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Preparation for Practice

Part 1- Cardiovascular Assessment (Mr. Richard Kleinfelt)

Subjective assessment- Subjective clinical data is generally presented by the patient in his own wordings and as per his own perception and understandings (Ha 2016, pp. 11-17). For carrying out an extensive cardiovascular assessment for a 55-year-old male, following questions can be asked from the patient under the below-mentioned sub-headings.

Any Current Problems

This is to make sure that the patient is not having current primary concerns. This aspect can cover following question to be asked from the patient:

  • Are you currently having any symptoms?
  • Are you currently experiencing any pain?
  • If yes than, how long you have been experiencing these symptoms?
  • Factors that aggravate or relive the symptoms (Moon 2018, pp. 251-257).

Personal History

  • Do you smoke, use drugs or consume alcohol on current basis?
  • How often do you exercise in a week?
  • What do you prefer to eat for your breakfast, lunch and dinner?
  • Have you had any heart surgery in the past?
  • Do you currently experience stress?
  • What is a typical working day for you?

Family History (Dzikowicz 2020)

Is anyone in your family having a history of heart disease or any underlying cardiovascular issue?

  • Has anyone in your family passed away because of cardiovascular disease?
  • If yes, then at what age the person passed away?

Physical Health History

  • Do you experience any chest pain?
  • Do you experience breathlessness very often?
  • Do you sweat profusely at times?
  • Do you experience swelling in your feet and arms?
  • DO you develop any wound any often and experience delayed healing?
  • Do you feel lethargy and fatigued very often?

Objective assessment- This comprises of the clinical assessment carried out by a professional nurse to note for the adverse clinical signs and symptoms present in the patient (Hunt 2020, pp. 102-179). Objective assessment can be inclusive of the following points:

General

  • Noting for the build of the patient.
  • Assessing for signs of pallor and difficulty in breathing.
  • Noting for increased central or peripheral cyanosis (Tran 2017, pp. 158-167).
  • Assessing for clubbing in hands.
  • Checking the patient for Osler’s nodes. These nodes are generally present at the fingertips that can be indicative of infective endocarditis (Kiefer 2019, pp. 105-120).

Pulse

  • Noting for normal pulse range.
  • Noting for respiratory rate and rhythm.
  • Noting for common signs of heart rate abnormalities such as, bradycardia or arrythmias.
  • Noting for inequality of pulses, especially in the peripheral regions.

Blood pressure reading

  • This is required to determine any underlying complication due to increased blood pressure.
  • For patients having asymmetrical radical pulses, bilateral radial pulse should be assessed (Gkaliagkousi 2018, pp. 850-857).

Chest examination

  • Checking for any chest deformity (Behr 2019, pp. 1926-1928).
  • Noting for normal chest expansion.
  • Palpating the chest for noting the respiratory interval.
  • Observing and palpating trachea for any deviation or any abnormality.
  • Chest auscultation for presence of any abnormal breath sounds or chest murmurs.

Investigations

  • 12 lead ECG monitoring as well as ambulatory ECG monitoring.
  • ECG based exercise testing.
  • General blood work-up including LFT and KFT panel, testing for cardiac enzymes.
  • Chest X-ray
  • Noting for ambulatory blood pressure.

Part 2- Nursing Assessment (Mrs. Ruth Jones)

SOAP assessment is an acronym for Subjective, Objective, Assessment and Plan (Sando 2017, pp. 576-584). This is one of the most effective methods which is used by the healthcare professionals to document the details of the patient through a detailed and structured manner. The data for the patient included as per various sub-headings include as follow:

Subjective

The patient in the give case study is a 65-year-old female. She appears alert and oriented to the time and place. She is visiting the clinical setting as she is experiencing shortness of breath on exertion. The patient has been experiencing these symptoms over the last few days. This is accompanied with increased chest pain and cough with green coloured sputum. Patient mainly feels breathless while lying flat. Patient is also having anxiety and hopes to see her son very soon.

Objective data

  • Patient is having dyspnoea on exertion.
  • Chest pain as measured on VAS scale is 5/10.
  • Thick sputum with greenish color appearance.
  • Increased shortness of breath in supine lying.
  • Mild cyanosis present in extremities.
  • Delayed capillary filling time observed of 5 seconds as compared to the normal time of 1-2 seconds (Flower 2017, pp. 92-100).
  • Bilateral chest auscultation observed. The right lower lobe reveals presence of crackles.
  • Positive use of accessory muscles observed on auscultation.
  • No abnormality observed on palpitation.
  • The blood pressure readings are observed on a hypertensive trend. The reading for systolic blood pressure is higher as compared to diastolic reading.
  • Patient is able to maintain a good oxygen saturation rate of 99% on room air.
  • The respiratory rate of the patient is also within normal range.
  • Body temperature of the patient is normal.
  • ECG recording observed is within normal reading.
  • Pulse rate of the patient is also within normal range.

Assessment

Patient is having a diagnosis of cardiorespiratory symptoms. The patient is having a diagnosis of Chronic Obstructive Pulmonary Disease and overall cardiac insufficiency.

Planning

The patient intervention planning has to be drafted in sync with both cardiac and pulmonary aspect. Following intervention planning can be carried out for the patient:

  • The patient can be enrolled in physical activity to be included as a part of activity of daily living. The inclusion of exercise can be useful in reducing the underlying cardiovascular risk (Grossman 2017, pp. 167-174).
  • The patient can be helped with respiratory rehabilitation. This can be done for enabling smooth facilitation of ventilation rate. The role of physical therapist can be vital in the process. The physical therapist can help in devising an exercise plan as per the patient’s requirements. This can also be considered from the point of view of enhancing lung capacity and improved ventilation.
  • The role of dietician is also vital in the process. The dietary constrains for the patient can be helpful in reducing the overall cardiovascular impact on the patient.
  • Nurse can also help the patient by working in close coordination with the medical team members to provide holistic care approach to the patient (Connolly 2017, pp. 840-847).
  • The patient can also be educated about the harmful effects of the condition on the patient and as to how the condition can be managed.
  • Apart from patient education, family education should also be carried out. The nurse can help the family members to be involved in the process of patient care and coordination.
  • Precautionary measures can be taught to the patient, such as maintaining bronchial hygiene, noting for vitals such as blood pressure at home through constant monitoring. Bronchial hygiene can be taught to the patient to make sure for effective cleaning of the lung passages and thus, attaining positive airway clearance. This will help in lowering the chances of development of underlying chest infection in the patient.
  • Educating the patient about noting the adverse signs such as extreme fatigue, extreme breathlessness and reporting the same to the concerned authority.
  • Medication education and reconciliation can be carried out for the patient. This will help in lowering the risk of adverse medication reaction in case the patient is suffering from multiple comorbidities. Regular medication reconciliation is also to be done to regulate the medication dosage as per the current clinical signs and symptoms reflected by the patient (Rungvivatjarus 2020, pp. 27-36).
  • The inculcation of regular follow-ups should be done with the patient, to keep a close monitoring in the health status and enabling patient care in accordance with the same (De 2016, pp. 70-76). The patient might reflect on abnormal patterns that need emergent care and thus, care can be provided within the stipulated time-frame.
  • Planning of the patient care can also be inclusive of the diagnostic testing to be carried out as per the patient’s clinical signs and symptoms. Some of the routine check-ups can include, Chest X-ray, ECG monitoring, blood gas analysis and random blood workup to keep a vigil on blood glucose and other levels.
  • Self-care management is another positive method that can be most appropriate for the patient. The patient can be taught self-management techniques (Miguel 2016, pp. 240-256). These can be inclusive of taking steam inhalation for infection prevention, practising deep breathing techniques for ventilation promotion and easy medication administration to be done in a religious manner. Self-care management can also help in lowering the associated anxiety of the patient and can be helpful in promoting and enhancing an independent status of living for the patient (Auld 2018, pp. 543-551). This can be considered as a positive implication for attaining desired healthcare outcomes from the patient. Thus, helping in promoting overall well-being of the patient and considerably lowering the side effects.

References for The Effect of A Telephone-Based Self-Management Program

Auld, J.P., Mudd, J.O., Gelow, J.M., Lyons, K.S., Hiatt, S.O. and Lee, C.S., 2018. ‘Patterns of heart failure symptoms are associated with self-care behaviors over 6 months’. European Journal of Cardiovascular Nursing, vol. 17, no. 6, pp.543-551. DOI https://doi.org/10.1177%2F1474515118759074

Behr, C.A., Denning, N.L., Kallis, M.P., Maloney, C., Soffer, S.Z., Romano-Adesman, A. and Hong, A.R., 2019. ‘The incidence of Marfan syndrome and cardiac anomalies in patients presenting with pectus deformities’. Journal of Pediatric Surgery, vol. 54, no. 9, pp.1926-1928. DOI https://doi.org/10.1016/j.jpedsurg.2018.11.017

Connolly, S.B., Kotseva, K., Jennings, C., Atrey, A., Jones, J., Brown, A., Bassett, P. and Wood, D.A., 2017. ‘Outcomes of an integrated community-based nurse-led cardiovascular disease prevention programme’. Heart, vol. 103, no. 11, pp.840-847. DOI http://dx.doi.org/10.1136/heartjnl-2016-310477

De Souza, J., de Almeida, L.Y., Moll, M.F., Silva, L.D. and Ventura, C.A.A., 2016. ‘Structure of the social support network of patients with severe and persistent psychiatric disorders in follow-ups to primary health care’. Archives of Psychiatric Nursing, vol. 30, no. 1, pp.70-76. DOI https://doi.org/10.1016/j.apnu.2015.10.001

Dzikowicz, D.J., 2020. ‘The Unintended Consequences of Subjective Assessments and the Need for Objective Measurement in Emergency Departments’. Journal of Cardiovascular Nursing, vol. 35, no. 5, pp.9-10. DOI 10.1097/JCN.0000000000000724

Flower, R.W. and Kling, R., 2017. ‘A clinical method for quantification of tissue microvascular blood perfusion in absolute terms [blood-volume/(time· tissue-area)]’. Microvascular Research, vol. 114, pp.92-100. DOI https://doi.org/10.1016/j.mvr.2017.05.009

Gkaliagkousi, E., Anyfanti, P., Lazaridis, A., Triantafyllou, A., Vamvakis, A., Koletsos, N., Dolgyras, P. and Douma, S., 2018. ‘Clinical impact of dipping and nocturnal blood pressure patterns in newly diagnosed, never-treated patients with essential hypertension’. Journal of the American Society of Hypertension, vol. 12, no. 12, pp.850-857. DOI https://doi.org/10.1016/j.jash.2018.08.004

Grossman, D.C., Bibbins-Domingo, K., Curry, S.J., Barry, M.J., Davidson, K.W., Doubeni, C.A., Epling, J.W., Kemper, A.R., Krist, A.H., Kurth, A.E. and Landefeld, C.S., 2017. ‘Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors: US Preventive Services Task Force recommendation statement’. JAMA, vol. 318, no. 2, pp.167-174. DOI 10.1001/jama.2017.7171

Ha, E.H., 2016. ‘Undergraduate nursing students' subjective attitudes to curriculum for Simulation-based objective structured clinical examination’. Nurse Education Today, vol. 36, pp.11-17. DOI https://doi.org/10.1016/j.nedt.2015.05.018

Hunt, L., Ramjan, L.M., Daly, M., Lewis, P., O’Reilly, R., Willis, S. and Salamonson, Y., 2020. ‘Development and psychometric testing of the 10-item satisfaction with Nursing Skill Examination: Objective Structured Clinical Assessment scale’. Nurse Education in Practice, p.102-179. DOI https://doi.org/10.1016/j.nepr.2020.102779

Kiefer, T.L. and Bashore, T.M., 2019. ‘Infective endocarditis: a comprehensive overview’. Reviews in Cardiovascular Medicine, vol. 13, no. 2, pp.105-120. DOI 10.3909/ricm0633

Miguel Padilha, J., Sousa, A.P. and Pereira, F.M., 2016. ‘Participatory action research: A strategy for improving self-care management in chronic obstructive pulmonary disease patients’. Action Research, vol. 14, no. 3, pp.240-256. DOI https://doi.org/10.1177%2F1476750315606196

Moon, M.K., Yim, J. and Jeon, M.Y., 2018. ‘The effect of a telephone-based self-management program led by nurses on self-care behavior, biological index for cardiac function, and depression in ambulatory heart failure patients’. Asian Nursing Research, vol. 12, no. 4, pp.251-257. DOI https://doi.org/10.1016/j.anr.2018.10.001

Rungvivatjarus, T., Kuelbs, C.L., Miller, L., Perham, J., Sanderson, K., Billman, G., Rhee, K.E. and Fisher, E.S., 2020. ‘Medication reconciliation improvement utilizing process redesign and clinical decision support’. The Joint Commission Journal on Quality and Patient Safety, vol. 46, no. 1, pp.27-36. DOI https://doi.org/10.1016/j.jcjq.2019.09.001

Sando, K.R., Skoy, E., Bradley, C., Frenzel, J., Kirwin, J. and Urteaga, E., 2017. ‘Assessment of SOAP note evaluation tools in colleges and schools of pharmacy’. Currents in Pharmacy Teaching and Learning, vol. 9, no. 4, pp.576-584. DOI https://doi.org/10.1016/j.cptl.2017.03.010

Tran, D.M.T., Zimmerman, L.M., Kupzyk, K.A., Shurmur, S.W., Pullen, C.H. and Yates, B.C., 2017. ‘Cardiovascular risk factors among college students: Knowledge, perception, and risk assessment’. Journal of American College Health, vol. 65, no. 3, pp.158-167. DOI https://doi.org/10.1080/07448481.2016.1266638

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