Integrated Nursing Practice

Nursing Issues

The patient in the given case study is having cardiac symptoms. He is having multiple comorbidities and has been admitted to the emergency department with the complaint of chest tightness and increased shortness of breath. With the given clinical representation, the patient can be having three main underlying health issues that should be focused upon. These health issues are below-mentioned:

Hypertension
Tachycardia
Increased blood glucose level

Prioritizing of Health Concerns

Hypertension- The patient in the given case study is having multiple comorbidities. Patient is having a prior history of idiopathic (non-ischemic) dilated cardiomyopathy, diagnosed two years ago. He is also having a BMI of 29.4kg/m². He falls in the category of overweight. This adds to the underlying risk factors for the patient (Jian, 2017). Hypertension is also directly associated with decreased cardiac output (Brandt, 2019). This is an additional burden on the patient’s health as the patient is also having an underlying condition of dilated cardiomyopathy. This decrease in cardiac output can lead to the formation of multiple other complications such as increased vascular resistance, myocardial ischemia and with progression of the condition can also lead to ventricular hypertrophy or rigidity (Stewart, 2018). This add to the underlying risk for the patient, having a cardiac condition. Obesity is also an unfavorable factor for the development of hypertension in the patient. This development of obesity in the patient can bring about various cardiovascular complications in the patient. There has been a direct relation observed between the patients having severe obesity and advancement of hypertension. When the person is overweight, the heart has to work a bit harder to pump blood through. This exerts and additional strain on the arteries and thus, adds to the resistance on the blood flow. This leads to rise in blood pressure readings as well as development of multiple cardiovascular conditions in the patient (Carbone, 2019). The condition can life-threatening for the patient given in our case study, as he is already suffering from dilated cardiomyopathy.

Tachycardia- The heart rate readings of the patient observed in the emergency care department was found to be 110 beats per minute. This is reflective of patient having tachycardia. Heart diseases are considered as an underlying risk factor for development of tachycardia in the patient. Tachycardia is generally referred to the heart beat observed faster than the normal pattern. The beat is generally observed as more than 100 beats per minute (Yetkin, 2016). Some of the forms of tachycardia can be life-threatening for the patient. Tachycardia is also characterized by a rapid, inadequate heart rhythm. With an increased heart rate of the patient, there is an added burden on the heart to pump more oxygenated blood to compensate for the circulatory loss. The rapid increase in the heart rate can be life-threatening for the patient as well. It is very difficult to bring back the heart rate of the patient, back to normal easily and might require very aggressive approach to tackle with the same (Aspit, 2019). The parameter of accelerated heart rate is statistically proven to determine the underlying risk for cardiovascular disease development. The mortality rate with high heart rate is also significantly higher in patients having any underlying cardiovascular disease. Tachycardia is an independent risk factor for promoting hypertension in patients, that might require emergent medical management for enabling positive healthcare outcomes from the patient. Thus, tachycardia for the given case study is a major risk factor for the patient.

Increased blood glucose level- The patient is a known case of type-2 diabetes. The reflection of increased blood glucose levels can be a danger for the patient. with an increased blood glucose levels, the patient might develop long-term complications. These include, cardiovascular diseases, neuropathy, damage to the kidney functioning and other joint related issues as well. Both type 1 and type 2 diabetes form the foundational basis for the patient to develop increased risk of dilated cardiomyopathy. As the patient is having diabetes type-2, he might have developed the cardiomyopathy secondary to these symptoms. If the blood glucose levels rise than the normal range there are further complications that can be developed in the patients as well. Diabetic ketoacidosis is one of the complications that might develop secondary to the high blood glucose levels. With a rise in blood glucose levels the body tend to break down the fat for energy deposits (Peters, 2016). This process leads to the increased production of toxins in the body known as ketones. Excessive number of ketones are then accumulated in the blood which are then passed out in the urine. This condition, when left untreated, can cause a diabetic coma in the patient. the condition is also found to be life-threatening for the patient. Another underlying complication that might arise from the situation can be hyperglycemic hyperosmolar state. Condition can be observed when the person might be able to produce insulin but is not able to function as estimated. This might result in an accelerated rise in blood glucose levels, that eventually starts to use up body fat for producing energy (Fayfman, 2017). This eventually leads to increased urination frequency. If and when left untreated the condition can assimilate into a life-threatening dehydration and diabetic coma. The patient in the given case study is having an underlying risk factor for the development of both, to an increased blood glucose level reflected.

Role of Nurse

The clinical presentation of the patient, represents on the worsening of the symptoms of heart failure. This is marked by evidence of pulmonary hypertension and bilateral lower lobe congestion. The role of nurse in managing care for any patient, can be deemed as vital. In the given case scenario, the below-mentioned role can be reflected by the nurse:

Assessment- The detailed assessment for patient history should be undertaken in the study. The assessment can be inclusive of noting down the vitals and all of lab reports to connect the missing pieces in the clinical presentation (Lin, 2017).
Respiratory management- The patient is having signs of breathlessness and chest tightness. This is causing a respiratory distress in the patient. However, the patient is being managed with the help of oxygen supplement, it might not be enough for the patient. The patient can be kept in semi-fowler position to relieve him of his breathlessness (Simandalahi, 2020). It will be helpful in promoting ventilation for the patient.
Fluid management- The patient is observed to be having swelling in the extremities. This can be due to fluid overload in the body and reduced cardiac output due to underlying cardiomyopathy. Fluid management therapy or fluid replacement therapy options can be considered by the nurse to relieve the patient of his abnormal symptoms. The input and output of the patient should also be monitored on an hourly basis to note for any deficit or abnormal signs of reflection (Wallhult, 2017).
Anxiety management- The patient might be having anxiety due to onset of abnormal clinical presentation. Anxiety is shown to bring about an increase in the heart rate of the person (Williams, 2017). By relieving the anxiety of the patient, the heart rate can also be lowered comparatively.
Self-care management- The patient can be encouraged to practice self-care and management for his comorbidities. He can be encouraged for noting the blood pressure readings on a regular basis to make sure that abnormal fluctuation can be easily noted down (Pinchera, 2018). The patient can also be taught to self-manage his diabetes, by closely monitoring for the blood glucose levels. This will be helpful in identifying the early onset of adverse clinical symptoms.
Multidisciplinary approach- The patient can be assisted by working in close coordination with the other team members of the healthcare team. The role of physical therapist can be crucial in promoting the physical health of the patient. This can be done by developing a customized exercise plan for the patient. Nurses can take help from dietician in defining a dietary plan for the patient, keeping a close consideration for the patient’s underlying comorbidities. This will be helpful in lowering the overall risk to the patient’s health (Nayeri, 2020).
Patient education- The nurses can work in close coordination with the family members, to teach them about the importance of medical management. Nurses can cite recommendations for life-style modifications and enlighten the family on the importance of the same (Fakhr, 2016). These modifications can be defined as low-salt intake, introduction of activity in daily living routine, getting enrolled in plans for smoking cessation, promoting alcohol withdrawal of the patient, teaching them about acknowledging the worsening signs and symptoms of the patients.
Follow-ups- Nurses can also work in close coordination with the families and general practitioners to conduct follow-ups on the patient’s health status. This will be good for keeping an update on the patient’s health as well medication reconciliation for the patient. This will also allow the nurse to have an insight as to what interventions can be planned for the patient for future management and care.

References for Symptoms in Supraventricular Tachycardia

Aspit, L., Levitas, A., Etzion, S., Krymko, H., Slanovic, L., Zarivach, R., ... & Parvari, R. (2019). CAP2 mutation leads to impaired actin dynamics and associates with supraventricular tachycardia and dilated cardiomyopathy. Journal of Medical Genetics, 56(4), 228-235. http://dx.doi.org/10.1136/jmedgenet-2018-105498

Brandt, M. M., Nguyen, I. T., Krebber, M. M., van de Wouw, J., Mokry, M., Cramer, M. J., ... & Cheng, C. (2019). Limited synergy of obesity and hypertension, prevalent risk factors in onset and progression of heart failure with preserved ejection fraction. Journal of Cellular and Molecular Medicine, 23(10), 6666-6678. https://doi.org/10.1111/jcmm.14542

Carbone, S., Canada, J. M., Billingsley, H. E., Siddiqui, M. S., Elagizi, A., & Lavie, C. J. (2019). Obesity paradox in cardiovascular disease: Where do we stand?. Vascular Health and Risk Management, 15, 89. https://dx.doi.org/10.2147%2FVHRM.S168946

Fakhr-Movahedi, A., Rahnavard, Z., Salsali, M., & Negarandeh, R. (2016). Exploring nurse’s communicative role in nurse-patient relations: A qualitative study. Journal of Caring sciences, 5(4), 267. https://dx.doi.org/10.15171%2Fjcs.2016.028

Fayfman, M., Pasquel, F. J., & Umpierrez, G. E. (2017). Management of hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Medical Clinics, 101(3), 587-606. https://doi.org/10.1016/j.mcna.2016.12.011

Jian, S., Su-Mei, N., Xue, C., Jie, Z., & Xue-sen, W. (2017). Association and interaction between triglyceride–glucose index and obesity on risk of hypertension in middle-aged and elderly adults. Clinical and Experimental Hypertension, 39(8), 732-739. https://doi.org/10.1080/10641963.2017.1324477

Lin, S. H., Neubeck, L., & Gallagher, R. (2017). Educational preparation, roles, and competencies to guide career development for cardiac rehabilitation nurses. Journal of Cardiovascular Nursing, 32(3), 244-259. https://doi.org/10.1097/JCN.0000000000000346

Nayeri, N. D., Samadi, N., Mehrnoush, N., Allahyari, I., Bezaatpour, F., & NaseriAsl, M. (2020). Experiences of nurses within a nurse-led multidisciplinary approach in providing care for patients with diabetic foot ulcer. Journal of Family Medicine and Primary Care, 9(6), 3136. https://doi.org/10.4103/jfmpc.jfmpc_1008_19

Peters, A. L., Henry, R. R., Thakkar, P., Tong, C., & Alba, M. (2016). Diabetic ketoacidosis with canagliflozin, a sodium–glucose cotransporter 2 inhibitor, in patients with type 1 diabetes. Diabetes Care, 39(4), 532-538. https://doi.org/10.2337/dc15-1995

Pinchera, B., DelloIacono, D., & Lawless, C. A. (2018). Best practices for patient self-management: implications for nurse educators, patient educators, and program developers. The Journal of Continuing Education in Nursing, 49(9), 432-440. https://doi.org/10.3928/00220124-20180813-09

Simandalahi, T., Morika, H. D., & Fannya, P. (2020). The effect of alternate nostril breathing exercise in vital signs of congestive heart failure patients. International Journal of Community Medicine and Public Health, 7(1), 67. http://dx.doi.org/10.18203/2394-6040.ijcmph20195834

Stewart, J. M., Pianosi, P., Shaban, M. A., Terilli, C., Svistunova, M., Visintainer, P., & Medow, M. S. (2018). Postural hyperventilation as a cause of postural tachycardia syndrome: increased systemic vascular resistance and decreased cardiac output when upright in all postural tachycardia syndrome variants. Journal of the American Heart Association, 7(13), 85-94. https://doi.org/10.1161/JAHA.118.008854

Wallhult, E., Kenyon, M., Liptrott, S., Mank, A., Ní Chonghaile, M., Babic, A., ... & Fink, C. (2017). Management of veno‐occlusive disease: The multidisciplinary approach to care. European Journal of Haematology, 98(4), 322-329. https://doi.org/10.1111/ejh.12840

Williams, S. E., van Zanten, J. J. V., Trotman, G. P., Quinton, M. L., & Ginty, A. T. (2017). Challenge and threat imagery manipulates heart rate and anxiety responses to stress. International Journal of Psychophysiology, 117, 111-118. https://doi.org/10.1016/j.ijpsycho.2017.04.011

Yetkin, E. (2016). Symptoms in supraventricular tachycardia: Is it simply a manifestation of increased heart rate? Medical Hypotheses, 91, 42-43. https://doi.org/10.1016/j.mehy.2016.04.014

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