Background Information on the Critically Ill Patient
Demographics
The patient in this case is an 86-year-old Caucasian male. He is married and retired from his employment. Basically, this means that he is a white American who lives with his wife and is not employed at the moment. From a medical perspective, it can be noted that the patient could have a number of risks associated with his age and ethnicity. He is relatively old.
History of Present Illness
My patient was an 86 year old Caucasian male. He is a retired maintenance worker, and lives in Manteno with his wife. He was admitted to Riverside Emergency room on September 18, 2015 after he experienced dizziness and fell in the bathroom. His wife found him after the fall. She said that he had diarrhea after the fall, and tremors. The patient has a past medical history of hypertension, anxiety, arthritis, history of CVA with no residual focal deficit, BPH, and a chronic foley that was placed last month. A spinal mass was found on a CT last month. He has been experiencing shortness of breath, increased fatigue, and tightness in the chest over the last month. A biopsy was completed at a different hospital. The results were unsuccessful. The etiology is unknown. He was treated with steroids, and no longer has any compression of his nerves. The patient’s activity level drastically decreased over the past 6 months. He used to take 6-mile-long bike rides every day with no shortness of breath. Now the patient states that he cannot walk across the room without shortness of breath. Prior to these last 6 months the patient had no cardiac medical history.
Relevant Past Medical and Surgical History
Past Medical History
Hypertension, CVA with no residual focal deficits, BPH with chronic foley, spinal mass, anxiety, arthritis, and head trauma after a mechanical fall, status post craniotomy to relieve cerebral hemorrhage.
Surgical History
The patient had a craniotomy 15 years ago.
Admitting diagnosis
The patient was taken in after experiencing a dizzy spell and falling in the bathroom. All his symptoms pointed to a case of ACS, considering he had chest pains, palpitations, and shortness of breath as well as a great decrease in activity tolerance over the past six months. Tests, however, had to be conducted before this diagnosis could be confirmed.
Course of current hospitalization to date
The patient was brought in on September 18. The first step was to deal with his discomfort and symptoms through administering pain medication and oxygen therapy. He was then tested and later admitted for monitoring, and once his condition confirmed, he was scheduled for an angiogram. He was also put on pain medication in order to deal with the symptoms of his condition.
Review of Systems
Patient lost 10 lbs. over the past two months. He has increased fatigue, increased weakness, and night sweats. Patient denies any skin changes or vision loss. He has no changes in hearing, no throat pain or swelling or tenderness. He admits to palpitation, chest pain, and dyspnea on exertion. Patient has shortness of breath, but denies any wheezing or coughing. He admits to decreased appetite and diarrhea. He denies of having any nausea, abdominal pain, or constipation. No edema noted. Patient denies having muscle weakness, or change in range of motion. He denies any loss of sensation, numbness or tingling.
Rationale
Weight loss, fatigue and palpitations are all characteristics of cardiovascular challenges that develop over time. The fact that the patient is also getting weaker, and is unable to maintain a normal level of activity without experiencing shortness of breath simply indicates a problem with his oxygen uptake (Czarnecki, Chong, Lee, Schull, Tu, and Ko, 2013). He is unable to sustain his energy levels due to the limited oxygen getting to his heart and brain as well. The decreased appetite and diarrhea explain the weight loss too.
Assessment Findings
Vital Signs
Temperature 98.7 F, Blood pressure 110/60, Heart Rate 88, Respirations 20, Spo2 95%. The patient is alert and oriented x 3. He is pleasant, friendly, and no agitation. Eyes are round, equal, and reactive to light. No nasal flaring or drainage noted. Heart sounds S1 & S2 present, with a murmur. Bilateral lung sounds noted on auscultation of the lung fields. Abdomen is soft, non- tender, and non-distended. Hyperactive bowel sounds x 4. Positive range of motion in all extremities.
Laboratory and Diagnostic Tests
Laboratory Data
Ph of 7.45, PC02 33, P02 74, bicarbonate of 23.5, creatine phosphokinase 118. UA was positive for nitrates, small amount of leukocyte esterase, and large amount of blood. CBC, white count 16.3, hemoglobin 8.9, and platelets of 257,000. BNP of 14,559.Troponin T of 0.310. Sodium 135, potassium 4.1, chloride 99, CO2 22, BUN 21, creatinine 1.1, glucose 178, albumin 3.1, alkaline phosphatase 86, ALT 10, and AST 24. Estimated GFR 67.
Results show likely sepsis secondary to urinary tract infection. Elevated troponins. EKG showed no ST segment elevation myocardial infarction just positive left ventricular hypertrophy, etiologies for this include sepsis, or congestive heart failure (Czarnecki et al., 2013). Cardiology was notified. He was started on aspirin and Lovenox. He had a Coronary angiography that showed three blockages in his arteries. He is having a consult for an AVR & CABG. His UA shows that he has a urinary tract infection. The foley was replaced with a new one.
The lab tests show that the patient’s serum glucose is at 178. This matches with the EKG interpretation that the patient is suffering from non ST elevation ACS. Elevated troponins are also an indication of a myocardial infarction in the patient, thus justifying the coronary angiography that he was scheduled to get.
Medications
Sertraline Hydrochloride (Zoloft)
Classification: Selective serotonin reuptake inhibitors
Therapeutic use: antidepressant/ antianxiety. Patient was using it for anxiety.
Major adverse effects: Increased risk for suicide, bleeding risk, hepatic impairment. Watch for any allergic reactions, shortness of breath, agitation, or confusion.
Nursing Implications/Patient teaching: Ask the doctor before taking with any NSAID’s. Also notify the doctor of any other medications you are taking with this medication. This medication can increase drowsiness, so be careful while driving (Lambert, Brown, Segal, Brophy, Rodes-Cabau & Bogaty, 2010). Let the doctor know if you have any worsening symptoms.
Tamsulosin/Flomax
Classification: Antiadrenergic agents, peripherally acting
Therapeutic use: Used to improve urination in men
Major adverse effects: Drowsiness, dizziness, back pain, trouble swallowing, voice changes, body aches, decreased muscle strength, chest pain.
Nursing Implications/Patient teaching: This medication cannot be taken with similar medications. Do not take if you have allergies to sulfa drugs or have history of low blood pressure, liver or kidney disease, or history of prostate cancer (Rollando, Puggioni, Robotti, De Lisi, Ferrari, Vardanega, Pattaro, De Benedetti, and Brignole, 2012).This medication can cause severe dizziness, you need to get up slowly, and use caution when driving. If you stop taking your medication, notify your doctor before restarting it.
Midazolam/Versed
Classification: Benzodiazepines
Therapeutic use: Used for sedation usually prior to minor surgeries.
Major adverse effects: Vomiting, dizziness, loss of consciousness, difficulty with coordination, can cause respiratory depression or arrest.
Nursing Implications/Patient teaching: This medication should be given under close supervision. Do not use if the solution is discolored or has particles in it.
Metoprolol Tartrate/Lopressor
Classification: Cardio selective beta blockers
Therapeutic use: It is used to treat angina, hypertension, or to prevent a heart attack.
Major adverse effects: Blurred vision, chest pain, dizziness, sweating, confusion, shortness of breath, or irregular heartbeat, loss in consciousness.
Nursing Implications/Patient teaching: Do not stop taking this medication suddenly. Sudden discontinuation of this medication can lead to severe chest pain or a heart attack.
Ferrous Sulfate 325mg
Classification: Iron product
Therapeutic use: Used to treat iron deficiency anemia
Major adverse effects: Any signs of a severe allergic reaction like hives or chest tightness. Other side effects are constipation, diarrhea, or dark green stools, loss of appetite, stomach pain.
Nursing Implications/Patient teaching: Iron can stain your teeth. Patient should be advised to drink it through a straw. It should be taken on an empty stomach with a full glass of water. Tablets should not be crushed or chewed (Rollando et al., 2012). Do not take any antacids or antibiotics within 2 hours of taking this supplement.
Fentanyl Citrate/PF
Classification: Narcotic Analgesics
Therapeutic use: Prevent pain after a procedure
Major adverse effects: Respiratory depression, death, drug addiction, withdraw, overdose
Nursing Implications/Patient Teaching: This drug needs to be prescribed and administered with severe caution. Overdosing can be lethal. This drug should be checked by at least two nurses before administered.
Enoxaparin Sodium/Lovenox
Classification: Heparins
Therapeutic use: Used to prevent or treat deep vein thrombosis. This can occur in patients after surgery or that are on bed rest.
Major adverse effects: Gum bleeding, coughing up blood, dizziness, nosebleeds, paralysis, red or dark urine, red or black tarry stools.
Nursing Implications/Patient education: Do not take with aspirin or NSAID’s, if you have a low platelet count, if you have severe hypertension, or if you allergic to heparin, benzyl alcohol, or pork products.
Cefepime HCL
Classification: Fourth generation cephalosporins
Therapeutic use: It is an antibiotic used to treat many different types of bacterial infections
Major adverse effects: bleeding gums, back aches, confusion, convulsions, stomach cramps, fever, change in mental status, numbness around mouth.
Nursing Implications/Patient Education: Do not give if the vial is broken, if the solutions is cloudy or has particles in it. Make sure that you use the entire prescription (Lambert et al., 2010).
Nursing Diagnoses
1) Activity Intolerance Related to Angina
Collaborative Interventions:
1) Increase the patient’s activity level slowly, and give him breaks in between.
2) Take the patient’s vital sign immediately before and after activities.
3) Reduce the patient’s activity if he is feeling dizzy or having any chest pain.
Outcomes:
1) The patient will be able to stay within normal blood pressure limits after 3 minutes of activity (Meadows, Bae, Zagar, Sugihara, Ramaswamy & Heiselman, 2012).
2) The patient will be able to recognize and identify factors that cause activity intolerance.
3) The patient will have no chest pain after walking down the hallway and back.
2) Anxiety Related To Chest Pain
Collaborative Interventions:
1) Provide the patient with reassurance.
2) Try to keep the patient’s environment calm and quiet.
3) Explain all treatment slowly and answer any questions.
Outcomes:
1) Patient will be able to identify his anxiety triggers, and coping mechanisms.
2) The patient will identify one new idea a day to reduce the anxiety.
3) The patient will seem less anxious by the time of discharge.
3) Risk For Bleeding Related To Post Angiogram
Collaborative Interventions:
1. Assess site and dressing every 15 minutes for bleeding or hardness.
2. Monitor vital signs every 15 minutes (Meadows, Bae, Zagar, Sugihara, Ramaswamy & Heiselman, 2012).
3. Decrease all activities for 3 hours to avoid injury.
Outcomes:
1) The patient’s vitals will stay in normal range throughout the hospital stay.
2) The patient’s site will stay intact and dry with no signs of bleeding.
3) The patients will identify the risks of injury.
Interventions
During my time with the patient, I provided care to his needs. I assessed his vitals according to how often they needed to be taken before and after his angiogram. I made sure that he was comfortable by assessing his pain and comfort level. I looked at and softly palpated his insertion site every 15 minutes after his procedure to monitor for bleeding or any complications. This was not my day to pass medications, but I did try to observe the nurse and other staff when they were with the patient.
Routine Nursing Management
Activity Level
The patient reported having trouble walking down the hallway due to shortness of breath. This means that there is a need to balance his activity and rest so as to manage his activity level at a functional state. First, it is important to understand how long the patient is able to partake in physical activity before he suffers the shortness of breath. It is also important to note that the patient in this condition would not be able to do much without feeling the shortness of breath (Lambert, et al., 2010). In this case, my main goal was to get the patient to understand his tolerance level so that he could attain a balance and, thus, be able to do only as much as his heart could handle. However, since this was his first day and he had to prepare for an angiogram, I was not able to do much. I only got him to walk down the hall for about 3 minutes while monitoring his vital signs. The patient got an elevated heart rate after less than 2 minutes of activity. The significance here is to get the patient to understand what he can and cannot do, in order to get him to plan his activities carefully and, thus, remain as independent as possible despite his current situation. Over the course of his admission, it will be important to keep the patient as active as possible.
Apart from that, the patient’s responses to any antiarrhythmic medication must be noted since these medications are likely to have a significant impact on his pulse rate and blood pressure. The idea is to get accurate measurements during and after the activities so as to monitor the patient’s tolerance. With more exercise and ample rest, it is possible to build the patient’s activity tolerance to a good level. Consistency will also allow the patient to understand his body and, thus, work within his physical limits once discharged (Heiselman, 2012). This will encourage independence rather than having to fully depend on someone else after being discharged. It is also important to teach the patient how to minimize oxygen consumption in his body in order to build his activity tolerance even further.
Rationale
Helping the patient with his medication and preparing for the angiogram is not enough. This patient also needs to understand that he is no longer able to stay active for a long period of time. More importantly, he needs to learn how to balance his limited energy in order to remain active and significantly independent. For this to happen, the nurse not only has to understand the patient’s exact activity tolerance but also to train the patient on how to manage his energy. Energy conservation techniques require practice and a lot of monitoring both, by the nurse and the patient (Villanueva, 2010). The main expected outcome is independence and a relatively higher activity tolerance level.
Patient Education
The patient needs to be educated regarding his condition in order to eliminate his anxiety among other things. The first part of the routine management in this case would be to establish the patient’s level of knowledge regarding his condition. ACS may be a relatively common problem but most people do not know much about it. However, rather than making assumptions it would be better to know the amount and type of knowledge that the patient needs. This implies starting with questions on how much the patient actually understands when it comes to what he is going through (Heiselman, 2012). Once accomplished, the nurse has to be able to explain the pathophysiology of ACS and how it affects the patient’s body. It will shed more light on the symptoms and any probable complications that could come up. In addition, the patient will be able to watch out for any alarming signs that could be life threatening if not caught on time. Giving the patient ample education will also be useful when he gets discharged since he will know what he needs to do in order to stay healthy and independent. The education aspect also covers references to support groups and communities on the outside. Therefore, it is possible for the patient to become well educated regarding his condition and its management but only if the nurse in question is able to find out how much the patient needs to know first.
Rationale: Educating the patient gives the nurse a chance at health promotion since the patient will be more aware of what he is dealing with. Patient can thus manage his situation more effectively while in and out of the hospital.
It will also be important to give the patient adequate information regarding the kind of medication that he has to start taking. In order to manage the condition effectively, lifestyle changes will have a significant impact but medication is also very important. Therefore, as a part of the routine management, it will be important to speak to the patient about all the medications that he will be getting, how they work, what side effects they could have and how important it is to take them as prescribed. Also, contraindications for each medication must be included in the patient’s education since he needs to avoid any eventualities coming from misusing the medication or combining it with something that reacts badly with the components of the medicine.
Rationale
Medication is a great part of managing ACS and unless the patient has adequate information, it will be really hard for him to manage the condition effectively once out of the hospital. It is also important to not mix medications with substances that could impede their action.
Ongoing Monitoring
This is also a very important part of the routine nursing management. While at the emergency room or in the intensive care unit, it is likely that the patient will be connected to an ECG in order to monitor the activity in his heart (Czarnecki et al., 2013). Once transferred to a lower unit, a patient with ACS needs to continue with the monitoring so that prompt responses can be made in the case of deterioration in his condition. As the nurse in this case, it is important to understand the readings on the ECG in order to ensure that any complications can be identified and dealt with promptly. The cardiovascular status of the patient requires regular monitoring since the changes could be rapid and life threatening.
Rationale
Spending time with the patient and monitoring his condition is important not only to the process of providing primary care but also to the healing of the patient. It is important to keep the situation under control and catch any eventualities before they become life threatening for the patient.
Interdisciplinary Care
Collaborative Management
In order to fully cater to the patient in question, a lot of professionals had to be involved. It is because there are various activities that had to be undertaken from the time the patient was brought in until they were diagnosed and stabilized, and thus prepared for the angiogram (Czarnecki et al., 2013). The main collaborators in this case included the physician, pharmacist, diagnostic tests and lab personnel, respiratory therapist, and the physical therapist (Meadows et al., 2012).
Physician
The physician is considerably the most primary professional here. Once the patient is admitted, it is the physician who takes charge and calls for the right exam to be conducted based on what they learn about the patient. While it is up to the nurse to collect the information on the patient, it is the physician who is responsible for making most of the critical decisions regarding what to do, which medications and therapeutic modalities to use and even whether or not the patient needs to be admitted (Meadows et al., 2012). Basically, the physician is the pillar of the whole health care program for the patient.
Pharmacist
This is the second important collaborator in this process. The pharmacist not only administers the medication required for the patient, but also ensures that the patient is getting the right combination of medication. A pharmacist is also responsible for ensuring that all the required medication is readily available within the health care facility. This implies understanding and anticipating all the possible medical challenges that could come up. In this case, the pharmacist would be specifically useful in finding the right combination of medication that the patient will use to manage the pain and when they get discharged.
Lab/Diagnostic Tests Personnel
Here, it is important to understand that the patient required a lot of tests and not all of them were conducted by the lab. First, there was a need for blood work to establish the pathological nature of the patient’s situation (Bernal, Stafford, Bereznicki, Castelino, Davidson, and Peterson, 2012). Then, there was also a need for imaging techniques in order to fully understand what was going on in the patient’s heart. The lab personnel in this case are responsible not only for conducting the tests but also for reporting the obtained results and offering clarification where the results seemed vague.
Respiratory Therapist
The first step to this patient’s treatment procedure involved oxygen therapy as a means of resuscitating the patient. There was a need for a respiratory therapist to help the patient with the breathing challenges. It can be appreciated that the patient had an oxygen deficit and he needed some help in order to regain a good gas balance in his respiratory system (Bernal, et al., 2012). The main role of the respiratory therapist lies with the oxygen therapy where they are supposed to help the patient to breathe well and effectively.
Physical Therapist
In order to balance his activity tolerance and be able to live independently, the patient needs help in terms of how long to engage and how long to rest in order to avoid the shortness of breath and dropping energy levels. This requires the help of a physical therapy who in this case will be offering ample guidance on how to space activities in order to stay functional for longer. The patient will also have to learn about energy conservation with regards to physical activities and breathing techniques. Generally, it is the physical therapist’s responsibility to guide the patient back to normalcy in as far as their ability to stay active is concerned (Packard, Campbell, Knezevich & Davis, 2012).
Therapeutic Modalities
Oxygen Therapy
Oxygen therapy involves helping the patient to regain a gas balance within their respiratory system. In this case, the patient required this therapy because he had been suffering from shortness of breath for a while. The respiratory therapist in this case had to ensure that they prescribe and administer the right amount of oxygen based on the patient’s needs. Supplemental oxygen is especially useful in this case as a way of relieving the symptoms presented by the patient in terms of tightness in the chest and the increased fatigue.
Rationale: This patient was brought in after collapsing in his bathroom. His laboratory results also showed some possibility of a congestive heart failure. Generally, oxygen therapy is recommended for as a symptomatic therapy for patients with ACS who complain of breathlessness among other things (Packard et al., 2012).
The Nurse’s Responsibilities and Skills Required
Oxygen therapy is commonly left to the experts to perform although a nurse could also provide it if he/she has the right set of skills and experience. First, it is important to understand the patient’s blood oxygen saturation. Ordinarily, one should not administer oxygen therapy to a patient whose blood oxygen saturation is above 90% especially if they are having a cardiac situation (Piegas, Avezum, Guimara?es, Muniz, Reis, Santos, Knobel & Souza, 2013).Also, the nurse needs to be able to enter the right settings in order to prevent oxygen poisoning among other possibilities. It, thus, remains critical for nurses to only perform oxygen therapy under supervision until they have acquired all the required skills and experiences. As for responsibilities, after the oxygen therapy has been started the nurse simply has to keep monitoring the patient’s vital signs and EKG readings so as to ensure that everything is going as expected (Bernal, et al., 2012).
Low Weight Molecular Heparin
This has been proven to have a higher effectiveness in the treatment of ACS. Unlike the other possible treatment modalities, the use of low weight molecular heparin is becoming popular based on recent medical evidence. This particular patient was put on Lovenox as soon as it was established that he had ACS. The combination of Lovenox and aspirin is proven to reduce the recurrence of myocardial infarction in non ST segment elevation ACS. This also prevents death in most patients with acute myocardial infarction.
The required skills here mainly involve the understanding of how heparin works. The nurse needs to understand contraindications and risk factors that would limit the patient’s eligibility for heparin. Being an anti-coagulant, patients who are scheduled for surgery are especially not expected to take on this therapy. A nurse who does not know this is likely to put the patient’s life in grave danger.
Nursing Role Reflections
As a nurse in this case, I was actively involved in the procedures undertaken with respect to the patient’s wellbeing. This means that I was generally an active part of the interdisciplinary team taking care of the patient with ACS. There are a number of reflections regarding this experience that stood out.
Communication Style Preferences
First, I had to work with numerous other professionals with different backgrounds and work ethics. This meant having to understand each of the individuals involved in the critical care setting including the medical personnel, the patient and their family members as well as myself. First, it should be noted that I did not have a tough time communicating with the other nurses. They even allowed me to watch when I was not even supposed to be there while they attended to the patient. Since I was not in charge when the patient was brought in, I would not have been able to participate at all in the case. The nurses were forward and thorough in their communications, as was the physician. They all preferred direct conversations rather than written notes or short messages. Their communication was also mostly clear and precise, often simplified with consideration for their level of expertise compared to that of the person they would be communicating with. Whether the patient or his family members, or even myself, the nurses and the physicist were very elaborate and they explained a lot of things that they considered relevant for the full understanding of the situation at hand (Piegas et al., 2013).
The lab/diagnostic tests personnel were also not too difficult. Their communication was mostly done in writing since they were reporting to the physicist but they also took some time to explain the results to me. I was able to learn a lot about the various blood work and imaging tests conducted on the patient. The therapists were also forward and considerate with their communication. First, they did not make any assumptions. Rather, they explained themselves adequately and even asked the patient if he had any questions for them (Dunckley, Quinn, Dickson, Jayram, Wright & McDonald, 2006). This means that they were able to interact fruitfully with the patient to a point that it can be appreciated that there could be no miscommunications. The pharmacist also communicated mostly in writing, leaving it to me to relay his communications to the patient and his family. At first, this was rather confusing for me but after considering how much work he has to do, I got to understand that he could not be faulted for limiting his personal interactions to critical situations. However, his writing was clear and to the point, thus, making it easy for me to understand the instructions and assertions and, hence, relay them correctly to the concerned parties.
System Barriers and Facilitators
By appreciating the value of team work within the critical care setting, it can be appreciated that the organizational framework facilitates the quality of care and patient outcomes. It should be noted that the decisions within the critical care situation are mainly made by the physician and the primary care nurse (Villanueva, 2010). This leaves little room for mistakes since these personnel are well aware of the patient’s specific situation and his needs in terms of medical attention. These major players are then expected to communicate regularly and effectively with all the other personnel involved in providing critical care services. This implies that the framework is highly considerate and by emphasizing on communication it eliminates the risk of mistakes due to misinformation.
In order to enhance interdisciplinary collaboration however, it would be important for the framework to emphasize on personal interactions between the involved professionals. The writings on a prescription paper from a pharmacist could just as easily be misread or misinterpreted by another nurse. The primary care nurse may know exactly what the patient needs but upon changing shifts, it is likely that the next nurse could be confused by the handwriting and give the wrong dosage. It, thus, follows that rather than writing these down, the nurses should actually get to talk before the change of shift, or the pharmacist should be consulted with regards to the medication being given. The key is in interpersonal communications in order to avoid misunderstandings amongst the various disciplines.
Also, other than emphasizing on the communication it will be important for all the involved professionals to use the right words when communicating. The lab team is especially rather confusing with their presentation of results, making it hard for novice nurses to understand them most of the time. This implies a need for the novice nurses to either learn the words used in the lab or for the lab team to use words that are easier to understand regardless of one’s level of expertise. Communication is generally the most important factor in interdisciplinary collaboration and the only way to improve effectiveness would be by enhancing communication amongst the various disciplines involved.
Professional Development
Currently, my expertise is rather limited but I still get the right amount of exposure to practical situations where I can learn and practice as well. From this particular experience, I intend to work hard on my communication techniques in order to be more effective within an interdisciplinary setting. First, it is important for me to be able to communicate with the patient in a way that is ethical and effective. This means being able to explain medical conditions and complications in a way that is accurate and yet easy to understand (Dunckley, Quinn, Dickson, Jayram, Wright & McDonald, 2006). This, however, is not the most important challenge that I should undertake. I also have to be able to read and interpret lab results effectively with or without the help of the lab personnel. Usually, I may need to get some basic information that is readily available amongst the lab results and yet not highlighted anywhere else. This is why I should be able to speak the same language with the lab personnel. Generally, I have to be able to understand all the disciplines involved within the health care setting in order to improve my ability to work with them effectively at all times.
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