Nursing Assignment Analyzing Cardiac Case Scenario

Question

Task: Cardiac case scenario for Nursing Assignment Patient name: Brendan Walsh

• Handover report to Ward 3B Cardiology
• Date of handover report: 15th September 2021 at 10.00 hours
• MRN: 755 845 DOB: 15.04.1965
• Weight: 90kg
• Height: 175cm
• BMI: 29.4kg/m2 (overweight)

Introduction
Brendan Walsh a 56 year old male presented to the Emergency department early this morning complaining of chest tightness and increasing shortness of breath. The patient’s partner has accompanied him to the hospital.

Situation
On examination in the Emergency department upon arrival at 07:00hrs, Brendan initially presented with chest tightness and shortness of breath, feeling occasionally lightheaded, tachycardia, hypertension and swelling in his ankles to his knees. He is alert and orientated. An ECG, CXR and Echocardiogram were performed. ECG shows left ventricular hypertrophy with no ST changes. Echocardiogram shows worsening heart failure and reduced ejection fraction with evidence of pulmonary hypertension. CXR shows the heart is enlarged and bilateral lower lobe congestion. Oxygen was applied as the Sp02 was 93% on RA, currently 95% on 2L via NP.

Background
Brendan has a medical history of Idiopathic (non-ischemic) Dilated Cardiomyopathy NYHA class II diagnosed two years ago, Hypertension managed with Metoprolol, Type II Diabetes Mellitus (Diet controlled), ETOH (Ethyl alcohol) usually drinks 4 - 5 bottles of wine per week and smokes one packet of cigarettes per week. Brendan lives with his partner and has one son who lives interstate. Brendan and his partner manage a wine vineyard on the south coast.

Assessment
Observations taken on arrival to the Emergency department:

• BP: 160/90 mmHg
• HR: 110 beats per minute
• SpO2: 93% R/A; 95% on 2L NP
• RR: 28 breaths per minute
• Temp: 36.8 OC (oral)
• Glasgo Coma Scale (GCS): 15/15 (Eye = 4, Verbal = 5, Motor = 6)
• Pain score: 6/10
  
• BGL: 9.6 mmol/L

Recommendations
Formal Bloods including: Full Blood Count, Urea, Electrolytes, Creatinine (UEC’s)

Arterial Blood Gas
Monitor GCS and vital observations
Alcohol Withdrawal Scale (AWS) Administration of Diuretics and Beta blocker medications as charted

Fluid restriction of 1.5 Litres per day and strict fluid balance

Daily weight
Students will review the above case scenario and identify and prioritise the patient’s complex health issues. Students will provide rationales for their prioritisation decisions which will be supported by current literature and related nursing and healthcare standards and health department policies.

1. Identify a total of three patient health issues from ONE of the case scenarios that nurses can address within their scope of practice. You may include ‘risk for’ or ‘potential for’ health issues.

2. Rank the three patient health issues that were selected in part 1 in order of priority. Provide a rationale for the order of the rankings. The rationale must be supported with current literature.

3. Outline the nurse’s role in addressing the top three priority patient health issues in relation to patient assessment, coordination of care and delivery of care. Relate the discussion to nursing and healthcare standards and health department policies. e.g. RN Standards for Practice, NSW health policy, National Safety and Quality Health Service (NSQHS) standards etc.

Answer

Part – 1: Identification Of Health Issues
The case scenario chosen for this nursing assignment is the cardiac case scenario. The patient in this particular case is Brenden Walsh, who is 56 years old and has had a cardiac arrest.

Brenden Walsh was brought to the emergency department of the hospital and after arriving he was thoroughly assessed for his health condition. There were various tests and examinations performed as well which helped in assessing the present health condition of the patient. It was observed that the patient had severe chest pain and was out of breath and BP was also observed to be very high (Cui et al., 2019). Therefore, a thorough assessment was done to help Brenden overcome his health complexities.

The three main health issues in the cardiac arrest case scenario by conducting A-G assessment are pulmonary hypertension, shortness of breath, and swelling in ankles to knees. The patient has undergone surgery after repeatedly facing chest pain and shortness of breath (Katta et al., 2016). The following are the main priority care areas and health issues for the patient using A-G patient assessment as below;

Airway: The airways of the patient revealed nil issues however he was a tachycardiac.
Breathing: The second health issue which was observed was that of shortness of breath. The ECG report showed that there was an enlargement of the heart and bilateral lower lobe congestion which affected the shortness of breath. Moreover, it was also observed that the RR was 28 minutes per minute which is very low for the patient and therefore has impacted the lives of the patient immensely. After arriving at the emergency department, it was observed that there was a blockage in his airways and there was also a complexity with his breathing pattern.

Circulation: Pulmonary hypertension – After arriving at the emergency department of the hospital, Brendan was assessed thoroughly and an ECG was performed to assess his present health condition. The ECG report showed that heart failure is worsening and that it has reduced ejection fraction and has shown the presence of pulmonary hypertension. Moreover, it has also been observed from the report that the size of the heart has enlarged and that there was also enlargement of bilateral lower lobe congestion (Liu, & Baloescu, 2019).

Disability: Swelling in ankles to knees – The third identified health issue was that of swelling in ankles to knees. This affected the patient to a great extent and has resulted in causing pain in the ankles and knee area of the patient. The patient was highly affected by the pain and therefore required nursing intervention for pain management in the mentioned areas.

Exposure: Assessment of the patient for skin, nutrition-related changes nil alteration.
Further information-Family and Friends: This revealed that the patient consumes 4 to 5 bottles of wine per week and smokes a packet of cigarettes weekly.
Goals: Assessing his needs, SMART goals for the patient is as follows;

Table 1: SMART Goals
Source: Author

Part – 2: Prioritization Of Health Issues And Rationale
As regards the above segment of the discussion, it is clear that the top three priorities of health are pulmonary hypertension, swelling of ankles to knees, and shortness of breath. These three aspects must be rationalized and determined the most important one to the least important one in the priority order. So according to the priority order, the topmost priority area of the area will be to fix the problem of shortness of breath. This is so because shortness of breathing and imbalance in the airways may even cause the loss of life of the patient. In the present situation where Brenden has been observed to have undergone a cardio arrest, it is of utmost importance to provide oxygen supplements to fix the issue so that other issues are treated efficiently.

Karam et al., (2016) mention that there are several identified risks during a prehospital sudden cardiac arrest and therefore the nursing professionals must treat the shortness of breath to help the patient to witness the speedy recovery of the health condition of the patient.

Del Buono et al., (2017) mentions that shortness of breath and chest pain are the most important aspects of cardiac arrest and may affect the health of the patient to a great extent which may even cause the loss of life of the patient. Thus, this article tries to focus on the importance of nursing intervention on the shortness of breath during cardiac arrest. The article mentions that there is an expansion of lungs during cardiac arrest which results in the shortage of breath for the patient.

Further, Liuet al., (2019) mentions that the approach of the nursing professionals towards treating patients with shortness of breath has to be very delicate and simple as this may affect the cause of retraction of pulses which may be caused because of thecardiac arrest. However, this article also points out the importance of treating and administering treatments to the patient of shortness of breath as it may cause issues related to a reduction in the pulse rate (Kim, 2018). The nursing professionals play a significant role in the regulation of the clearance of airways and providing oxygen supplements so that it helps in protecting the life of the patient who has undergone sudden cardiac arrest.

Part – 3: Nurse’s Role
The nursing professionals play a significant role in the administration of healthcare to the patient so that it helps the patient to provide standard healthcare and witness a speedy recovery. During the emergency assessment, there is an importance for the nursing interventions for the patient. The role of the nurses is immense in administering care and providing delivery of care to the patients. The first health issue which has been observed is that of pulmonary hypertension (Clark, & McLean, 2018). The first and foremost role of the nursing profession is to assess the patient's vital signs and symptoms to help in understanding the present health condition of the patient by partnering with consumers according to NSQHS standards. The nursing professionals must observe the findings of the report and then create an accurate diagnosis to administer appropriate medications and diagnosis to the patient to help the patient to recover from the present condition, according to Standard 1 of NMBA to think critically and analyze. The nursing professionals may provide supplemental oxygen bottles so that it maintains the breathing pattern of the patient. This is a proven fact that a shortage in the oxygen level may cause severe problems and impact the health of the patient to a great extent (Guetterman et al., 2019). Moreover, the nursing professionals must also intervene to help the patient to educate regarding stress management so that it helps in the reduction of the stress of the patient. It is also a proven fact that an increase in stress management may increase pulmonary hypertension immensely and therefore impact the health of the patient further.

Moreover, the second health issue is that of shortness of breath which has to be assessed efficiently by the nursing professionals to help the patient to recover faster, according to the comprehensive care standard of the NSQHS (Robinson et al., 2016). The shortness of breath is a complex health issue and therefore requires extensive care from the nurses, and nurses need to maintain the same according to standard 3 of the NMBA by maintaining the capability for practice. The nursing professionals have to administer due care to the patient to help him to preserve the health and life of the patient. The shortness of breath may severely impact the health condition of the patient and result in the creation of complex issues of lungs and breathing patterns. This may impact the health condition of the patient to a great extent and result in the contraction of the lungs. Therefore, the nursing professionals may administer oxygen supplements from time to time and also assess the RR. The last recorded RR was28 per minute which is very low considering the present health condition of the patient. The nursing professional must assist the patient in the recovery of cardiovascular fitness (Brooks et al., 2016). At times, shortness of breath may also be an impact of the overweight or the obesity of the patient. Thus, Furthermore, the third health condition is that of swelling of the ankles and knee area of the patient, this is done according to NSQHS standard for recognizing and responding to acute deterioration. The swelling of the ankle or knee area is caused due to sudden cardiac arrest and requires heavy treatment by nursing professionals, as per NMBA standard 4 by conducting comprehensive assessments. The nursing professionals may intervene by assessing the presence of palpitating the tibia, ankles, and sacrum, and feet of the patient. Analyzing and assessing these conditions will help in understanding the pain and swelling in the patient’s body and help to administer medications and deliver care based on the assessment (Chou et al., 2016). The nurses may check the bounding peripheral pulses and further examine the condition of the lunge. As in the present case, it was observed that there was shortness of breaththerefore there were also complex issues in the respiratory system of the patient which may impact the patient and his health (Leary et al., 2016). Thus, the nurses must deliver acute nursing care to the patient who may help the patient with his swelling of ankles and peripheral muscles. The nurses may administer pain relief medications anddeliver exercises to help the patient to recover from the condition faster. This will help in the execution of nursing care.

References
Brooks, S. C., Simmons, G., Worthington, H., Bobrow, B. J., & Morrison, L. J. (2016). The PulsePoint Respond mobile device application to crowdsource basic life support for patients with out-of-hospital cardiac arrest: challenges for optimal implementation. Resuscitation, 98, 20-26. https://doi.org/10.1016/j.resuscitation.2015.09.392

Chou, M. H., Huang, H. H., Lai, Y. J., Hwang, K. S., Wang, Y. C., & Su, H. Y. (2016). Cardiac arrest during the emergency cesarean section for severe pre-eclampsia and peripartum cardiomyopathy. Taiwanese Journal of Obstetrics and Gynecology, 55(1), 125-127. https://doi.org/10.1016/j.tjog.2015.12.010

Clark, R., & McLean, C. (2018). The professional and personal debriefing needs of ward based nurses after involvement in a cardiac arrest: An explorative qualitative pilot study. Intensive and Critical Care Nursing, 47, 78-84. https://doi.org/10.1016/j.iccn.2018.03.009

Cui, C. Q., Cook, B. S., Cauchi, M. P., & Foerst, J. R. (2019). A case series: alternative access for refractory shock during cardiac arrest. European Heart Journal-Case Reports, 3(3), ytz101. https://doi.org/10.1093/ehjcr/ytz101

Del Buono, M. G., O'Quinn, M. P., Garcia, P., Gerszten, E., Roberts, C., Moeller, F. G., & Abbate, A. (2017). Cardiac arrest due to ventricular fibrillation in a 23-year-old woman with broken heart syndrome. Cardiovascular Pathology, 30, 78-81. https://doi.org/10.1016/j.carpath.2017.06.007

Guetterman, T. C., Kellenberg, J. E., Krein, S. L., Harrod, M., Lehrich, J. L., Iwashyna, T. J., ... & Nallamothu, B. K. (2019). Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals. BMJ quality & safety, 28(11), 916-924. http://dx.doi.org/10.1136/bmjqs-2019-009487

Karam, N., Bataille, S., Marijon, E., Giovannetti, O., Tafflet, M., Savary, D., ... & Lambert, Y. (2016). Identifying patients at risk for prehospital sudden cardiac arrest at the early phase of myocardial infarction: the e-MUST study (Evaluation en Médecine d’Urgence des Stratégies Thérapeutiques des infarctus du myocarde). Circulation, 134(25), 2074-2083.

Katta, N., Balla, S., & Aggarwal, K. (2016). Clozapine-induced hypersensitivity myocarditis presenting as sudden cardiac death. Nursing assignmentAutopsy & case reports, 6(4), 9. DOI: 10.1161/CIRCULATIONAHA.116.022954

Kim, E. (2018). Effect of simulation-based emergency cardiac arrest education on nursing students' self-efficacy and critical thinking skills: Roleplay versus lecture. Nurse education today, 61, 258-263.

Leary, M., Schweickert, W., Neefe, S., Tsypenyuk, B., Falk, S. A., & Holena, D. N. (2016). Improving providers’ role definitions to decrease overcrowding and improve in-hospital cardiac arrest response. American Journal of Critical Care, 25(4), 335-339. https://doi.org/10.4037/ajcc2016195

Liu, R. B., Bogucki, S., Marcolini, E. G., Connie, Y. Y., Wira, C. R., Kalam, S., ... & Cone, D. C. (2019). Guiding cardiopulmonary resuscitation with focused echocardiography: a report of five cases. Prehospital Emergency Care. https://doi.org/10.1016/j.nedt.2017.12.003

Liu, R., & Baloescu, C. (2019). Approach to the Patient with Shortness of Breath. Fundamentals of Emergency Ultrasound, 139. https://doi.org/10.1080/10903127.2019.1626955 Robinson, P. S., Shall, E., & Rakhit, R. (2016). Cardiac arrest leadership: in need of resuscitation?. Postgraduate medical journal, 92(1094), 715-720. http://dx.doi.org/10.1136/postgradmedj-2015-133738