Question:
Discuss about the Nursing Placement for Ischemic Heart Disease.
The purpose of the paper is to gain a deep insight regarding the importance of pathophysiology, pharmacology, assessment of the diseases that are manifested by the patient in the given case study. In the given case study, the patient named Jackson Roland was admitted to Hampstead hospital as he fell in the aged care and got injured sustaining cervical spine. The actual patient name has been used in here. As he has no one to look after him, he has permanently stayed in aged care. Jack had a past medical history of Diabetes Mellitus (DM) type 1, hypertension, Ischemic Heart Disease (IHD), atonic bladder (SPC), Peripheral vascular disease (PVD). A catheter that is inserted surgically through the lower part of the abdomen directly into the bladder is known as suprapubic catheter or SPC. He also underwent bilateral transmetatarsal amputation, carpal tunnel surgery and CABG* 2 8 stunt 2008. As he is suffering from severe sensorimotor polyneuropathy due to diabetic neuropathy, there is risk for fall due to decreased sensation and lack of muscle coordination and control. Due to high blood sugar level, the nerves are damaged and can lead to neuropathy enhancing the risk for fall (Vinik et al. 2015). This condition is a diabetic complication and mostly occurs when diabetes remain undiagnosed or not well controlled. This could be the reason for Jack’s fall and his need for admission at the hospital.
For the access to Jack’s information, informed consent is required from him or his caregiver at the aged care. The confidentiality is important while getting access to his personal information like past medical history, current medications, past surgeries and in getting previous medical records (Keast 2016, pp.20). Patient confidentiality has been maintained in here. The main risk for Jack after admission is the moderate or severe brain injury that could be associated with the sustained cervical spine injury (Theologis et al. 2014, pp.356-361). Therefore, there is a requirement of diagnosis and management of cervical spine trauma and assessment of diabetes and hypertension being the major concern and SPC supra pubic catheterisation due to atonic bladder.
As mentioned above, the medical history of Jack revealed that he is suffering from DM type 1, IHD, PVD, hypertension, atonic bladder (SPC) and severe sensorimotor polyneuropathy. Diabetes and hypertension are the major concern that could have manifested the signs and symptoms in Jack and made him prone to fall.
Type 1 DM or juvenile diabetes is a condition when the body does not produce insulin that is important to break down the starches and sugars for energy generation (American Diabetes Association 2015). The pathophysiology of DM type 1 is the destruction of beta cells that secrete insulin from the islets of Langerhans in the pancreas (Jennings 2015). There is decline in beta cell mass that in turn decreases the insulin secretion until there is no adequate insulin to maintain the normal blood sugar levels where autoimmunity is the major DM type 1 pathophysiology (American Diabetes Association 2015). There is sensory neuropathy caused by segmental demyelination and axonal degeneration that is manifested in Jack making him prone to fall due to sustained hyperglycaemic condition. A patient having chronically elevated glucose level is exposed to damage to the longest nerves in their bodies that convey sensory information from the feet and toes to the spinal cord. The loss of muscle tone and sensation are worst felt at the ankles and feet. This makes it difficult for the patient to walk or stand up. This is more prominent at old age. The condition brought about by neuropathy is one of the major reasons that people with diabetes have such a high risk for falls (Atkinson, Eisenbarth and Michels 2014, pp.69-82).
Pathophysiology of hypertension is multi-factorial and complex where kidney acts as the major target organ and contributing factor. Arterial hypertension is the persistent systemic blood elevation where the cardiac output is elevated or systemic vascular resistance increase. There is a strong link between hypertension and diabetic neuropathy where hypertension acts as the independent risk factor as RBCs and Na/K ATPase decrease. An alteration in the microcirculation plays an important role in this regard. Hypertension leads to up-regulation of matrix metalloproteinase (MMP) expression at the sites of myelin thinning at sensory nerve fibers. This potentially worsens comorbid diabetes (Visser et al. 2014). This could be the pathophysiology of hypertension in Jack with diabetes, both being intertwined conditions sharing significant overlap in the manifestation of the underlying risks (Burnier and Wuerzner 2015, pp.655-683).
There are macrovascular complications associated with longstanding hypertension or diabetes which includes IHD (Ischemic Heart Disease) and PHD (American Diabetes Association 2015). Microvascular complications include sensorimotor polyneuropathy that is witnessed in Jack on admission.
IHD is a condition in which there is narrowing or blockage of the blood vessels that affects the blood supply to the heart. This occurs due to cholesterol deposition on the walls of the vessels reducing the nutrient and oxygen supply to the heart muscles that is essential for the proper functioning of the heart. Therefore, this condition occurs when some part of the heart is deprived of the oxygen and blood supply that can lead to heart attack (Shepard et al. 2015, pp.455-456). In the given case study, Jack is suffering from DM type 1 that is the major risk factor for the disease. Hypertension also acts as a risk factor for the development of IHD and with time, the disease progresses. The longstanding high glucose levels damages arteries that make them hard and stiff. There is building up of fatty materials on the walls of these vessels blocking the blood flow to brain and heart that can lead to stroke (Shepard et al. 2015, pp.455-456).
PVD is also caused due to diabetes and hypertension, being the primary factor for the development of the disease. There is slow narrowing or blocking of the blood vessels that can also cause spasms. PHD is a progressive circulation disorder that also involves blood vessels outside heart like arteries, lymphatic vessels or veins. These vessels supplying blood to brain, legs are also constricted and results in improper functioning. PHD most commonly affects feet and legs where there is decrease in the inner size of vessels and eventually blocks the major arteries (Mascarenhas et al. 2014, pp.149-166).
Postural hypotension (PH) is the one of the signs associated with Jack’s fall, which he sustained at home and it could be a risk for him as he suffers from type I Diabetes Mellitus. PH is defined as fall in the systolic blood pressure > 20mm Hg or a fall in the diastolic blood pressure > 10mm Hg, following 3 minutes of continuous standing. It is associated with sympathetic autonomic dysfunction in patients suffering from diabetes mellitus (Bharucha et al. 2013, pp.330-339). It can cause renal failure and even sudden death. It is caused as a result of poor diabetic control and ageing. Diabetes is linked to PH as autonomic neuropathy and inappropriate usage of antihypertensive medications can give rise to sudden drops in the blood pressure, thereby resulting in falls as a result of syncope or fainting (Hjortkjær et al. 2016, p.e012307). Under normal conditions, when an individual changes to a standing position from a sitting position, the brain sends signals to the blood vessels of the legs to undergo constriction reflexively and in an instant manner. This prevents blood to accumulate in the leg, preventing blood and oxygen deprivation to the brain. However, in patients with diabetes mellitus, the nerves involved in signalling send poor signals to the leg blood vessels and thereby results in fall in blood pressure. This is a sign of sympathetic neuropathy and results in PH. However, anti-hypertensives like diuretics and alpha-1-antagonists like terazosin and prazosin can also cause postural hypotension. Individuals with diabetes are also at an increased risk of sustaining dehydration. High blood glucose levels in can lead to decrease in water content of the body resulting in dehydration. One of the symptoms of severe dehydration is fall in blood pressure, which can cause fainting in individuals. The patient was suffering from diabetes mellitus, so one of the reasons for his fall could be dehydration. Apart from diabetes, peripheral neuropathy can also cause postural hypotension (Canal et al. 2013). The peripheral nervous system helps to connect the central nervous system with the rest of the body like arms, legs, internal organs, mouth, among others. In peripheral neuropathy the nerves associated with the connections and the necessary signalling undergoes malfunction. These malfunctions are caused as a result of damage to these nerves. One of the symptoms associated with peripheral neuropathy is a drop in blood pressure, which can result in fainting. Nerve damage in peripheral neuropathy is mainly caused by diabetes (Metzler et al. 2013, pp.2212-2219; Tsantoulas et al. 2017, p. eaam6072).
The condition of atonic bladder is also linked with poorly controlled or long-standing diabetic condition. This condition is a urologic complication of diabetes referred as bladder dysfunction. There are complaints of urge incontinence to decreased bladder or overactive bladder and overflow incontinence. This is a condition faced by the patient as he had undergone supra pubic catheterisation. Neurological destruction is linked to the development of atonic bladder. Destruction of damaging of the nerves that are responsible for bladder control are associated with atonic bladder condition. This may result in obstructive urinary bladder, underactive or overactive urinary bladder. This is caused as a result of the alterations in the physiology of the detrusor muscles, neuronal impairment and urothelial dysfunction. This is the reason SPC supra pubic catheterisation was being administered in Jack. This could be a reason for dehydration in Jack leading to postural hypotension and risk for falls. An overactive bladder can cause the frequent release of urine from the body and if this fluid is not replaced, it results in dehydration (Chu, Tsai and Hwang 2016, p.S66; Ay et al. 2013, p. E135 ).
The resulting neuropathic condition that is witnessed in Jack in sensorimotor polyneuropathy, where he has lost the ability to feel or move due to nerve damage. Polyneuropathy is defined as the systemic or body wide condition where the nerves are damaged in different parts of body like nerve fibres, nerve cells and nerve coverings (Taveggia et al. 2014, pp.242-252). Sensorimotor polyneuropathy can cause damage in nerve cells, axons and the myelin sheaths. This damage takes place in the covering of the nerve cells that makes nerve signals to become slow or stop working. One of the causes of sensorimotor polyneuropathy is diabetes. Transmetatarsal amputation (TMA) is performed to preserve limb viability and is used to treat patients with diabetic neuropathy among other medical conditions. TMA is done in cases of forefoot ulcerations and gangrene complicated due to the presence of diabetes mellitus. The patient had also undergone carpal tunnel surgery. This surgery relieves pressure from the median nerve, thereby preventing carpal tunnel syndromes. Carpal tunnel syndrome causes numbness, weakness and tingling sensations in the hand because of pressure building in the median nerve of the wrist. Diabetes is one of the causes of carpal tunnel syndrome. Reduction in heart rate variability (HRV) is generally associated with diabetic sensorimotor polyneuropathy. The patient had also undergone coronary artery bypass surgery (CABG) to improve his blood flow to the heart. Thus, the patient suffers from severe sensorimotor polyneuropathy, which has affected his limbs like forefoot and wrists. Moreover, his heart is also affected.
From the above discussions regarding the pathophysiology of the conditions that are manifested in Jack, it is evident that diabetes and hypertension are the main reasons for the development and progression of these diseases. He developed postural hypotension as a result of his diabetes. He also suffered from sensorimotor polyneuropathy, which is associated with diabetes. For this reason, he had to undergo TMA to maintain his limb viability and also had to undergo carpal tunnel surgery to relieve pressure from the median nerves in his wrist. Another symptom of sensorimotor polyneuropathy is heart rate variability and as a result he had to undergo CBG. The cervical spine injury also exhibit complications like bladder dysfunction that leaves the detrusor muscles incapable of contraction and causes urine to flow back to the kidneys and so, SPC is being used that permit passive urine drainage at regular intervals for the prevention of bladder overfilling. The conditions are due to the complications of long-standing diabetes or hypertension in Jack that was either undiagnosed or poorly managed. Therefore, the main concern for his care are the diabetes and hypertension conditions and the SPC supra pubic catheterisation due to atonic bladder.
Jack’s current medications include Navorapid, Lantus solo star pen, Amlodipine. The immediate concern is to manage his diabetes and blood pressure levels. He suffered a sustained cervical spine injury, but it is not possible to reverse the spinal cord damage. However, pharmacological medications could promote regeneration of nerve cell and improve the nerve functioning. Therefore, the pharmacological interventions in spinal cord injury treatment is focused on the prevention of further injury and empowering Jack to lead a productive and active life.
The medication NovoRapid is used for the lowering of the blood sugar levels, as the pancreas cannot produce insulin to meet the requirements of the body (Wendt et al. 2017, p. 1932296817693254). The expected outcome of this medication is to lower the blood glucose levels as glucose cannot store or accumulated by the body for use. Novorapid stimulates the glucose uptake in fat and skeletal muscle, inhibits the production of hepatic glucose. This medication also inhibits proteolysis or lipolysis and enhances protein synthesis (Davisplus.fadavis.com, 2017). It has a rapid action and onset with shorter duration as compared to human insulin. It has a therapeutic effect of controlling hyperglycemia and so it can control the blood glucose levels of Jack, which were found to be high as he was suffering from type I diabetes mellitus, which results in inability of the body to produce insulin. The side effects of this drug include hypoglycemia in the endothelial cells and have local effects like swelling, erythema, pruritis and liposystrophy. It also has miscellaneous side effects include allergic reactions like anaphylaxis. The contraindications of this drug are in hypoglycemia, hypersensitivity or allergy and should be cautiously used in infection and stress. As Jack is suffering from type 1 diabetes, this drug must be used with longer-acting insulin that includes the precautions before using this drug for lowering the blood glucose levels. These precautions include inadequate dosing or treatment discontinuation. Inadequate or discontinuation of treatment can lead to diabetic ketoacidosis and hyperglycaemia. NovoRapid must not be injected if symptoms of hypoglycaemia develop. Dose adjustment is considered following blood glucose adjustment. Rapid onset of action of NovoRapid can be expected in the case of patients with concomitant diseases. Concomitant diseases increases patient’s requirements for insulin and as a result, the doses need to be changed. Insulin antibodies can form and insulin administration needs to be regulated in order to prevent hyper or hypoglycaemia. The nursing considerations include the proper administration of the drug and check for dose, type and expiration date. This drug should be administered by disposable external insulin pump and discarding of cartridges after 7 days. The infusion site should be changed every 48 hours and most importantly, insulin aspart should be administered along with a long-duration acting insulin due to Novorapid’s short duration of action (Jennings 2016, pp.132-23; Bowering et al. 2017, pp. 161770). The patient used a Lantus Solostar pen for insulin injection.
Amlodipine is used to lower blood pressure and also helps to improve blood flow to the heart, in case of blocked arteries. Amlodipine is an antihypertensive and calcium channel blocker that inhibit the transportation of calcium into vascular and myocardial smooth muscle cells that result in inhibition of excitation-contraction coupling and contraction. It has a therapeutic effect of vasodilation that results in decreased blood pressure. This coronary vasodilatation result in decreased severity and frequency of angina attacks and also helps in the treatment of high blood pressure or hypertension. The patient in the case study is treated with Amlodipine for the treatment of hypertension. However, the side effects of this drug include fatigue, dizziness, angina, peripheral edema, hypotension, bradycardia, angina, palpitations and may cause flushing, nausea and gingival hyperplasia. This drug is contraindicated in low systolic BP below 90 mm Hg and hypersensitivity. This drug should be cautiously used in aortic stenosis, severe hepatic impairment and should be used with utmost precaution. Before administration, nurse should consider the dose, route of administration and expiry date and may be administered without regard to the meals (Higaki et al. 2017, p.251). Amlodipine can cause low blood pressure, which can result in dizziness and fainting. Thus, it is necessary to monitor the blood pressure before its administration.
Lantus solostar pen or insulin glargine has therapeutic effect by lowering of the blood glucose levels through stimulation of glucose uptake in the fat and skeletal muscles. It inhibits the production of hepatic glucose and inhibition of lipolysis, proteolysis. It also enhances protein synthesis and control hyperglycemia. The adverse reactions of this drug are hypoglycemia, swelling, erythema, lipodystrophy and pruritis and can cause hypersensitivity including anaphylaxis. Before administration, the nurse should consider the dosage and administration of this drug as medication errors are common in insulin. Insulin syringes should be properly used and there should be no mixing of the drug with other insulin solutions. The drug should be administered subcutaneously once daily at the same time each day and should not be administered with insulin pumps or IV (Rosselli et al. 2015, p.251; Ranjan et al. 2016, p.410-418).
The assessment of the vital signs and diagnostic tests or activities is important for the patient-center care and planning. The patient history, vital signs, laboratory tests and physical examination is important for the proper planning of care and disease management. Vital signs of a patient are important for the healthcare professionals to determine the treatment options and provide critical information to make the decisions for treatment and management. In the given case study, after admission to the hospital, Jack was diagnosed with type 1 DM, hypertension through the diagnostic testing of blood. He suffered a serious fall at his home as a result of postural hypotension, which indicates that he had these medical conditions prior to hospital admission but was diagnosed after admission. Everyday Jacjkson was monitored thrice daily to check his blood sugar level before administration of insulin. It is necessary to check blood glucose levels before insulin administration, since, insulin administration following low blood glucose levels can give rise to serious health concerns and can also give rise to hypoglycaemia. Monitoring of blood glucose levels is essential to guide the therapy for diabetic patients. Patients with Type 1 diabetes are usually given 2 injections of two types of insulin per day. This generally progresses to 3-4 injections of different types of insulin. Types of insulin depends on blood glucose levels. Monitoring of blood glucose levels is essential in order to modulate the insulin dosage, activity and food consumption. The main reason for admission was fall, so X ray was done to look for any kind of injury that he has sustained after cervical spine injury. The patient’s past medical history revealed that he suffers from hypertension and diabetes. His blood pressure and blood glucose levels had to be monitored in the aged care, so that proper medications and nursing implementations were carried out to provide sufficient care to the patient. In the aged care, the patient’s blood pressure was checked regularly. This was because, he was suffering from hypertension, moreover, high blood glucose levels can also result in high blood pressure. Jack also suffered from heart problems and hypertension is a major risk factor for the development of ischemic heart disease. Therefore, it is necessary to monitor blood pressure, in order to prevent ischemic heart disease. Measurement of blood pressure is also needed in patients suffering from postural hypotension, which can increase the risk of falls. High blood pressure can also intensify the symptoms in patients suffering from angina, which in turn can increase the risk of heart attack. As Jack is hypertensive and sustained cervical spine injury, x-ray and ECG are important to assess his heart condition and any kind of internal injury after falling (Forbes and Watt 2015, pp.60). ECG can detect patterns in heart beats to monitor proper blood flow to the heart and necessary nursing care plan can be designed to prevent heart attack. Necessary care and monitoring is needed for patients with supra pubic catheterization. The bag should be present below the waist to prevent urine flow back to the bladder. It is also necessary to monitor whether the catheter is connected and to identify presence of kinks. It is also necessary to move the tubing in the absence of proper draining.
In the nursing process, the physical assessment and medical history are important part of data collection for the individualized, patient-centered and holistic care. The medical history is the foundation of diagnosis and treatment as it helps in the identification of patient care needs. The investigations are the key component in the patient assessment that enables healthcare professionals to enable high quality of patient care by giving them a better understanding of the patient’s complexities, conditions and processes that are involved in the planning care and treatment (LeMone et al. 2015, pp.7-9).
After Jack’s discharge from the hospital, it is necessary to hand over his necessary diet plan, nursing care and medications to the staff members in the aged care. It is necessary to monitor his blood pressure and blood glucose levels regularly to provide necessary care with respect to his medical condition. The rationale for choosing this issue is that as he is suffering from diabetic complications and sustained cervical injury, it is important to manage his diabetic or hypertensive condition and his compliance with medications. However, falls may not be an urgent issue but high blood pressure can affect his already deteriorating heart condition. For this, there is need for inclusion of other healthcare professionals who can promote his proper health and improve quality of life. Registered dietician, nurse educator, exercise physiologist and physiotherapists are required for Jack in keeping his diabetes and hypertension under control and compliance to medications. An exercise physiologist can inform patients about blood glucose and how to monitor it, so that proper medications can be taken. Moreover, they also provide information about eating strategies and exercises that would help to reduce body fat and high blood glucose levels. Nurse educator would help to educate Jack so that he can take control of his condition and coordinates treatment (American Diabetes Association 2015, pp.S4-S10). Registered dietician can educate and encourage him to follow his daily meal plan as a part of self-management at home and exercise physiologist would help him to develop appropriate exercise for maintaining his fitness level (American Diabetes Association, 2013, pp.S80-S85). Thus, a patient can carry out self -management at home, in the absence of others to take care of him.
According to the Nursing and Midwifery Board in Australia (NMBA) under National Competency standards for the registered nurses, feedback is important as it provides support and reassurance (Birks et al. 2016, pp.522-543). It helps the nurses to become motivated and by taking an active participation in the feedback progress, they can better understand their nursing practice and work towards their professional development. Seeking feedback in nursing practice helps to improve the nursing care and participate in the quality improvement processes. Self-appraisal and constructive feedback enhance critical thinking while reflecting on their nursing practice and in achieving a benchmark in the professional nursing development. Feedback from colleagues helps nurses to critically reflect on their nursing practice and undertake self-regulation on a daily basis for the enhancement of professional development and in identifying the professional needs (Fisher, 2017, p.4). Feedback aids in contributing to the professional development as they actively take part in the professional nursing practice as it provides additional knowledge to the existing nursing practice for its enhancement. Feedback can be gained from patients, carers, doctors, colleagues, among others. It helps in communicating with the patients, care givers and relatives to provide highly enhanced care for the patients. It also helps to carry out self-assessment, which can essentially help in improving the nursing practices. These in turn helps in the continuation of the nurse’s professional development. The NMBA standards for nurses stresses on a variety of domains. These include collaborative and professional practice, provisions for care and reflective or analytical practice. Collaborations in professional practice is necessary to make improvements in the existing nursing practices. Moreover, reflection of one’s practices are essential in order to analyse and self deduce the pros and cons associated with the practice to make improvements in the future in order to provide enhanced care to patients. Concisely, NMBA standards states that seeking feedback and using information from others by nurses helps in professional development and understanding on how to assess their nursing practice in variety of clinical settings.
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