrombus formation in blood vessels. The interventions might also involve use of opioid analgesic in order to settle and relieve the pain (Kisely, Campbell, Yelland & Paydar, 2015).

References:

Barley, E. A., Walters, P., Haddad, M., Phillips, R., Achilla, E., McCrone, P., ... & Tylee, A. (2014). The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study. PLoS One, 9(6), e98704. Retrieved from: https://doi.org/10.1371/journal.pone.0098704

Bittencourt, M. S., Hulten, E. A., Murthy, V. L., Cheezum, M., Rochitte, C. E., Carli, M. F. D., & Blankstein, R. (2016). Clinical outcomes after evaluation of stable chest pain by coronary computed tomographic angiography versus usual care: a meta-analysis. Circulation: Cardiovascular Imaging, 9(4), e004419. DOI: 10.1161/CIRCIMAGING.115.004419

Brown, S. A., Sandhu, N., & Herrmann, J. (2015). Systems biology approaches to adverse drug effects: the example of cardio-oncology. Nature Reviews Clinical Oncology, 12(12), 718. Retrieved from https://www.nature.com/articles/nrclinonc.2015.168

Dewey, M., Rief, M., Martus, P., Kendziora, B., Feger, S., Dreger, H., ... & Hamm, B. (2016). Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial. bmj, 355, i5441. DOI:  https://doi.org/10.1136/bmj.i5441

Durak, I., Kudaiberdieva, G., & Gorenek, B. (2015). Prognostic implications of arrhythmias during primary percutaneous coronary interventions for ST-elevation myocardial infraction. Expert review of cardiovascular therapy, 13(1), 85-94. doi/abs/10.1586/14779072.2015.987127

Fihn, S. D., Blankenship, J. C., Alexander, K. P., Bittl, J. A., Byrne, J. G., Fletcher, B. J., ... & Naidu, S. S. (2014). 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Journal of the American College of Cardiology, 64(18), 1929-1949. DOI: 10.1016/j.jacc.2014.07.017

Forbes, H., & Watt, E. (2015). Jarvis's Physical Examination and Health Assessment. Elsevier Health Sciences. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=clZ3CwAAQBAJ&oi=fnd&pg=PP1&dq=importancxe+of+health+history+taking&ots=7SoTR_nY77&sig=3aMeUM-p0G0T7e3Qfnx-y6xTLWo#v=onepage&q=importancxe%20of%20health%20history%20taking&f=false

Fordyce, C. B., Newby, D. E., & Douglas, P. S. (2016). Diagnostic strategies for the evaluation of chest pain: clinical implications from SCOT-HEART and PROMISE. Journal of the American College of Cardiology, 67(7), 843-852. Retrieved from: https://doi.org/10.1016/j.jacc.2015.11.055

Foy, A. J., Liu, G., Davidson, W. R., Sciamanna, C., & Leslie, D. L. (2015). Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA internal medicine, 175(3), 428-436. doi:10.1001/jamainternmed.2014.7657

Gelinas, C., Arbour, C., Michaud, C., Robar, L., & Côté, J. (2013). Patients and ICU nurses' perspectives of non?pharmacological interventions for pain management. Nursing in critical care, 18(6), 307-318. Retrieved from: https://doi.org/10.1111/j.1478-5153.2012.00531.x

Hoffmann, U., Ferencik, M., Udelson, J. E., Picard, M. H., Truong, Q. A., Patel, M. R., ... & Fordyce, C. B. (2017). Prognostic value of noninvasive cardiovascular testing in patients with stable chest pain: insights from the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). Circulation, 135(24), 2320-2332 DOI:  10.1161/CIRCULATIONAHA.116.024360.

Kisely, S. R., Campbell, L. A., Yelland, M. J., & Paydar, A. (2015). Psychological interventions for symptomatic management of non?specific chest pain in patients with normal coronary anatomy. Cochrane Database of Systematic Reviews, (6). Retrieved from: https://www.cochnelibrary.com/cdsr/doi/10.1002/14651858.CD004101.pub5/abstract

Lewis, S. (2015). Qualitative inquiry and research design: Choosing among five approaches. Health promotion practice, 16(4), 473-475. Retrieved from: https://nategabriel.com/egblog/wp-content/uploads/2018/01/creswell2.pdf

Lin, C., Lin, S. W., Lin, Y. S., Weng, S. F., & Lee, T. M. (2013). Sudden sensorineural hearing loss is correlated with an increased risk of acute myocardial infarction: A population?based cohort study. The Laryngoscope, 123(9), 2254-2258. DOI: 10.1002/lary.23837

Mäkikallio, T., Holm, N. R., Lindsay, M., Spence, M. S., Erglis, A., Menown, I. B., ... & Ravkilde, J. (2016). Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. The Lancet, 388(10061), 2743-2752. Retrieved from : https://doi.org/10.1016/S0140-6736(16)32052-9

O'Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., De Lemos, J. A., ... & Granger, C. B. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), e78-e140. https://dx.doi.org/10.1016/j.jacc.2012.11.019

Pappas, Y., Anandan, C., Liu, J., Car, J., Sheikh, A., & Majeed, A. (2017). Computer-assisted history-taking systems (CAHTS) in health care: benefits, risks and potential for further development. Journal of Innovation in Health Informatics. Retrieved from: https://uobrep.openrepository.com/uobrep/bitstream/10547/622209/2/808-1651-1-PB.pdf

Ritchie, J., Lewis, J., Nicholls, C. M., & Ormston, R. (Eds.). (2013). Qualitative research practice: A guide for social science students and researchers. sage.. Retrieved from: https://epdf.tips/qualitative-research-practice-a-guide-for-social-science-students-and-researcher.html