Nurs 340 Evidence-Based Practice : Assessment Answers

Purpose: The student will evaluate the nurse’s role in facilitating safe, quality outcomes for patient-centered care.  The student will select one patient from the clinical course to complete the case analysis using the criteria below.  It is our experience that students who are most successful with this assignment select the patient after their fourth week of clinical.  

Admitting or medical diagnoses

Pathophysiology 

Presence of stenosis hampers the capacity of the heart to respond to the higher oxygen needs of the myocardium (Mahmod et al., 2014). Some of the most important regulators maintaining blood flow in the coronary artery are intramural pressure, metabolic rate of the myocardium, diastolic perfusion pressure of the aorta, endothelial function, blood viscosity and autonomic nervous system control. The anomalies of the coronary artery include split origin of the left coronary artery, irregular location of the coronary ostium, irregular position of coronary ostium, irregular origin of the coronary ostium, Congenital ostial stenosis, coronary hypoplasia split RCA and LAD, arteriolar ramifications and fistulas, among others (Mazur, Siegel, Miszalski-Jamka & Pelberg, 2013).

Symptoms 

Myocardial ischemia, angina or chest pain, pressure in the back, jaws, shoulders and arms, heart attack, nausea, vomiting, cold sweat, and shortness of breath, fatigue, swelling of ankles, feet, stomach, legs and veins in the neck are some of the symptoms. Another symptom is Arrhythmia (Nabel & Braunwald, 2012). Heart diseases like coronary heart diseases are the leading causes of death among men and women in America. In the case analysis, the patient has high cholesterol and blood pressure, do not exercise (activity using cane) and is a smoker, which cause such medical conditions.

Patient assessment

Evaluation of the diagnostic history of the patient reveals that she suffers from myocardial infarction, arrhythmia since, her ejection fraction is low. She has suffered from a heart attack. She has also undergone percutaneous coronary intervention (PCI) in order to open up the blocked coronary arteries (Li et al., 2013). She suffers from coronary, peripheral arterial diseases and OSA. She has high cholesterol and suffers from hypertension (high blood pressure). She has nocturnal cardiac dysrhythmia. Patients with ischemic heart disease usually suffer from antibiotic allergies due to the presence of cardiac mast cells, and in this case, the patient suffers from medicines like Benadryl and those that contain penicillin (Kounis, Soufras & Hahalis, 2013). She is on a cardiac diet to reduce her cholesterol and blood pressure levels.

Nursing practices and outcomes

The three nursing diagnoses associated with this case could be: hypertension, myocardial infarction and dysrhythmias.

Nursing diagnoses associated with hypertension, myocardial infarction and dysrhythmias involves decrease in cardiac output, acute pain, anxiety, insufficient tissue perfusion, activity intolerance, digitalis toxicity, among others (Ding, Yehle, Edwards & Griggs, 2014).

Nursing care plan for hypertension involves interventions like describing to the patient about the limits of a desired blood pressure level, explaining hypertension and its effects on the heart, helping the patient to identify risk factors associated with the diet like high sodium, cholesterol and saturated fats, planning exercises, following a treatment regimen, among others. The rationale is poor understanding about blood pressure and misconceptions like high blood pressure is only present in patients with symptoms and those who are sick. It is necessary to carry out proper evaluation of the patients to understand whether they have a sound knowledge about the disease and its treatments after carrying out the nursing care plan (Cicolini et al., 2014).

Nursing care plan for myocardial infarction involves interventions like assessing chest pain characteristics, identifying location, duration, intensity, quality, determine history of cardiac pain, assess respiration, heart rate and blood pressure after every chest pain, bed rest during chest pain, administer medications and monitor drug therapy, nitroglycerin SL administration, identify medication side-effects, carry out Electrocardiogram (ECG), among others. The rationale behind these is to assist the patient to rate pain, to make the patient understand that respiration may increase as a result of pain, reduction in consumption and demand of oxygen, ECG can help to determine cardiac damage, use of morphine during chest pain. Such nursing plan will provide the patient with comfort, reduced chest pain, reduced tension and anxiety, among others (Bermudez, 2012).

 Nursing care plan for dysrhythmias involves interventions like hemodynamic regulation to determine the pulse rate, amplitude, regularity, pulse deficit, monitoring cardiac output, blood pressure, respiration, changes in skin color, urine output, determine ventricular contractions, tachycardia, fibrillation, among others (Gazarian, 2014). The rationale behind these interventions involve the ability to determine differences in pulse rate, regularity, hearing heart beats, identifying myocardial infarction, digitalis toxicity, among others.

Systems approach 

A systems-based approach was used with regard to the care of the patient. Apart from cardiac surgeons, general practitioners, telemetry technicians and radiofrequency ablation experts were present during cardiac interventions.

Telemetry is an electronic system that helps to monitor the heart activity of patients. Differences in heart rhythms indicate various problems that require specific treatments (Walsh, Topol & Steinhubl, 2014). A telemetry technician needs to be accurate in analyzing the readings of the electrical impulses, since; the doctors base their treatment plan according to their analysis.

The patient described in this case study has blockage in many of her coronary arteries that leads to ischemic heart disease, cardiac arrhythmias, allergies to antibiotics like penicillin. These were revealed by telemetry. Thus, necessary steps were carried out to ensure the safety of the patient during cardiac intervention and planning treatments.

Discharge Planning

The patient was asked to follow a cardiac diet and was advised reduced movement and exertion. She was advised to use cane for carrying out any activity. She was asked to use BIPAP during sleeping. Antibiotics like penicillin was advised to be avoided.  Thus, following a proper diet and medications will help the patient to prevent such cardiac problems in the future.

The patient can be referred to nutritionists who can provide a suitable diet plan and sleep specialists who can monitor her progress regarding OSA. Community resources like health programs by institutes like the National Heart, Lung and Blood institute should be attended. Moreover, the Center for Disease Control and prevention (CDC) carries out many health programs in relation to ethnic and racial groups. Other community resources include educational programs, health programs by doctors and telephone based help facilities.

Prevalence of pain after surgery should be included in the anticipatory guidance. Information about pain management, addressing symptoms, management techniques should be provided to the patients in a comprehensive manner.

Culturally competent nursing

From the various informations provided about the patient, it can be said that she is a Native American. Native Americans consider smoking a part of their spiritual life. The characteristic features about them are, they are soft spoken people, good listeners, impart importance to personal space and do not express feelings of discomfort. The nurse needs to be soft spoken, always alert, not make eye contact, well versed in their native language and be aware of alternative methods that help in quitting tobacco smoking. The nurse can also recommend the patient to use herbs like Lobelia inflate (Willyard, 2015).

Agency specific policies

One of the policies of the hospital is the pay for performance. Payments are made according to the performance of the provider. These payment methods help to provide an organized system of care delivery to patients and enable them to opt high quality care, which was observed in this case. Thus, this hospital policy acts as a facilitator for care of the patients (Www.henryford.com, 2017).

Nursing leadership can provide for safe and quality care. The nurse should be highly trained, have high degrees in education, carry out quality data collection, effective work planning, policy making and partner with doctors for improvements.

Ethical and Legal Standards

The National Code of Ethics consists of ethical guidelines and responsibilities that are needed to be followed by nurses. These ethical responsibilities are classified under “Nurses and People”, “Nurses and Practice”, “Nurses and Profession”, “Nursing, Education and Research” and “Nurses and co-workers”. These codes help the nurses to carry out ethical conducts and decisions when performing the roles of clinical nurses, administrators, researchers and policy makers. Patient and family dignity is to be respected and maintain cultural sensitivity.

End of life decision making is highly important because of advances in medical science. Some medical interventions do not guarantee that the patient can lead a meaningful life without life support systems. As a result, the patient can choose their preferences in treatment when prioritizing end of life care. An advance directive either proxy or instructional, enables an individual to document and design their decision plan regarding healthcare, so that they can take necessary steps regarding any illness in the future.

The ethical rights of the patients include autonomy and beneficence. Autonomy refers to the right of every person to take his/her own decisions and earning respect from others with regard to their decisions associated with medical care. Beneficence refers to the duty of the physician to respect and favor the decisions that are beneficial for the patients (Reynolds, Drew & Dunwoody, 2013).

Reflection of additional learning

Additional learning that can be carried out to enhance patient care involves the nurses to be more people oriented rather than task oriented, develop a connection with the patient, provide undivided attention, and carry out research to provide best possible care.

Conclusion

This report describes the case study of a patient suffering from cardiovascular disease. Smoking and other lifestyle factors were responsible for her medical condition. She had undergone a number of surgical interventions that helped her to overcome her problems. This report describes the severity of the medical condition of the patient. Moreover, it also carries out assessment of the patient reports, provides nursing diagnosis, discharge plans and defines various ethical standards associated with nursing.

References

Bermudez, N. (2012). ACS: A triad of troubles sets the stage for MI. Nursing made Incredibly Easy, Vol: 10(6), pp: 14-17, doi: 10.1097/01.NME.0000421577.99021.b3.

Cicolini, G., Simonetti, V., Comparcini, D., Celiberti, I., Di Nicola, M., Capasso, L. M., & Manzoli, L. (2014). Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: A randomized controlled trial. International journal of nursing studies, Vol: 51(6), pp: 833-843, doi:10.1016/j.ijnurstu.2013.10.010.

Ding, Q., Yehle, K. S., Edwards, N. E., & Griggs, R. R. (2014). Geriatric Heart Failure: Awareness, evaluation, and treatment in primary care. The Journal for Nurse Practitioners, Vol: 10(1), pp: 49-54, doi:
10.1016/j.nurpra.2013.06.014.

Gazarian, P. K. (2014). Nurses’ response to frequency and types of electrocardiography alarms in a non-critical care setting: a descriptive study. International journal of nursing studies, Vol: 51(2), pp: 190-197, doi: 10.1016/j.ijnurstu.2013.05.014.

Kounis, N. G., Soufras, G. D., & Hahalis, G. (2013). Anaphylactic shock: Kounis hypersensitivity-associated syndrome seems to be the primary cause. North American journal of medical sciences, Vol: 5(11), pp: 631, doi:  10.4103/1947-2714.122304.

Li, J., Elrashidi, M. Y., Flammer, A. J., Lennon, R. J., Bell, M. R., Holmes, D. R. & Lerman, A. (2013). Long-term outcomes of fractional flow reserve-guided vs. angiography-guided percutaneous coronary intervention in contemporary practice. European heart journal, Vol: 34(18), pp: 1375-1383, doi: 10.1093/eurheartj/eht005.

Mahmod, M., Francis, J. M., Pal, N., Lewis, A., Dass, S., De Silva, R., & Ashrafian, H. (2014). Myocardial perfusion and oxygenation are impaired during stress in severe aortic stenosis and correlate with impaired energetics and subclinical left ventricular dysfunction. Journal of Cardiovascular Magnetic Resonance, Vol: 16(1), pp: 29, doi: 10.1186/1532-429X-16-29.

Mazur, W., Siegel, M. J., Miszalski-Jamka, T., & Pelberg, R. (2013). Coronary Artery Anomalies. In CT Atlas of Adult Congenital Heart Disease (pp. 183-202). Springer London. Retrieved from: https://link.springer.com/chapter/10.1007/978-1-4471-5088-6_16

Mencel, G., Kowalczyk, J., Swierad, M., Swiatkowski, A., Honisz, G., Kalarus, Z., & Sredniawa, B. (2013). Ostial stenosis of the left main coronary artery as the result of the previous percutaneous coronary intervention on the left coronary artery. Post?py w Kardiologii Interwencyjnej= Advances in Interventional Cardiology, Vol: 9(3), pp: 317, doi:  10.5114/pwki.2013.37521.

Nabel, E. G., & Braunwald, E. (2012). A tale of coronary artery disease and myocardial infarction. New England Journal of Medicine, Vol: 366(1), pp: 54-63, doi: 10.1056/NEJMra1112570.

Reynolds, J., Drew, D., & Dunwoody, C. (2013). American Society for Pain Management Nursing position statement: pain management at the end of life. Pain Management Nursing, Vol: 14(3), pp: 172-175, doi: 10.1016/j.pmn.2013.07.002.

Walsh, J. A., Topol, E. J., & Steinhubl, S. R. (2014). Novel wireless devices for cardiac monitoring. Circulation, Vol: 130(7), pp: 573-581, doi: 10.1161/CIRCULATIONAHA.114.009024.

Willyard, C. (2015). Pharmacotherapy: Quest for the quitting pill. Nature, Vol: 522(7557), pp: S53-S55, doi: 10.1038/522S53a.

Www.henryford.com. (2017). Glossary. Henryford.com. Retrieved 26 October 2017, from https://www.henryford.com/about/quality/performance/glossary

Yzer, M., Weisman, S., Mejia, N., Hennrikus, D., Choi, K., & DeSimone, S. (2015). Informing tobacco cessation benefit use interventions for unionized blue-collar workers: A mixed-methods reasoned action approach. Prevention Science, Vol: 16(6), pp: 811-821, doi: 10.1007/s11121-015-0566-7.