Patient - pseudonym Mary is a 64 year old female who was brought in by an ambulance service after complaining of chest pain and shortness of breath at work. Patient presented to the ambulance service with hypertensive systolic blood pressure in excess of 200 mm/Hg and the ECG changes which were indicative of the late presenting myocardial infarction, also the inspiratory chest sounds suggested the pulmonary oedema. After the admission to the hospital the diagnosis of Pulmonary oedema was confirmed by the chest x-ray and ECHO, also a small pericardial effusion was discovered. Mary has previous history of Hypertension on currently on herbal remedy.
Pulmonary oedema - fluid accumulation in the air spaces and parenchyma of the lungs. It leads to impaired gas exchange and may cause respiratory failure. It is due to either failure of the left ventricle of the heart to adequately remove blood from the pulmonary circulation ("cardiogenic pulmonary oedema"), or an injury to the lung parenchyma or vasculature of the lung ("noncardiogenic pulmonary oedema"). Mason RJ, Broaddus VC, Martin TR, et al. (2010) Murray & Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier;
Mary is currently prescribed
80 mg Furosemide - twice daily
GTN infusion - 0.6 mg/h
2 litres of O2 per hour via nasal cannula
A Mary is self-ventilating with no complications, speaks in full sentences.
B After she was commenced on oxygen and furosemide twice daily her respiratory rate has improved from 20-22 breaths per minute to 10-12 breath per minute and her saturation of oxygen is currently at 96% on 2 litres of oxygen per minute via the nasal cannula.
C Regardless of GTN and Ace Inhibitors administration, Mary still remains hypertensive, with the systolic blood pressure fluctuating between 170-200 mm/Hg and with the pulse rate of 60-70 beats per minutes. She is apyrexial and has good urine output, with fluid balance being negative 600 ml.
D Mary's GCS is 15/15 and her blood sugar level is 7.4 mmol. She reports no pain at the time of the assessment.
E Her PAR score is 3 due to hypertension and temperature of 35.8 degrees Celsius.
On the admission Mary was unable to finish her sentences due to shortness of breath, she verbalised and reflected in her body language high level of anxiety. But following treatment received and the explanation of care and discharge plan, Mary has improved tremendously and appears to be more relaxed and confident about her present state and future.
Patient - pseudonym Jane is a 90 year old female who was admitted to the hospital for an elective Transcatheter Aortic Valve Implantation, the procedure was indicated by the Severe Aortic Stenosis diagnosed earlier. During the procedure Jane had 2 cardiac arrests but was successfully resuscitated and the outcome was positive. Jane has previous history of Hypertension, Ischaemic heart disease, Arthritis and Hiatus Hernia.
Severe Aortic Stenosis - is a disease of the heart valves in which the opening of the aortic valve is narrowed or constricted. Lilly LS (ed) (2003). Pathophysiology of Heart Disease (3rd ed.). Lippincott Williams & Wilkins.
Transcatheter Aortic Valve Implantation - a replacement of valve in the high-risk patients which is delivered via a catheter using one of several access methods: transfemoral (in the upper leg), transapical (through the wall of the heart), subclavian (beneath the collar bone) and direct aortic (through a minimally invasive surgical incision into the aorta). Smith, Craig R.; et al. (2011). "Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients". N Engl J Med (june)364: pp 2187-2198.
Jane is currently prescribed
75 mg Aspirin - once daily
75 mg Clopidogrel - once daily
10 mg Ramipril - once daily
2.5 mg Bisoprolol - twice daily
10 mg Enalapril - twice daily
400 mg Bezafibrate - once daily
2.5 mg Indapamide - once daily
100 mg Allopurinol - once daily
A Jane is self-ventilating with no complication, speaks in full sentences.
B She is respirating at the rate of 10-11 breaths per minute and her saturation of oxygen is currently at 98% on room air.
C Jane's has recovered from the procedure unremarkably, and her current blood pressure is 148/68 mmHg. She is in the sinus rhythm with the pulse rate of 75. Jane is apyrexial and micturating urethrally with reduced urine output, she currently has the positive fluid balance of 300 ml.
D Jane's GCS is 15/15 and according to arterial blood gases, done after procedure, her blood sugar level is within normal range. She reports no pain at the time of assessment.
E Jane still has post-procedure transapical wound side with sutures insitu, which is for daily checkup and appears to be healing well.
Jane appears to be recovering well from the procedure, but vocalises that she would like to get her pre-procedure level of functionality and independence as soon as possible, and she is eagerly waiting to be mobilised, which is planed for the next couple of days.
Patient - pseudonym Joe is 87 year old male who was transferred in by an ambulance service from another hospital with ECG changes suggesting myocardial infarction. On admission to the hospital Joe presented in Atrial Fibrillation at which point the ECHO has confirmed the diagnosis of severe aortic stenosis and Congestive Heart Failure. As well on admission Joe was pyrexial with the temperature of 38.4 degrees Celsius. Joe is an ex smoker and has previous medical history of anterior myocardial infarction with following Coronary Artery Bypass Graft 10 years ago, also suffers from Hypertension and stable Angina. Prior to this transfer Joe was due for the investigation of his Aortic-Valve.
Atrial Fibrillation - is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function. European Society of Cardiology (2006) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text Europace (2006) 8, pp 651-745.
Congestive Heart Failure - a clinical syndrome characterized by systemic perfusion inadequate to meet the body's metabolic demands as a result of impaired cardiac pump function. Hosenpud JD (ed), Greenberg BH (ed), (2007) Congestive Heart Failure (3rd Ed.), Philadelphia: Lippincott Williams & Wilkins.
Joe is currently prescribed:
250 mg Levofloxacin - once daily intravenously
20 mg Furosemide - once daily
75 mg Aspirin - once daily
75 mg Clopidogrel - once daily
10 mg Ramipril - once daily
5 mg Bisoprolol - once daily
A Joe is self-ventilating with no complication, speaks in full sentences.
B He's respiratory rate is 8-10 breaths per minute, and his saturation of oxygen is 98% on room air. Joe has occasional cough, sputum was send away for the microscopy, culture and sensitivity as per medical team request.
C Joe is still in AF rhythm with pulse rate between 95-110, he maintains systolic blood pressure between 120-130. Joe has declined to have the indwelling urinary catheter put in, at the time of the assessment he still has good urinary output and balance of negative 400 ml but according to medical team his output needs to be closely monitored due to worsening renal function. Following the commencing of intravenous antibiotics Joe has become apyrexial.
D Joe's GCS 15/15 and no pain is reported, blood sugar level is within normal range.
E Joe's PAR score at the time of the assessment is 1 due to he's pulse rate.
Joe appears to be anxious about the Angiogram that has been planed for him in near future. More specifically Joe has vocalised that he is anxious about the outcome of Angiogram and the prospect need for another major heart surgery if the percutaneous coronary intervention is not going to be sufficient. Joe was reassured that the safest and most beneficial for his health course of action is going to be take by the multidisciplinary team in charge of his care. Joe's body language seemed to have responded well to reassurance.
Patient - pseudonym Mike is a 60 year old male who was brought in by an ambulance service after experiencing at home sudden onset of tightness in chest. Patient presented to the ambulance service with the angina and ECG changes indicating the Anterior Myocardial Infarction. This diagnosis was confirmed by cardiac biomarkers after Joe's admission to the hospital, at the time the decision for the Angiogram and the Percutaneous Coronary Intervention was made by the medical team and consented with the patient. Mike is an occasional smoker with a family history of Heart Disease and a previous medical history of Hypertension, Hight Cholesterol, Type 2 Diabetes, Irritable Bowel Syndrome and Gastric Oesophageal Reflux Disease.
Myocardial infarction - (heart attack) is where a coronary artery has become blocked thus preventing the supply of blood to an area of myocardium. The myocardium becomes rapidly ischaemic and then necrotic.The fibrous / necrotic area is unable to contract or to conduct electrical impulses and therefore will reduce the efficiency of the chamber affected. Anterior MI - is due to an occlusion of the left anterior descending artery and affects the front wall of the left ventricle. The papillary muscles and intraventricular septum may also be affected (anteroseptal). This sort of infarction has disastrous consequences on the patient by reducing the cardiac output dramatically. [Online] accessed 04.10.12 http://www.nursingtheory.nhs.uk/cardiac/myocardial%20infarction.htm
Angiogram an invasive, non-surgical procedure done to study the arteries that bring blood to the heart muscle and to check the function of the main pumping chamber of a heart. During an angiogram, the cardiologist inserts a small, hollow tube (catheter), into an artery or vein, and then guides it into the heart using x-ray. The cardiologist injects contrast (x-ray dye) through the catheter to outline the arteries and to show any blockages or narrowing that may exist.
Percutaneous Coronary Intervention or PCI is a treatment procedure that unblocks narrowed coronary arteries without performing surgery. During this procedure, cardiologist determines the best treatment for the condition. Treatment will vary from patient to patient.
Mike is currently prescribed:
Dobutamin infusion 5.4 ml/hr to finish in 6 hours on the day of assessment
20 mg Furosemide - once daily
75 mg Aspirin - once daily
75 mg Clopidogrel - once daily
10 mg Ramipril - once daily
5 mg Bisoprolol - once daily
30 mg Lansoprasole - once daily
500 mg Metformin - twice daily
A Mike is self-ventilating, with no complications, speaks in full sentences.
B His respiration rate is 16-18 and saturation of oxygen is 94-95% on room air.
C Mike's systolic blood pressure on Dobutamin is remaining between 130-140 mmHg, he is in sinus rhythm with the pulse rate of 70-80 beats per minute. Mike's CVP remains patent with no significant oozing. He still has indwelling urinary catheter with the urine output exceeding 70 ml/hour. Mike is apyrexial at the time of this assessment.
D Mike's GCS is 15/15, his blood sugar is slightly elevated at 9.7 mmol, Metformin is withheld for the 48 hours due to x-ray dye contraindication. Mike reports no pain at the time of this assessment.
E Mike's PAR score is 1 due to the oxygen saturation. His femoral Angiogram access site is soft and dry.
Mike appeared very anxious on admission, he was breathing shallow and hyperventilating with facial expression suggesting discomfort and pain. Since the angiogram and the percutaneous coronary intervention Mike has improved significantly which is indicated in the change of his vital signs observations as well as his own words and body language.
Reflection
This experience not only allowed me to gain the valuable cardiological nursing skills and knowledge, but also it provided me with the framework for the systematic assessment of any patient. It is clear that this style of the assessment is going to be useful at any stage in my nursing training or even after the qualification and in both a critical care setting or in general ward.
7. Critical reflection on 3 acute patients within the provision of care with some or all:
2.1 OBS normal values, deterioration/improvement → action, priorities in delivery of care, PAR → action
2.2 Emergency care, CPR
airway assessment and breathing, recovery pst, CPR - ALS, DR ABC, resuscitation equipment check +
2.8 Respiratory
tracheal suctioning, tracheostomy, Oxy_M/Nasal Cn, Peak Flow, assessment of RR and paterns, SpO2, Expectoration, Chest Drain.
"s (subjective data) - chief complaint or other information the patient or family members tell you.
o (objective data) - factual, measurable data, such as observable signs and symptoms, vital signs, or test values.
a (assessment data) - conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses.
p (plan) - strategy for relieving the patient's problems, including short- and long-term actions.
i (interventions) - measures you've taken to achieve expected outcomes.
e (evaluation) - analysis of the effectiveness of your interventions.
r (revision) - changes from the original care plan"
The Patient pseudonym John, has been admitted to the critical care with the complaint os shortness of breath and chest tightness.On arrival John presented with the high blood pressure of 174 / 97 accompanied by severe acute dyspnoea with respiratory rate between 27 to 29 breaths per minute and systemic oxygen desaturation below 85% on 35% on humidified oxygen system. He was also apyrexial with the temperature reading of 36.7 had blood glucose reading of 7.4 mmol and had an indwelling catheter insitu with urine output of less than 25 ml/hr. John's facial expression and body language as well as the vital signs observation were suggesting that he was very anxious about his own state, which in turn increased his vasoconstriction and hyperventilation.
From the nursing diagnosis John was in the respiratory distress caused by the pulmonary oedema from the medical diagnosis he had the acute Left Ventricular Failure caused by the overloading due to contrast induced nephropathy. Aforementioned vital signs observation, equals to the combined patient at risk (PAR) score of 5, and the individual score of 3 based on the oxygen saturation reading. Both, the early warning scores and the visual assessment of patient were indicating the high risk requiring the immediate intervention.
In order to achieve the immediate relive of John's respiratory symptoms John needed to be repositioned in to the upright sitting, also his anxiety needed to be reduced through constant reassurance in order to reduce his hyperventilation, also he would benefit from facial hygiene because the high volume humidified oxygen that he was on was making him perspiring a lot. He was also in the need of adjustment of his Oxygen therapy that was clearly ineffective at the moment. In the long term John needed the relive to his pulmonary oedema and the hypertension as well as his urine output needed to be improved.
John was put in the upright sitting position his oxygen therapy was changed to the Continuous positive airway pressure (CPAP) and he was commenced on the infusion of Glyceryl Trinitrate (GTN) and Furosemide. John was also given the constant reassurance and the rationale for the use of CPAP to reduces anxiety, then the face mask was applied and head strapped to make an adequate seal. Effective continuous positive pressure treatment is dependent on good seal. The head strap was adjusted, making sure no unnecessary pressure is applied to ear preventing the skin breakdown. John was monitored for nausea caused by air entering the stomach and had suction equipment available. His vital sign observations and arterial blood gases were continuously reevaluated in order to prevent John from becoming hypotensive due to the use of GTN and Furosemide, and to establish whether John will need to go on active ventilation.
The CPAP was chosen because it provides an additional therapy between conventional oxygen therapy and controlled ventilation. It helps to prevent collapse of lungs, reduce the work of breathing and eliminate or reduce hypoxia. It allows normalisation of the functional residual capacity. In the management of pulmonary oedema it can improve cardiac output although in normal volunteers without oedema cardiac performance is reduced. Ashurst S (1995). "Oxygen Therapy". British Journal of Nursing. 9: 508 - 516.
The infusion of GTN was chosen as a potent vasodilator that by increasing venous capacity, pools venous blood in the peripheral veins and reduces ventricular filling pressure and decreases arterial blood pressure. Because of this vasodilation capacity it also activates coronary vasodilation in coronary arteries which are in spasm and may assist redistribution of blood flow along the collateral channels in the heart. Cameron et al (2004) "Adult Emergency Medicine" 2nd ed, Churchill Livingstone.
The infusion of Furosemide was chosen as a diuretic for the relief of congestive symptoms and fluid retention in patients with heart failure. Chronic Heart Failure. NICE clinical Guideline CG108. Issued Aug 2010 Available from http://guidance.nice.org.uk/CG108/Guidance
As a result of these interventions John's saturation level became normal and over the course of two days his blood pressure and the fluid output were stabilised allowing him to be relieved from pulmonary oedema and to begin further planing of his cardiac treatment.
The Patient pseudonym Mike, has been admitted to the critical care with the complaint of shortness of breath, back pain, generalised weakness, inability to micturate and abdominal distension. On arrival Mike presented with the low blood pressure of 78/52 accompanied by severe acute dyspnoea with respiratory rate between 25-30 and the oxygen saturation on 35% on humidified oxygen system, below the 89%. Mike was apyrexial with the blood glucose reading of 10.5 mmol and had a very poor urinary output of less than 10 ml/hr , from his indwelling catheter, he also appeared to have not only the abdominal distention but also the generalised oedema. Mike had the history of the Type 1 Respiratory failure caused by pneumonia that resulted in sepsis which in turn caused the Congestive Cardiac Failure as well as the Acute Kidney Injury. Mike was previously offered the Implantable cardioverter-defibrillator and Heart transplantation, both of which he refused. On admission Mike verbalised that he was very anxious about his state and was saying that he reconsidered his earlier decision about the Heart surgery.
From the nursing diagnosis Mike was in respiratory distress combined with the hypovolemia and complicated by the aforementioned Congestive Cardiac Failure. The medical diagnosis of right sided pleural effusion was established via the ECHO and chest X-ray. Aforementioned vital signs observation, equals to the combined patient at risk (PAR) score of 6. Both, the early warning scores and the visual assessment of patient were indicating the high risk requiring the immediate intervention.
In order to achieve the immediate relive of Mike's respiratory symptoms he needed an increase in his oxygen therapy, repositioning in the upright sitting position and the reassurance to address the anxiety. Also the decision needed to be made by the medical team to insert the chest drain, as well medical team decided that Mike was to be commenced on the Dopamine, Dobutamine and Furosemide infusion to control Mike's heamodynamic state. The long term planing for Mike was to refer him back to specialist Heart transplantation service and begin his renal management.
Mike was explained the rational for the drain insertion as the reassurance was constantly given in order to elevate the anxiety level, following that the drain was inserted by the doctor and connected to the underwater drainage system. The drain tubing inside of the drainage system bottle was submersed by 3 centimetres of sterile water. The drain bottle was checked routinely for the presence of bubbling of the fluid inside. The drain evacuated over 2 litres of fluid from the pleural effusion. The vital sign observations were reevaluated regularly, post drain insertion, and a fluid balance chart for the recording of chest drain activity was started.
The Chest Drain is a tube inserted through the chest wall between the ribs and into the pleural cavity to allow drainage of air (pneumothorax), blood (haemothorax), fluid (pleural effusion) or pus (empyema) out of the chest.This allows drainage of the pleural contents and re-expansion of the lung. Laws D, Neville E, Duff J. (2003) British Thoracic Society guidelines for the insertion of a chest drain. Thorax;58 (Suppl II): pp53-59
The Dopamine and Dobutamine are the Vasopressor agents that increase the Mean arterial pressure (MAP), which increases organ perfusion pressure and preserves distribution of cardiac output to the organs. Maintenance of an adequate systemic pressure is essential for adequate tissue perfusion. When MAP falls below the autoregulatory range of an organ, blood flow decreases, resulting in tissue ischemia and organ failure. Vasopressor agents also improve cardiac output and oxygen delivery by decreasing the compliance of the venous compartment and thus augmenting venous return. 1 Beale RJ, Hollenberg SM, Vincent JL, Parrillo JE. (2004) Vasopressor and inotropic support in septic shock: an evidence-based review. Crit Care Med 2004; 32: S455-S465.
As a result of these intervention Mike returned to his normal oxygen saturation levels and gradually became haemodynamicaly stable. Eventually he was transferred to the heart transplantation hospital for the long term management of his co-morbidities.
The Patient pseudonym Jane, was transferred over from another hospital were she was initially admitted 3 days prior with chest pain, and diagnosed with a myocardial infarction. She had an angiogram via the femoral access approach and 3 day later, after the transfer to the new hospital Jane had the repeat angiogram with the percutaneous coronary intervention, via the radial access route.
During her post-procedure recovery Janne started to deteriorate, which reflected in the gradual increase in the respiration rate from 18 to 22-24 and then followed by the reduction of systolic blood pressure below 75 mmHg and increase in the pulse rate above 115 beats per minute. Through out the deterioration Jane remained hypothermic and her blood glucose reading was within normal range. That change in the vital sign observations was accompanied with the visually observable increase in drowsiness and perspiration of the skin giving patient cold and clammy appearance. There was also the difference in skin colour between Jane's right and left leg as well as weak pedal pulse on Jane's right foot.
From the nursing and medical diagnosis Jane had the clinical representation that was indicative of hypovolemic shock, and potential haemorrhaging therefore it was caring the high risk to the patient and required immediate intervention. Although the aforementioned combination of vital signs only gave the patient at risk (PAR) score of 4.
In order to achieve the immediate relive of hypovolemia Jane needed to have some fluid replacement therapy started but most importantly it was necessary to establish if there was any active haemorrhaging taking place. Especially, her femoral approach site had to be checked for the signs development of the post-procedure haematoma or the pseudoaneurysm of femoral artery and retroperitoneal bleed.
Jane was explained what was going to take place, than she was asked if she was actively bleeding or feeling abnormally somewhere in her body. The assessment of affected leg for colour, warmth movement and sensation and palpation of pedal pulses was performed. Also the puncture site was observed for bleeding, bruising and palpated for swelling. The suspected diagnosis was confirmed based on Jane"s complaint of swelling and pain and the presence of haematoma and discolouration of leg and reduction of temperature and pedal pulse; and verified by the follow up ultrasound. Jane was closely monitored for the signs of further increase of hypovolemia and increase in pain or decrease in circulation to the right leg until she was consecutively transfused 6 units of blood to bring her systolic blood pressure to the normal range of above 100 mmHg and haemoglobin level to normal range of above 11, her femoral artery had to be surgically repaired.
Haematomas caused by bleeding in the soft tissue surrounding the site of the femoral sheath will feel firm and will have defined boundaries. There may also be swelling and localised pain. If unsure whether a haematoma is present, the site of the sheath should be compared with the other side. Larger Haematomas have potential to result in oedema of the lower leg with possible obstruction of blood flow; if the femoral nerve is also compressed there may be deficits in movement & sensation. Most haematomas can be managed with manual compression. Large haematomas can cause considerable discomfort to the patient and have the potential to develop into false aneurysms.
Pseudoaneurysm (false aneurysm) is a result of blood leaking from the artery into the surrounding tissue with persistent communication between the originating artery and the terminating blood filled cavity. A pseudoaneurysm can be detected by physical examination and palpation of a pulsatile femoral mass as well ultrasound. The patient may report back pain and moderate localised tenderness. The mass may gradually or abruptly increase in size, and compress a nerve sufficient to cause neuralgia, or an adjacent vein, reducing blood flow from the extremity. A pseudoaneurysm may also cause a distal embolization, or potentially rupture. Most small pseudoaneurysms will spontaneously close within 6-8 weeks; treatment of larger ones includes ultrasound guided compression, thrombin injection with ultrasound guidance or surgical closure.
A Retroperitoneal Bleed from a ruptured pseudoaneurysm may occur in to the retroperitoneal area and manifest as severe back pain, hypotension and bruising around the puncture site. Any increase in back discomfort or severe back pain, or hypotension should be investigated immediately.
Dressler, D. & Dressler, K. (2006) Caring for patients with Femoral Sheaths: After percutaneous coronary intervention, sheath removal and sit monitoring are the nurses responsibility. American Journal of Nursing, Vol 106(5).
As a result of these interventions Jane became haemodynamically stable and was later discharged in to here usual place of residence.