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Integrated Nursing Practice

Table of Contents

Introduction.

Discussion and analysis.

Reference list

Annotation of the sources.

Introduction to The Deteriorating Patient

The management of critical condition of a patient demands high analysing power, knowledge over pharmacology, nursing skill along with other interdisciplinary skills. In the context of nursing the application of evidence-based practice has immense importance as it helps in the development of all the mentioned skills within the nurse. In this study, the analysis and discussion about the management of deteriorating patients with cardiogenic shock should be analysed.

Discussion and Analysis on The Deteriorating Patient

Jonty Clement is the patient with the age of 71 years and has a coronary artery bypass operation (triple vessel). The acute clinical condition of the patient also includes a myocardial infarction at the anterior wall. As per the viewpoint of Dohi et al. (2015, p. 565-566), the main pumping action of the heart is modulated by the anterior wall tissues and muscles. Bhardwaj et al. (2014, p. 44) has added that the degradation and deterioration in the normal function of the anterior wall leads to the decrease of the blood pressure along with heart rate amplification and cardiogenic shock as well. All these factors have been noticed and this has driven to the deterioration of the patient.

As per the case study, the past social history of Jonty has revealed that he is behaviourally challenged. The fluctuation of mood or getting verbally disruptive and getting aggressive is quite common in his behaviour. This residential care staffs has revealed that all the factors have driven them to conclude that the patient has impulsive behaviour. As per the viewpoint of Pazokian & Borhani (2017, p. 76-80), NSQH standard of nursing for acute deteriorating patients provides stress over the fact of delirium. In this context Boyd & Sheen (2014, p. 36-37) have also mentioned that the nurse has to have knowledge and the skill, about early identification of post-operative delirium and should have knowledge regarding the benefit of the treatment of the same. In the case of Jonty Clement, this factor of NSQH is highly applicable as the patient has the tendency of impulsive behaviour which includes frequent episodes of depression, happiness, agitation and verbal aggression.

The failure in recognition of the condition of clinical deterioration takes place majorly due to the lack of efficiency of the nurse. As per the idea of Flanigan (2016, p. 23), knowledge deficit, lack of monitoring skill along with the lack of analytical skill of the caregiver drives the patient towards acute deterioration. The lack of monitoring skill regarding the clinical condition along with the sign and symptoms of delirium has been noticed in the RN (Registered Nurse) of Jonty. In this case, the contributing factor includes the improper handover of the patient. The cause of deterioration of the behaviour of the patient has been explained as the change of environment and lack of sleep but the fact of delirium has not been mentioned. Moreover, the lack of knowledge in the implementation of the drug dosage is another factor which has invoked a crisis.

The analysis of the signs and symptoms along with the medical and social history of the patients as per the NSQH standard should be followed in future to minimise the issue of clinical deterioration. As per the viewpoint of Girard et al. (2018, p. 2509-2512), Haloperidol is an effective medicine for delirium as it has been identified as first-generation drug and it has inhibitory action over dopamine molecules (D2 receptor) to increase its turnover. This has been charged by the RN to manage the patient. As per the viewpoint of Agar et al. (2017, p. 35-41), the maximum dosage of Haloperidol is 2.5mg for 8 hour. However, the RN has administered 5 mg of the drug within 3 hour. This has invoked a major crisis for the patient. Hence, the deficient of knowledge should be managed to minimise the chance of clinical deterioration.

Jonty is a patient with bypass surgery and has myocardial infarction in the anterior wall. Hence, the analysis of heart rate and BP (blood pressure) is highly crucial. As per the idea of Woodruffe et al. (2015, p. 335-340), the regular monitoring and comparative analysis of data regarding the BP and pulse of a CVD patient is highly necessary in the process of clinical care giving. However, this has not been properly done which has triggered the situation of clinical deterioration of the patient. As per the case study, at the deteriorating condition, the patient has 90/46 mmHg BP and irregular pulse rate as well. The heart rate has been identified as 52 per minute and irregular as well. This is highly associated with the pathophysiology of the patient. As per the idea of Freeman et al. (2015, p. 395-399), with the lowering of BP and irregular cardiac rate is tagged with the pathophysiology of Atrial fibrillation. This has effectively been identified in the patient with ECG. It has already been mentioned that the patient with anterior wall myocardial infarction suffers from low BP. On the other hand, the administration of Diltiazem has been done along with Metoprolol.

As per the idea of Omray et al. (2014, p. 443-445), Diltiazem is often used for the patients with Angina. Additionally, as per Omboni et al. (2014, p. 15-19), Ramipril helps in the minimisation of hypertension of the patient by being an ACE inhibitor. In the case study it has been identified that Ramipril has been charged over the patient along with Metoprolol, which is one of the leading molecules to treat patients with high BP. Hence, it can be analysed that the selection of the drug combination for the patient indicates lack of knowledge of the nurse in the pharmacology. Additionally, it has been noticed that, to minimise the impulsive and aggressive behaviour of the patient, Haloperidol has been charged in the wrong (higher) dosage. Hui et al. (2017, p. 1047-1049) has researched the antipsychotic impact of Haloperidol and has mentioned that the side effect of this molecule is associated with the lowering of BP of the patient. All these factors have invoked the crisis in the management of the BP rate of the patient. The persistent low BP triggers sinking of the patient and indicates clinical deterioration. These factors have specifically been noticed in the body of Jonty.

The irregular heart beat is the most priority problem in the patient and has been identified as the root cause for the deterioration of the patient. Scarsoglio et al. (2014, p. 912-915) has researched in this domain and has mentioned that irregular cardiac output and heartbeat indicates malfunction of the heat of the patient. Improper cardiovascular function invokes hypoxia in the body and the body turns blush and cold as well. The same factor has been noticed in the body of Jonty. A cold flush has been identified in the cheeks of the patient. Moreover, bluish ting has been noticed in the fingertips of the patient as well. As per the idea of Morand et al. (2018, p. 2-7), the improper supply of fresh blood in the body parts invokes blush ting which triggers improper functioning of the same. The lack of supply of oxygenated blood has also taken place in the kidney of the patient. This has triggered the minimisation of the renal output of the same. The case study has informed that there is oedema (grade 2) in the body of the patient probably for the deposition of fluid. The 30 ml output of urine has also been noted which also indicates the lowering of the renal functioning. All these factors have happened for the improper functioning of the heart and improper supply of fresh blood in the different parts of the body.

The major clinical intervention of this condition should include pharmacological intervention in the specific manner. Formerly, the dosage of the drugs should be restructured and the combination of the drugs prescribed for hypertension should be discontinued immediately. The administration of Metoprolol should be stopped and the dosage of the drug like Haloperidol should be restructured. For the next 24-16 to 20 hours no application of haloperidol is done. On the other hand, Diltiazem should be continued as the patient has Angina. However, another drug specifically for Arrhythmia and Atrial fibrillation should be implemented which will help the patient to regain its stable stage. As per the idea of Darkner et al.(2014, p. 3356-3364) Amioderon directly acts in the management of arrhythmia and Atrial fibrillation. Class III antiarrhythmic molecule , it has effectiveness in blocking repolarisation in the cardiac muscle Steffel et al. (2015, p. 2239-2245). Hence, this should be the best option for the management of the crisis of Jonty Clement.

On the other hand, to manage the issue of delirium, patient-centered care should be implemented. The meaningful interaction with the patient along with the management of the sleep hygiene and emotional needs should be focused.

Conclusion on The Deteriorating Patient

At the end of the study, it can be concluded that the management of the critical condition of a patient along with safeguarding the patient from getting further deteriorated is quite critical for a caregiver. The skill in sign and symptom analysis along with the selection of drug molecules is important as per the deteriorating condition of the patient. However, in this case, the dosage of the drug has been identified as one of the major causes behind the deterioration.

Reference List for The Deteriorating Patient

Agar, M. R., Lawlor, P. G., Quinn, S., Draper, B., Caplan, G. A., Rowett, D., ... & McCaffrey, N. (2017). Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA internal medicine177(1), 34-42. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2588810

Bhardwaj, R., Kandoria, A., & Sharma, R. (2014). Myocardial infarction in young adults-risk factors and pattern of coronary artery involvement. Nigerian medical journal: journal of the Nigeria Medical Association55(1), 44. https://doi.org/10.4103/0300-1652.128161

Boyd, L., & Sheen, J. (2014). The national safety and quality health service standards requirements for orientation and induction within Australian Healthcare: A review of the literature. Asia Pacific journal of health management9(3), 31-37. http://dro.deakin.edu.au/view/DU:30069760

Darkner, S., Chen, X., Hansen, J., Pehrson, S., Johannessen, A., Nielsen, J. B., & Svendsen, J. H. (2014). Recurrence of arrhythmia following short-term oral AMIOdarone after CATheter ablation for atrial fibrillation: a double-blind, randomized, placebo-controlled study (AMIO-CAT trial). European heart journal35(47), 3356-3364. https://academic.oup.com/eurheartj/article-abstract/35/47/3356/2293164

Dohi, T., Maehara, A., Brener, S. J., Généreux, P., Gershlick, A. H., Mehran, R., ... & Stone, G. W. (2015). Utility of peak creatine kinase-MB measurements in predicting myocardial infarct size, left ventricular dysfunction, and outcome after first anterior wall acute myocardial infarction (from the INFUSE-AMI trial). The American journal of cardiology115(5), 563-570. https://doi.org/10.1016/j.amjcard.2014.12.008

Flanigan, K. (2016). NSQHS standard-patient identification. ACORN: The Journal of Perioperative Nursing in Australia29(1), 23. https://search.informit.com.au/documentSummary;dn=883877754554045;res=IELHEA

Freeman, J. V., Simon, D. N., Go, A. S., Spertus, J., Fonarow, G. C., Gersh, B. J., ... & Chang, P. (2015). Association between atrial fibrillation symptoms, quality of life, and patient outcomes: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation: Cardiovascular Quality and Outcomes8(4), 393-402. https://doi.org/10.1161/CIRCOUTCOMES.114.001303

Girard, T. D., Exline, M. C., Carson, S. S., Hough, C. L., Rock, P., Gong, M. N., ... & Khan, B. (2018). Haloperidol and ziprasidone for treatment of delirium in critical illness. New England Journal of Medicine379(26), 2506-2516. https://doi.org/ 10.1056/NEJMoa1808217

Hui, D., Frisbee-Hume, S., Wilson, A., Dibaj, S. S., Nguyen, T., De La Cruz, M., ... & Epner, D. (2017). Effect of lorazepam with haloperidol vs haloperidol alone on agitated delirium in patients with advanced cancer receiving palliative care: a randomized clinical trial. Jama318(11), 1047-1056. https://jamanetwork.com/journals/jama/article-abstract/2654385

Morand, J., Arnaud, C., Pepin, J. L., & Godin-Ribuot, D. (2018). Chronic intermittent hypoxia promotes myocardial ischemia-related ventricular arrhythmias and sudden cardiac death. Scientific reports8(1), 1-8.

Omboni, S., Malacco, E., Mallion, J. M., Fabrizzi, P., & Volpe, M. (2014). Olmesartan vs. ramipril in elderly hypertensive patients: review of data from two published randomized, double-blind studies. High Blood Pressure & Cardiovascular Prevention21(1), 1-19. https://doi.org/10.1007/s40292-013-0037-9

Omray, K. L., Jain, P. K., Kharia, A. A., & Pounikar, Y. (2014). Development of transdermal drug delivery system of diltiazem hydrochloride for the treatment of hypertension. International Journal of Pharma Sciences and Research5(8), 441-445. http://www.ijpsr.info/docs/IJPSR14-05-08-102.pdf

Pazokian, M., & Borhani, F. (2017). Nurses’ perspectives on factors affecting patient safety: A qualitative study. Evidence Based Care7(3), 76-81. http://eprints.mums.ac.ir/8319/

Scarsoglio, S., Guala, A., Camporeale, C., & Ridolfi, L. (2014). Impact of atrial fibrillation on the cardiovascular system through a lumped-parameter approach. Medical & biological engineering & computing52(11), 905-920. https://link.springer.com/article/10.1007/s11517-014-1192-4

Steffel, J., Giugliano, R. P., Braunwald, E., Murphy, S. A., Atar, D., Heidbuchel, H., ... & Ruff, C. T. (2015). Edoxaban vs. warfarin in patients with atrial fibrillation on amiodarone: a subgroup analysis of the ENGAGE AF-TIMI 48 trial. European heart journal36(33), 2239-2245. https://academic.oup.com/eurheartj/article-abstract/36/33/2239/2466008

Woodruffe, S., Neubeck, L., Clark, R. A., Gray, K., Ferry, C., Finan, J., ... & Briffa, T. G. (2015). Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014. Heart, Lung and Circulation24(5), 430-441. https://doi.org/10.1016/j.hlc.2014.12.008

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