This case is about Harry who was complaining of chest pain. For proper clinical assessment and nursing intervention clinical reasoning cycle has been used in this paper. Each of the eight phases of this cycle pertaining to this case are discussed below:
Considering the patient situation- Harry was suffering from acute pain showing symptoms of heart attack or the myocardial infarction. He was admitted to the emergency department as he was complaining of excruciating chest pain that affected his jaw and left hand.
Collect information and cues- vital signs of Harry are not very stable. BMI ranging from 25 to 29. Shows overweight condition which may be linked with health disorders. Harry is therefore overweight as his BMI is 29. Waist circumference of more than 80 cm puts male individuals on a higher risk of chronic diseases like diabetes and cardiovascular diseases. A blood pressure (BP) reading in the range of 60/110 and 167/100 indicates stage 2 hypertension. This condition is described as a systolic BP of higher or equal to 140 or/and a diastolic BP greater than or equal to 90. Harry had a higher blood pressure in his arteries as his BP reading was 174/100. Auscultation of his chest was clear hence his had no respiratory problems.
The serum cholesterol is high at 7.2 mmol/L as this is higher than 6.2mmol. His HDL is poor with a value of 0.7 mmol/L and this shows that he is at a higher risk of cardiovascular diseases (Sniderman, et al 2011). Familial hypercholesterolaemia is a form of inherited elevated cholesterol which requires changes in lifestyle and proper treatment (Defesche, et al 2017). LDL tests of Harry revealed a higher value of 6.2 mmol/L and therefore, this presents the risk of Familial hypercholesterolaemia. Fasting triglyceride level at 5.9mmol/l in his case is very high and this points out at the higher risk of cardiovascular diseases. Additionally, his family history shows that his parents had suffered from heart failure. Further, his uncle had heart surgery for his heart attack.
Processing information- the vital signs are used for measuring the normal physiological functioning of the body. Considering the test results and symptoms of Harry, the vital signs shown to be abnormal and this clearly marks the acute cardiovascular disease that is a heart attack. This condition has been defined as a medical emergency which occurs when the blood flow to the heart is stopped. This blockage can be due to cholesterol, fat and other substance which can form plaque in the coronary arteries. This plaque can rupture and form blood clot blocking the passage of blood to the heart. With this interruption in the flow of oxygen rich blood to the muscles of the heart results in damaging the heart muscles.
When the heart muscles do not receive oxygen rich blood then the muscle cells die out leading to heart attack or myocardial infarction. This presents with acute pain in the left side of the chest and in left side of the body including shoulder, jaw and left arm.
Identification of issues and problems- the first problem in this case was chest pain. Therefore, the RN orders for ECG and blood pathology tests. An ECG is significant in this case and it revealed an elevated ST having leads in V3 and V4 showing anterior wall myocardial infarction. Moderately elevated values of troponin proteins I and T was presented and this shows injury to the myocardial cells. ST elevation in leads V3 and V4 shows Anterior Wall Myocardial Infraction (AWMI) This occurs when the myocardial tissues in the anterior wall suffers from injury due to lack of blood supply by the left anterior descending coronary artery. Moderately high levels of troponin I and T also confirm heart tissue injury as these proteins are released into bloodstream when the heart cells suffer from injury.
Establishing goals- a plan of care therefore had to be made for Harry. The goal was to reduce the symptoms and relieve the chest pain.
Take action- For the chest pain relief, two large gauge peripheral intravenous cannulas (PIVC) were inserted for administering 300 mg of aspirin according to the clinical pathway. Sublingual GTN stat was also given. PRN-IV morphine was also administered. A large PVIC was used for the rapid administration of the medications into the bloodstream of the patients (Beecham, and Tackling, 2019). A high dose of aspirin was used as it stabilizes the circumflex coronary-artery blood flow, reduces the mass of thrombus and the incidence of thrombus occlusion, prolongs the time for thrombosis and also decreases the adherence of platelets to the site of arterial injury (Dai, and Ge, 2012). A sublingual GTN stat dose had been administered which is the Nitroglycerin and this is the medication for the heart failure. It is used for treating angina or the chest pain resulting from myocardial infarction (Hsieh et al 2018). This is given to patient orally and has to be dissolved under the tongue. PRN VI morphine is given to the heart attack patients as in this case for relieving symptoms (Miro, Gil, and Peacock, 2017). Therefore, the goals have been reduction and relieving of the symptoms.
He was then transferred to the cardiac catheter lab for performing minimally invasive tests and procedures for diagnosing and treating cardiovascular disease. Primary percutaneous coronary intervention (PCI) was used for conducting coronary angioplasty. This was done through his right radial artery with the help of 2x stents that were inserted into the Left-Anterior Descending (LAD) artery. Angioplasty is done for restoring the flow of blood by removing the blockage (Kulick, and Stoppler, 2020).
Evaluating outcomes- the given care was evaluated when he was shifted to coronary care unit. Regular cardiac assessment and monitoring was done to evaluate the outcomes.
Reflection- the nurses have to reflect on their practice for deriving knowledge and lessons for future practice. In this case, the given interventions were apt for relieving and diagnosing the patient and therefore, I as a RN was able to manage the patients’ condition. However, I as a nurse must improve my practice by educating the patient and his family about the risk factors related to being overweight and unhealthy lifestyles. Harry is at risk as his family members have suffered from this disease in the past. Further, his physical exercise is limited and is working in a stressing job. Additionally, he is overweight. Therefore, he has to manage his lifestyle and exercise regularly apart from regular health check-ups for keeping his heart healthy.
Beecham, G. B., & Tackling, G. (2019). Peripheral Line Placement. In StatPearls [Internet]. StatPearls Publishing.
Dai, Y., & Ge, J. (2012). Clinical use of aspirin in treatment and prevention of cardiovascular disease. Thrombosis, 2012.
Defesche, J. C., Gidding, S. S., Harada-Shiba, M., Hegele, R. A., Santos, R. D., & Wierzbicki, A. S. (2017). Familial hypercholesterolaemia. Nature reviews Disease primers, 3(1), 1-20.
Hsieh, Y. T., Lee, T. Y., Kao, J. S., Hsu, H. L., & Chong, C. F. (2018). Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turkish Journal of Emergency Medicine, 18(1), 34-36.
Kulick, D. L. & Stoppler, M., C. (2020). Percutaneous Coronary Intervention (PCI): Angioplasty and Stents. [Online] Available at https://www.medicinenet.com/coronary_angioplasty/article.htm
Kulick, D. L., Marks, J. W. & Davis, C. P. (March 3, 2020). Heart Attack (Myocardial Infarction). [Online] Available at https://www.medicinenet.com/heart_attack/article.htm
Miro, O., Gil, V., & Peacock, W. F. (2017). Morphine in acute heart failure: good in relieving symptoms, bad in improving outcomes. Journal of Thoracic Disease, 9(9), E871.
Sniderman, A. D., Williams, K., Contois, J. H., Monroe, H. M., McQueen, M. J., de Graaf, J., & Furberg, C. D. (2011). A meta-analysis of low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B as markers of cardiovascular risk. Circulation: Cardiovascular Quality and Outcomes, 4(3), 337-345.
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