Chest Pain Evaluation – NSW Chest Pain Pathway

Troponin Level and its Association with Heart Disorder

Describe about the Chest Pain Evaluation (NSW Chest Pain Pathway?

Elevated troponin level indicates muscle cell death of the heart, as troponin is secreted into the blood stream after heart injury. Troponin is considered as a biomarker for heart disorder most importantly for myocardial infarction. There is a strong association between the pathology of troponin rise and pathology of acute coronary syndrome. It is very important to mention that smooth muscles do not have troponin but cardiac muscles contain troponin (Cheitlin, 2008). Production of muscular force in cardiac muscles is controlled by the alterations in the calcium concentration; when calcium concentration falls, muscles relax and when calcium concentration increase, muscle contracts. Along with tropomysin and actin, troponin, the component of the thin filaments, forms a protein complex. Calcium binding with this complex leads to the muscular force production. In case of cardiac complication the subunits of these proteins undergo conformational change. ACS is said to be the condition of plaque formation inside heart arteries. Mr. Lars expressed chest pain prior to having a cardiac arrest. 

2. The NSW chest pain pathway mentions that ECG interpretation is very much significant to manage the ACS associated pathology because it highlights the necessity to recognize patients rapidly with acute coronary syndrome. This is to make sure that the patient is receiving proper interventional care or thrombolysis as soon as possible; to standardize myocardial salvage and diminish ‘door-to-needle’ time of least 30minutes or less than that. It is hence very much important that the cardiology nurses are capable enough to verify and interpret ECG reports so that the required treatment can be started on an urgent basis. This will ensure better clinical consequences for Mr. Lara. With proper interpretation of electrocardiogram a nurse could state whether Mr. Lara has ST-elevation or no ST-elevation (Branch, 2015). From the case study it is known that Mr. Lara has unstable angina, the interpretation depends upon the cardiac marker (troponin). Negative result shows the presence of unstable angina and positive results leads the case further towards myocardial infarction.

3. Angina pectoris or chest squeezing is said to be a form of discomfort, tightness and pain, which initiates when a region of cardiac muscle is obtaining reduced supply of blood oxygen (Jackson, 2008). Angina is not a disease but an indication of coronary artery disease, a common form of cardiac disease. The deficiency of oxygenated blood to the heart is considered as the consequence of narrowing down the coronary arteries because of plaque formation, which is medically termed as atherosclerosis. Narrow arteries raise the possibility of pain and subsequently a heart attack. The main aims of antiaginal agents are easing severe chest pain, chest tightness by relaxing cardiac blood vessels, reducing work load of the heart and ensure that the oxygenated blood reaches to the heart.

The adverse effects of glyceryl nitrate include headaches, dizziness, elevated heart rate, vertigo, drowsiness, vomiting, and nausea (CSONT and FERDINANDY, 2005). The route of administration includes sublingual, intravenous, patches, topical (spray and ointment). Initially one tablet need to be placed under the tongue. In case the first dosage does not work, a second dose can be administered after 5minutes.

Importance of ECG Interpretation in NSW Chest Pain Pathway

4. Diagnosis of potassium level is important to detect abnormal heart rhythms. Abnormal rhythms can take place because of poor electrical signals generated by the affected heart muscles. Therefore, low potassium level can indicate presence of any kind of complication within the heart.

Keeping a track of blood calcium level is considered as one of the best predictor of upcoming heart attack. According to some researchers testing the level of calcium in coronary arteries can indentify individual with cholesterol in a better way, while comparing between C-reactive protein blood test and cholesterol lowering statin medicines.

Magnesium is a significant electrolyte required for proper enzyme, nerve and muscle function. It helps to move sodium and potassium in and out of the cells. Reduced level of magnesium in the blood represents poor muscle condition. Hence from the reduced level it could be inferred that complications might be present inside the system.

5. Defibrillation is said to be a widespread treatment for cardiac dysrhythmias, ventricular tachycardia and ventricular fibrillation. Defibrillation includes providing a therapeutic dosage of electrical energy. This treatment is assisted with defibrillator (‘Defibrillation’, 2011). It is said that the only efficient treatment for ventricular fibrillation is an on time defibrillation. However, defibrillation is effective only when it is given within initial few minutes during an unexpected cardiac arrest incident. This increases the chance of patient survival.

6. The main body fluid compartments include extracellular (interstitial fluid, transcellular fluid and plasma) and intracellular fluid. The intracellular fluid of cytosol or cytoplasmic matrix is liquid and found inside the cells. Cytosol is said to be a complicated mixture of components that include ions, proteins and organelles suspended in water. Extracellular fluid refers to the body fluid outside cells. Plasma serves as protein reserve of human system. It has a vital function in intravascular osmotic effect. This maintains electrolyte balance and protects human system from blood disorders and infections.  Transcellular fluid is considered as the part that contains water of the total system within the epithelial cell lines. Increased temperature and extended fever raises fluid loss and metabolic rate through evaporation. Heart rate increases and elevating tachycardia may specify systematic deficit of fluid. Symptoms of volume depletion: hypotension, tachycardia, reduced peripheral pulses, diminished urine output and diaphoresis. Symptoms of volume overload: dyspnoea, pitting oedema and fatigue.

7. a) Nurse should check patients’ neurological status; Glasgow Comma Scale assessment should be documented comprising limb assessment and pupil. Nurses should increase or decrease their observation frequency depend upon patient’s condition. They should reposition the patient frequently after the assessment of respiratory function and pressure areas. Skin integrity need to be monitored. The administration of anticoagulants and anti-embolism stockings need to be considered for nervous thromboembolism prophylaxis.

b) Pulse should be checked manually, this is because it gives significant medical information. Nurses should evaluate the pulse strength or pulse volume, regularity and rate. Thready, rapid and weak pulse indicates dehydration. During this time patient’s skin texture and temperature need to be assesses. Patients who are prone to dehydration, develops cool peripheries. If the condition of dehydration is more severe the limb coolness also extends, as vasoconstriction takes place to maintain blood pressure.

8. Digoxin tablets are indicated for Mr. Lars to control his condition of Atrial fibrillation. Digoxin is cardiac glycosides. Digoxin is excreted by the kidneys. It has positive inotropic and negative chronotropic activity. Digoxin controls ventricular rate in arterial fibrillation. Digoxin obstructs sodium potassium ATPase. Digoxin acts on the cardiac electrical activity and accordingly amplifying the gradient of phase four depolarization. This mechanism shortens the action potential duration and reducing maximum diastolic potential. The risk associated with toxic reactions to digoxin may be impaired renal function and exhaustion.

Yes, Digoxin is ordered correctly for Mr. Lars and it is administered twice oer day and the strength of the tablet is 250microgram.

9.

Sodium (Na+)	It is done to check electrolyte and water balance inside the system, indicates disease progression associated with adrenal glands or kidneys. Low sodium level indicates heart failure, diarrhoea and malnutrition.
Chloride (Cl¯)	It is done to check problems associated with adrenal glands or kidneys. Fluctuation of chloride level indicates muscle spasms, twitching, confusion, weakness and breathing problems.
Urea	It is performed generally to check the presence of Helicobacter pylori inside the stomach; this indicates the presence of condition like peptic ulcer and gastric ulcer.

10. Airway management is said to be a medical process to make sure that there is open passageway between outside world and patient’s lung along with diminishing aspiration risk. Airway administration is an important part of nursing care. Airway management is essential for Mr. Lars to support his diminish cardiac output and his condition of dyspnoea. Airway management steps include airway evaluation, acute management of airways and airway extubation. Nurses should be careful enough regarding airway management and deteriorating condition. Maintaining breathing is very important in any urgent situation. At cellular level, preoxygenation technique allows for denitrogenation or replacement of the nitrogen volume of lungs with oxygen. In case of ventilation difficulty, patient’s oxygen saturation level may fall rapidly. So nurses should be well aware of these factors during airway management. Nursing care includes preparatory steps: preoxygenation. This involves administration of almost 100% oxygen with help of face mask during spontaneous breathing prior anesthetic induction.

Progress notes

Date and Time	Progress Notes
19/3/2015; 9.00AM	Attended chest x-ray, waiting for review. IV administration into left orbital fossa. Blood taken and sent for analysis. Pain score 1/10 and ready to transfer to CCU.
20/3/2015; 10.00AM	Patient received and attached to ECG monitor; waiting for blood result. Chest x-ray report shows no active disease and intravenous channel is dislodged.

References:

Branch, A. (2015) Chest Pain Evaluation (NSW Chest Pain Pathway) – NSW Health. NSW Department of Health. Available at: https://www0.health.nsw.gov.au/policies/pd/2011/PD2011_037.html (Accessed: 20 March 2015).

Cheitlin, M. D. (2008) ‘Prognostic Value of Very Low Plasma Concentrations of Troponin T in Patients With Stable Chronic Heart Failure’, Yearbook of Cardiology, 2008, pp. 345–346. doi: 10.1016/s0145-4145(08)01032-0.

CSONT, T and FERDINANDY, P (2005) ‘Cardioprotective effects of glyceryl trinitrate: beyond vascular nitrate tolerance’, Pharmacology & Therapeutics, 105(1), pp. 57–68. doi: 10.1016/j.pharmthera.2004.10.001.

‘Defibrillation’ (2011) SpringerReference. doi: 10.1007/springerreference_224875.

Jackson, G. (2008) Angina. United Kingdom: Informa Healthcare.