Jack, a 58-year-old male suffering from a heart condition was admitted one day ago. He has been experiencing shortness of breath for the last two days but he reports to be worsening on admission. Jack was diagnosed with myocardial infarction 1 year ago. He has also been experiencing chest pains and discomfort when performing his activities of daily living but he now experiences pain even at rest. On admission, his vitals were respiratory rate of 30 bpm, pulse of 90 bpm, temperature of 37.8 and blood pressure of 140/90 mmHg. The patient is currently on oxygen to increase his oxygen supply and 500 mls of 10% dextrose is running intravenously.
Primary assessment
This assessment is designed to detect all immediate threaths to life and typically involves the airway, breathing and circulation (Karamercan, Bellou, & Blain 2018 pp. 23-48). This assessment focuses on six components which are;
Assessing the general impression of the patient. This will help to decide the seriousness of the patient’s condition basing on the level of distress and mental status.
Secondly, assessing the patient’s mental status to determine if the patient is responsive or unresponsive (Stuart, 2014). By using the AVPU scale one can be able to classify the patient successfully (Deakin, Fothergill, Moore, Watson, & Whitbread, 2014 pp. 905-909.). These are checking for alertness, verbal stimulation, painful stimulation and unresponsiveness. Alert patient will be awake, oriented and responsive. Verbal stimulation is assessed by patient’s responsiveness to loud verbal stimulus. The patient can either respond by speaking, grunting, groaning or opening their eyes. It does not necessarily mean that tge patient should answer questions or initiate a coversation even grunting alone is enough.
If the patient is not responsive to verbal stimulus, a painful stimulus is applied either a sternal rub or a pinch to the shoulder.
The patient said to be unresponsive if he does not respond to both verbal and painful stimuli.
Thirdly, asses the patient’s airway (Considine, & Currey 2015 pp. 300-307). This is checking if the patient’s airway is open. If the patient is unresponsive a jaw thrust maneuver is applied to open the airway (Meissen, and Johnson 2018, pp. 23-29). If a spinal injury is suspected, a chin lift maneuver is used.
If the airway is open, then breathing is assessed. This is done by listening to the patients mouth and nose for exhaled air and checking for chest movements. Chest symmetry and equal rise and fall of chest is noted. Any abnormal breath sounds on auscultation should be noted and an appropriate action taken.
Patient’s circulation is assessed by checking for pulse and bleeding. If the patient is not breathing, the carotid artery is used to check the pulse. If the patient is breathing, the radial pulse is used. If the carotid pulse is present and the radial pulse is absent then shock should be suspected. Shock is also suspected if the pulse is fast and bounding. Any uncontrolled bleeding is life threathening esspecialy in adults.
Finally, a decision is made on the priority or urgency of patient for transport. This depends on seriousness of patient’s condition.
A focused history and physical examination is obtained in order to care for a specific condition. Those requiring immediate intervention may not get to this stage. For example, CPR (Singletary, et.al, 2015 pp. S574-S589) A well detailed history of current complain and any other medical condition is helpfull in treatment of the patient.
Rapid or a focused assessment can be done. Rapid assessment is a quick head to toe assessment of a criticaly ill patient while focused assessment fouses on a specific injury or medical complaint. Vitals signs are also very important. Assessing pulse rate, respiration, skin signs such as color and temperature helps to know the condition of the patient. Pupil size, equality and reaction to light is also crucial in assessmwnt of a patient.
A head to toe examination is a quick physical examination of a patient and should not take more than three minutes.
Check the head for any bruises or cuts or any other signs of injury. Any deformities and depressions should also be noted. Eyes are inspected for any abnormal discharge, subconjuctival haemorrhage and pupil reaction (Krishna 2013, pp.537-544). Eyelids should also be inspected for any inflammation. Look for blood, clear fluids or bloody fluids from nose and ears. Any sign of inflammation should also be checked. Examine the mouth for airway obstruction color of the mucous membrane and the color of the tongue for any signs of dehydration. The neck is assessed for any signs of inflamation on both sides, trachael deviation and any other injuries esspecialy to the cervical spine.
The chest on inspection, identify any bruises or cuts. Symmetrical rise and fall of the chest is observed and respiratory rate taken. Any signs of difficulty in breathing such as chest indrawing should be identified and appropriate action taken. On auscultation any abnormal breath sounds such as crackles and rales are identified. Heart rate and heart sounds can also be heard. On palpation, check for any inflammations. Purcusion of the chest for resonance.
The abdomen is inspected for distention, any bruises and cuts. Auscultation to listen for bowel sounds is also done on the abdomen. Palpation for organomegally esspecially the spleen and the liver is done.
Lower extrimities are also assesed for oedema bruises and warmth. Capillary refill is also assessed.
Genitalia is inspected for any abnormal discharge and inflammations (Dillon 2015).
Findings on assessment of the chest there was chest in drawing when Jack breaths. The patient was showing signs of pain esspecially when breathing in as evidenced by patient guarding the chest. There was abnormal breath sound, crackles on auscultation of the chest. The respiratory rate of 34 breaths per minute was recorded. The patient had heart murmur and heart rate of 90 bpm. The radial pulse was fast and pounding on assessment.
Upper and lower extrimities
Oedema is evident esspecialy the lower extrimities.
– The first priority for this patient is to increase the oxygen supply for the patient. Jack is experiencing shortness of breath which makes him to breath at a higher rate than the normal breathing rate. This has to be corrected since rapid breathing by the patient may cause hyperventilation (Gelfand, Levin, Halpert, and Panteleon, Respicardia 2018, p. 488). This is because the level of carbon dioxide in the body will reduce
Chest pain is also a priority for this assessment. Jack is suffering from Myocardial Infarction and therefore, his pain can be managed through bed rest, reassuring him and relieving the pain. Jack should be given oxygen therapy to increase oxygen supply. Coronary Vasodilators like glyceryl Trinitrate will also improve coronary perfusion and oxygen supply to the heart (Divakaran, and Loscalzo 2017, pp. 2393-2410) which aid in relieving pain. Aspirin can also be given in cases where it is not contraindicated in order to lower the risk of formation of thrombus in blood vessels.
Physiological changes for the patient and how it relates to the signs and symptoms presented
Myocardial Infarction occurs as a result of blockage of blood supply to heart. When the arteries are blocked the blood supply decreases and hence oxygen supply is reduced. This therefore makes a patient breath faster so as to increase oxygen supply. Cardiac ischemia also results due to lack of oxygen which causes chest pain.
– Nursing interventions are usually done in order to achieve a specific goal that is shown by the patient’s respond after set time limit (Moorhead, Johnson, Maas, and Swanson 2018). If the goal that was set is achieved or the patient improvements shows that the goal is almost achieved, then this indicate that the nursing interventions has been effective. Whereas, whenever the patient does not show any signs of improvement or the goals set have not been achieved then probably the nursing interventions used are ineffective. For jack, in case the pain is alleviated and his breathing rate returns normal then the interventions will have been effective.
– To evaluate the patient understanding concerning his current health status, I will ask some few questions concerning his health for examples, when it started or the events that lead to the condition. Patient’s behaviour also may reflect his understanding (Drummond, Sculpher, Claxton, Stoddart, & Torrance, 2015). A patient who adheres to medication and cooperates towards his management clearly shows that he understands his medical condition. Feedback is the main component of communication which shows how effective a communication is. Therefore, Jacks feedback will aid me to know how functional my communication is (Kurtz, Draper, & Silverman, 2016). No response shows that he does not get me or understand the information being communicated. Jack gave clear feedbacks.
– Jack clearly understood his medical status and therefore I encourage him to continue with his medication and to cooperate throughout his management so that he can recover well. His feedback also gave me a clear indication that my communication was effective.
1. Shortness of breath
This is minimized by giving him oxygen therapy
2. Anxiety
This may stress Jack since it will make him nervous and may instil fear to him. I will minimize this by reassuring him that all will be well and also educating him concerning his conditions. This will make him understand the condition better which will make him less anxious. Moreover, this will enhance him to cooperate throughout his management.
3. Fatigue
Jack easily gets tired when performing his activities of daily life whenever he exerts some effort. This may stress him so much since he may not get to carry out self-care activities such as bathing and toileting. To minimise this, encourage full bed rest and assist him to perform some of this activities. Only assist where he cannot so as to also discourage full dependence by the patient.
Transfer of a patient is one of the most common activities in a hospital setting. Transfer can either be within the hospital facility (inter- hospital) or outside the hospital facility (Iwashyna, 2012 pp.2470-2478). Transfer of the patient within the hospital facility may be for example, movement of a patient from on department to another, from a bed to chair or wheelchair or even from a chair to a wheelchair. Patient transfer outside the hospital may be due to referral or to home for home care. All the transfers are useful done in order to improve the management that is already being given to a patient. It may be done for diagnostic procedure or to seek for advance care. Since transfer of a patient may leads to several physiological changes, it should be done accurately and as per the guidelines that exists. For jack, his transfer should be done in a manner that will not involve him using much energy. For examples it can be done with him lying on a flat surface. Proper hand hygiene should also be considered so as to minimize spread of infections to him. Proper hand washing before and after contact with the patient and his environment will be considered appropriate for this case. It is also essential to introduce oneself to Jack so as to beware of people handling him and to make him feel safe. Before transferring Jack proper identification should be done to ensure that he is the one being transfer and to also minimize major confusion which may ensue as a result of wrong identifications. For example, performing surgery on wrong patient. Patient privacy and dignity must also be considered. The patient should not be exposed during transfer since there are many people out there or even within the hospital premises. Exposure will violate the patient rights to privacy. Jack must also be transported with supporting equipment such as oxygen machines and a mask to increase oxygen supply to him. The nurse must also explain to the patient why he should be transferred and where he is being taken and any other procedure pertaining his transfer (Olsen, Østnor, Enmarker, and Hellzén 2013, pp. 2964-2973). A consent form may be signed where necessary. Jack should also be place in a supine or lateral position during transfer to aid his breathing. A nurse must also stay close to Jack to avoid falling and to also monitor him for any complications with may arise.
References
Considine, J. and Currey, J., 2015. Ensuring a proactive, evidence?based, patient safety approach to patient assessment. Journal of clinical nursing, 24(1-2), pp.300-307.
Deakin, C.D., Fothergill, R., Moore, F., Watson, L. and Whitbread, M., 2014. Level of consciousness on admission to a Heart Attack Centre is a predictor of survival from out-of-hospital cardiac arrest. Resuscitation, 85(7), pp.905-909.
Dillon, P.M., 2015. Nursing Health Assessment The Foundation of Clinical Practice: Nursing’s Role in Health-Care Delivery. FA Davis.
Divakaran, S. and Loscalzo, J., 2017. The role of nitroglycerin and other nitrogen oxides in cardiovascular therapeutics. Journal of the American College of Cardiology, 70(19), pp.2393-2410.
Drummond, M.F., Sculpher, M.J., Claxton, K., Stoddart, G.L. and Torrance, G.W., 2015. Methods for the economic evaluation of health care programmes. Oxford university press.
Gelfand, M., Levin, H., Halpert, A. and Panteleon, A., Respicardia, Inc., 2018. Detecting and treating disordered breathing. U.S. Patent 9,987,488.
Iwashyna, T.J., 2012. The incomplete infrastructure for interhospital patient transfer. Critical care medicine, 40(8), pp.2470-2478.
Karamercan, M.A., Bellou, A. and Blain, H., 2018. Primary Assessment and Stabilization of Life-Threatening Conditions in Older Patients. In Geriatric Emergency Medicine (pp. 23-48). Springer,
Krishnan, D.G., 2013. Systematic assessment of the patient with facial trauma. Oral and Maxillofacial Surgery Clinics, 25(4), pp.537-544.
Kurtz, S., Draper, J. and Silverman, J., 2016. Skills for communicating with patients. CRC Press.
Meissen, H. and Johnson, L., 2018. Managing the airway in acute care patients. The Nurse Practitioner, 43(7), pp.23-29.
Moorhead, S., Johnson, M., Maas, M.L. and Swanson, E., 2018. Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.
Olsen, R.M., Østnor, B.H., Enmarker, I. and Hellzén, O., 2013. B arriers to information exchange during older patients’ transfer: nurses’ experiences. Journal of Clinical Nursing, 22(19-20), pp.2964-2973.
Singletary, E.M., Charlton, N.P., Epstein, J.L., Ferguson, J.D., Jensen, J.L., MacPherson, A.I., Pellegrino, J.L., Smith, W.W.R., Swain, J.M., Lojero-Wheatley, L.F. and Zideman, D.A., 2015. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation, 132(18_suppl_2), pp. S574-S589.
Stuart, G.W., 2014. Principles and Practice of Psychiatric Nursing-E-Book. Elsevier Health Sciences.
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