Maryannadirupo



Case Study AnalysisMaryanna DiRupoUniversity of New HampshireIntroductionCritical thinking is a “cognitive process that includes rational analysis of information to facilitate clinical reasoning, judgment, and decision-making” (Pérez, Lluch Canut, Pegueroles, Llobet, Arroyo, & Merino, 2015, pg. 821). Due to the ever-changing nature of health care and the importance of implementing evidence based practice, critical thinking is essential to the nursing profession. One way nursing students are able to practice critical thinking skills is through the use of case studies. Case studies allow nursing students to work through real-life scenarios without actually being present in the situation. In the presented scenario, students are introduced to 63-year-old M.M., who was admitted to the hospital for increasing weakness, swelling in her ankles and feet, and heaviness in her chest off and on over the past few days. She has a history of coronary artery disease. Throughout this study, several assessments and tests were carried out to determine the cause of M.M.’s symptoms. PathophysiologyCoronary artery disease (CAD) is a significant cause of death in developed countries. The primary cause of CAD is coronary atherosclerosis, which is the buildup of plaque and narrowing of the artery walls (De Torres-Alba et al., 2013, pg. 1). This plaque buildup and narrowing causes a decrease in blood flow and oxygenation. When blood flow is impeded, the heart muscle can experience myocardial ischemia leading to chest pain (angina) or a myocardial infarction. “The clinical spectrum of CAD ranges from stable angina pectoris to acute coronary syndromes, a term which includes unstable angina, non-ST elevation myocardial infarction and ST elevation myocardial infarction” (De Torres-Alba et al., 2013, pg. 1). Over time, CAD can weaken the heart muscle and lead to heart failure. “Heart failure occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion” (Henry, N. E et al., 2016, pg. 197). As CAD weakens the heart muscle, the heart cannot maintain adequate circulation to provide the body what it needs. New York Heart Association’s functional classification scale categorizes the level of activity it takes to make the client with heart failure symptomatic (having chest pain or shortness of breath). The scale is as follows: “Class I: client exhibits no symptoms with activity; Class II: client has symptoms with ordinary exertion; Class III: client displays symptoms with minimal exertion; Class IV: client has symptoms at rest” (Henry, N. E et al., 2016 pg. 197). Coronary artery disease is a major risk factor for heart failure. Expected findings of heart failure include: dyspnea; fatigue; pulmonary congestion; ascending dependent edema in the legs, ankles, or sacrum; weakness; etc. Diagnostic procedures done to determine heart failure include hemodynamic monitoring, ultrasound, transesophageal echocardiography, chest x-ray, and ECG, cardiac enzymes, electrolytes, and ABGs. Medications used in the treatment of heart failure include diuretics, afterload-reducing agents, inotropic agents, beta-blockers, vasodilators, and anticoagulants. Therapeutic procedures include ventricular assist devices and heart transplantations (Henry, N. E et al., 2016 pg. 197). When the heart muscle experiences myocardial ischemia, this can lead to a myocardial infarction (MI). An infarction is necrosis of the tissue, which results in permanent damage (Henry, N. E et al., 2016, pg. 191). “When the cardiac muscle suffers ischemic injury, cardiac enzymes are released into the bloodstream, providing specific markers of MI” (Henry, N. E et al., 2016, pg. 191). Risk factors include gender, age, obesity, hypertension, sedentary lifestyle, stress, etc. Those with coronary artery disease are at an increased risk for an MI because the atherosclerotic changes predispose the heart to poor blood flow and oxygen delivery. Expected findings of a client experiencing an MI include anxiety, shortness of breath, chest pain, nausea, vomiting, cool, clammy skin, tachycardia, and diaphoresis (Henry, N. E et al., 2016, pg. 191). The client’s cardiac enzymes need to be tested in order to see cardiac muscle injury. These enzymes include myoglobin, creatine kinase- MB, and troponin I or T. Diagnostic procedures to test the presence of an MI include an electrocardiogram, a stress test, and a cardiac catheterization. MIs are classified based on the affected area of the heart, ECG changes produced, and the time frame within the progression of the infarction. Medications used in the treatment of an MI include vasodilators, analgesics, beta-blockers, thrombolytic agents, antiplatelet agents, thrombolytic agents, and anticoagulants (Henry, N. E et al., 2016, pg. 191).Scenario: You are just getting caught up with your work when you receive the following phone call: “Hi, this is Deb in the emergency department. We’re sending you M.M., a 63-year-old Hispanic woman with a past medical history of coronary artery disease (CAD). Her daughter reports that her mom has become increasingly weak over the past couple weeks and has been unable to do her housework. Apparently, she has had complaints of swelling in her ankles and feet by late afternoon ‘she couldn’t wear her shoes’ and has had nocturnal diuresis x4. Her daughter brought her in because she has had heaviness in her chest off and on over the past few days but denies any discomfort at this time. The daughter took her to see her family physician who immediately sent her here. Vital signs are 142/92, 96, 24, 99 F. She has an IV of D5W at 50 ml/hr in her right forearm. Her laboratory results are as follows: Na 134 mEq/L, K 3.5 mEq/L, Cl 33.9%, Hgb 11.7 g/dL, platelets 162,000/mm3. PT/INR, PTT, and urinalysis are pending. She has had her chest x-ray and ECG, and her orders have been written.”Scenario QuestionsBased on the initial information given to the nurse during report, additional information must be obtained in order to treat M.M. She came in with the complaints of increasing weakness, nocturia, swelling in her ankles, and unstable angina. As these symptoms are indicative of cardiovascular issues, and because of her history of coronary artery disease, it is important to find out all of her information prior to taking action. It is necessary to gather the additional information about her cardiovascular history, such as her triglyceride and cholesterol levels; any history of smoking; any family history of cardiovascular disease; the last time she had chest discomfort; and a focused pain assessment. It is also important to seek out additional information about M.M.’s overall history including: any allergies, her full past medical history, past surgical history, social history (drug/alcohol use), sleeping and eating habits, allergies, and current medication use. It would also be important to find out when her last set of vital signs were taken in order to have the most current information. All of these factors are significant in the nurse’s development of a plan of care for M.M. In preparation for M.M, the nurse must seek out all of the additional information listed previously, focusing on her cardiovascular history, past medical and surgical history, diet and lifestyle, and a focused pain assessment. Any patient presenting with chest pain, even off and on like M.M., must have a thorough history taken to determine whether the pain is likely to be acute coronary syndrome, stable angina, or a non-cardiac disease radiating to the chest such as GERD. When taking a history of M.M., the nurse should inquire about past medical history, family history, medication history, psychosocial elements, employment status, relationship issues, smoking history and alcohol consumption. (Bostock-Cox, B. 2012, pg. 34). Obtaining every piece of information is essential for assessing a patient presenting with chest pain. “In the case of chest pain, the importance of thorough history taking, careful assessment, including examination, and the use of objective tests to ascertain whether the pain is likely to be cardiac or non-cardiac in origin, cannot be underestimated” (Bostock-Cox, B. 2012, pg. 34). A focused pain assessment is essential to developing the care plan for M.M. One helpful pneumonic in doing a focused pain assessment on a client presenting with chest pain is PQRST: “Pain- made worse by activity or emotion, relieved by rest or GTN; Q- pain is crushing, like a tight band or pressure around the chest; R- it is often central, retrosternal, radiating into the jaw, back, shoulders and/or arms; S-severity will vary but may be very severe; T- instable angina it is short-lived; more severe and prolonged symptoms are more likely to be related to ACS and will require urgent admission and intervention.” (Bostock-Cox, B. 2012, pg. 34).In addition to this focused pain assessment, the nurse should also find out if M.M. needs an interpreter, as she is Hispanic and English may not be her first language. The nurse should confirm that the ECG was completed so that he/she can assess for changes in M.M.’s electrical activity. ST depression and/or T-wave inversions can indicate ischemia which in turn can indicate angina. An ST-segment elevation indicates injury and an abnormal Q-wave indicates necrosis, which indicates a myocardial infarction (Henry, N. E et al., 2016, pg.192). The nurse should also obtain a baseline weight because weight gain is a symptom of heart failure and therefore must be monitored. Contacting the laboratory for blood work, i.e. the PT/INR, PTT, and urinalysis would be appropriate because the nurse is still waiting for these laboratory values to be ready for assessment. The nurse should also obtain vital signs to have her information be as current as possible. As M.M. arrives by wheelchair, it is important to assess her as soon as she is in your presence. Beginning with her appearance sitting in the wheelchair, it is important to note her general appearance, any objective signs of pain, any grimacing, or shortness of breath. As M.M. transfers from the wheelchair to the bed, the nurse should observe how she transfers (independently, one assist, etc.) and her overall gait, her general appearance (anxious, calm, sweaty, short of breath, pale, etc.), and any presence of orthostatic hypotension. Noting all of these factors are important in developing M.M.’s plan of care. As the nurse reviews the history she has received about M.M., he/she can anticipate orders that the provider may order. It would be appropriate to expect an order for vital signs every 5 minutes until stable, and then every hour (Henry, N. E et al., 2016, pg. 193). She needs more frequent vital signs than just every shift because she is not stable. Another order that would be anticipated is a serum magnesium STAT because abnormal heart rhythms can be caused by a deficient amount of magnesium. This in turn could cause the chest pain M.M. is experiencing. An order of “OOB with assist” could be expected because she complained of increasing weakness. An order of a 2g sodium, low-fat diet would be expected because she has a history of coronary artery disease, which is due to the buildup of fats and plaque in the artery walls. Another reason to anticipate this order is because M.M. has been retaining fluid in her ankles and feet and sodium contributes to this retention. The order of changing an IV to a saline lock is appropriate because M.M should not be receiving more fluid than necessary due to her retention. An order of obtaining cardiac enzymes on admission and every eight hours for 24 hours and then daily every morning is appropriate because of her complaint of chest pain. Myoglobin is the earliest marker of cardiac injury, creatine kinase-MB peaks around 24 hours after the onset of chest pain, and troponin of any positive value indicates cardiac damage (Henry, N. E et al., 2016, pg. 192). Along with cardiac enzymes, a CBC, BMP, and fasting lipid profile should also be obtained in order to further assess M.M.’s health and factors leading to an MI. Heparin 5000 units SC every eight hours is an anticipated order in order to prevent clot formation. Docusate sodium (Colace) 100 mg/PO may be written as a PRN order so that M.M. does not have to strain to poop and therefore avoids a vasovagal reaction. Furosemide (Lasix) 40 mg may be ordered in order to get rid of some of the fluid M.M. is retaining. Nitroglycerin 0.4 mg 1 SL every five minutes three times may be ordered to prevent coronary artery vasospasm and decrease the oxygen demand on the heart (Henry, N. E et al., 2016, pg. 193). Continuous cardiac monitoring and an echocardiogram would be expected orders as well.When administering subcutaneous heparin to prevent the formation of a clot, it would be appropriate to rotate injection sites with each dose, give the injection at least two inches away from the umbilicus, and not to aspirate the syringe before injecting the heparin. According to Avsar and Kasikci (2013), subcutaneous administration of heparin can cause bruising, pain, induration, and hematoma at the injection site (Av?ar, G., & Ka?ik?i, M., 2013). They did a study comparing four different methods of administering subcutaneous heparin to see which method caused the least pain and bruising. The results showed that the use of the air lock technique (leaving 0.2-0.3 ml of air in the injection) without aspiration and two-minute cold application to the injection site reduced bruising and pain (Av?ar, G., & Ka?ik?i, M., 2013). The air lock technique was shown to reduce bruising and hematoma, while the cold application slowed the inflammatory process and blood flow to the site. These findings are important to remember when administering subcutaneous heparin. As the case study progresses, M.M.’s call light comes on. When responding to the light, the nurse observes M.M. talking rapidly in Spanish and pointing to the bathroom. Her speech pattern indicates that she is short of breath; she is having trouble completing a sentence without taking a labored breath. The nurse helps her use the bedpan and notes that her skin feels clammy. M.M. vomits while sitting on the bedpan. On a scale of 0 to 10 (0 being no problem, 10 being a code-level emergency), this situation would be an eight because M.M. may be experiencing an MI. She is cool, clammy, and diaphoretic which indicates decreased blood flow to the extremities. She is also short of breath and having labored breathing which are signs of decreased cardiopulmonary blood flow to the extremities. Vomiting indicates hypoglycemia. All of these symptoms are expected assessment findings of someone experiencing an MI.The nurse in this situation should raise the head of the bed at least 45 degrees and administer oxygen 2-4 L/minute to ease the shortness of breath (Henry, N. E et al., 2016, pg. 193). The nurse should notify the provider immediately. The nurse should monitor vital signs every five minutes until stable and then hourly. M.M. should be attached to continuous cardiac monitoring. Cardiac enzymes should be assessed, along with electrolytes and ABGs (Henry, N. E et al., 2016, pg. 193). The nurse should obtain and maintain IV access and prepare to administer a medication regimen. Nitroglycerin may be order every five minutes three times in order to prevent coronary artery vasospasm and decrease myocardial oxygen demand (ATI, pg. 193). Morphine sulfate may be ordered to treat M.M.’s pain and to decrease the oxygen demand. A beta-blocker may be ordered to decrease the heart rate and afterload, and in turn decrease the myocardial oxygen demand. Aspirin, or another antiplatelet agent, may be ordered to prevent clotting (Henry, N. E et al., 2016, pg. 193). When the physician calls to find out what is happening, using SBAR, it is important to inform him/her of M.M.’s past medical history of coronary artery disease; her admission for increasing weakness, water retention in feet and ankles, and discomfort in her chest; and her current status. She is currently short of breath, cool, clammy, diaphoretic, and has vomited. The nurse should state the latest set of vital signs and any laboratory values that have been obtained. The nurse should state that M.M. has been sat up and started on 2L of oxygen to ease her shortness of breath and labored breathing. It should be stated that the nurse is prepared to administer the medication regimen ordered, but that he/she recommends giving Nitroglycerin SL, morphine sulfate, aspirin, beta blockers, and Furosemide (Lasix). After this SBAR is communicated between the nurse and the physician, the physician states that she is coming to the floor immediately to evaluate M.M. In the meantime, she orders Furosemide (Lasix) 40 mg IV push STAT. The nurse only has 20 mg in stock and has to decide whether to give the 20 mg now and then give the additional 20 mg when it comes from the pharmacy. The nurse decides to give the 20 mg IV push STAT because of the severity of M.M.’s condition. She needs to get rid of the fluid causing her shortness of breath. It is also unknown how much time it will take for the pharmacy to get the 40 mg of Furosemide (Lasix). After giving the 20 mg IV push STAT, the nurse should call the physician and explain that only 20 mg are available and that she needs to put in another order. The nurse should ask if the physician would like to give 20 mg for the next dose or 40 mg. After this conversation, the nurse should then follow up with pharmacy to make sure that the next dose was ordered.M.M. continues to experience vomiting and diaphoresis that are unrelieved by medication and comfort measures. A STAT 12-lead ECG reveals ischemic changes, and she is transferred to the coronary care unit. As the nurse is giving report to the receiving nurse, the most important laboratory measure to share is M.M.’s cardiac enzymes. Depending on any changes in her cardiac enzymes, the extent to the cardiac muscle injury can be determined. The nurse should also share the ECG findings which can reveal angina, ischemia, injury, or necrosis through electrical activity. An ST depression and/or T-wave inversion shows ischemia. An ST-segment elevation indicates injury and an abnormal Q-wave indicates necrosis (Henry, N. E et al., 2016, pg. 192). The nurse should also share M.M.’s most recent vital signs. M.M. is ordered IV potassium because her levels are low and this could be causing her cardiac difficulties. She may also become hypokalemic due to the Furosemide (Lasix). The nurse administering the medication should give the IV potassium at a rate no higher than 10 mEq/hour. This is the maximum rate of IV potassium (Henry, N. E et al., 2016, pg. 274). It cannot be given by slow IV push because this can increase the patient’s risk of cardiac arrest (Henry, N. E et al., 2016, pg. 275). IV potassium should never be added to a hanging bag as needed. It must always be diluted before given to a patient. It should also never be administered by gravity drip. It must be administered by a calibrated infusion device as to have total control over the rate of infusion. While recovering in the coronary care unit, M.M. tried to get up out of the bed, fell, and fractured her right humerus. Because of the surgical risks involved, M.M. was treated conservatively and put in a full arm cast. She is transferred back to your floor. A case manager has been asked to evaluate M.M.’s home to see whether she can be discharged to her own home or will need to stay in a long-term care facility. The case manager would assess multiple things before making this decision. Due to M.M.’s history of falls, factors that put her at an increased risk for falls would be assessed including: stairs outside and inside her home, where the bedroom and bathroom are located in her home, who she is living with, and potential functional limits due to her fractured arm. Other factors that need to be assessed are medication compliance, transportation methods, and hygiene management at home. If M.M. cannot take of herself or get the care she needs, she cannot live at home. M.M.’s nutritional intake over the past few weeks has been poor. She also has increased nutritional needs because of her fractured arm. It is important to make sure that she gets the recommended intake of calcium for her age. She should eat foods high in calcium, such as milk products, green vegetables, fortified orange juice and cereals, red and white beans, and cereal (Henry, N. E et al., 2016, pg. 445). She may need to take a calcium supplement if her dietary intake is inadequate. She should make sure she gets sufficient vitamin D and/or exposure to sunlight in order to absorb the calcium (Henry, N. E et al., 2016, pg. 451). She should eat foods rich in vitamin D, like fish, egg yolks, fortified milk, and cereal (Henry, N. E et al., 2016, pg. 445). She should engage in weight-bearing exercise on a regular basis in order to maintain her strength (Henry, N. E et al., 2016, pg. 451). She should always make sure that she is hydrated with plenty of fluids. Because the case manager determined that M.M. lived in an apartment with poor access, M.M. elects to stay with her daughter and five grandchildren in their small home. A home care nurse comes three times a week to check on her. M.M. is easily fatigued, and the children are quite lively. School is out for the summer. The nurse should suggest some ways for M.M.’s daughter to ensure that her mother is not overwhelmed and does not become exhausted in this situation. Some examples of this are having a private room or a private space to get away to, setting times to rest or nap, encouraging rest and a quiet environment, and setting times to get out of the house. Analysis and ConclusionWhile completing this case study, a significant amount of information was found on coronary artery disease, heart failure, and myocardial infarction. Evidence from the EBSCOhost database and the ATI Medical-Surgical Nursing Review was collected to solve the presented case study. M.M.’s history of coronary artery disease and admitting symptoms of water retention in feet and ankles, discomfort in her chest, and increasing weakness ultimately led to a myocardial infarction. Coronary artery disease was a contributing factor for M.M.’s myocardial infarction as presented in the literature. There were no inconsistencies between the research and the case study. Several critical thinking techniques were applied throughout the case study in order to determine both the source and treatment of M.M.’s current illness. In the beginning of the case study, it appeared as if M.M. was experiencing symptoms of heart failure: fatigue, weakness, ascending dependent edema in the ankles and feet, nocturnal diuresis, and angina. As the case study progresses, M.M. begins to develop symptoms of myocardial infarction: shortness of breath, labored breathing, cool, clammy, diaphoretic, and vomiting. She is treated with medications including diuretics and potassium, which were specifically treating the fluid overload and improving cardiac function. Further research needs to be done with this case because cardiac enzymes and cardiovascular diagnostic procedure results were never given. Therefore, it cannot be fully determined whether M.M. experienced a myocardial infarction. Although these laboratory values were never given, using critical thinking techniques, a plan of care for M.M. was developed during her possible myocardial infarction. Overall, this assignment was useful in developing strong critical thinking skills. References Av?ar, G., & Ka?ik?i, M. (2013). Assessment of four different methods in subcutaneous heparin applications with regard to causing bruise and pain. International Journal Of Nursing Practice, 19(4), 402-408. doi:10.1111/ijn.12079Bostock-Cox, B. (2012). Assessing chest pain in primary care. Practice Nurse, 42(14), 34-38.De Torres-Alba, F., Gemma, D., Armada-Romero, E., Rey-Blas, J. R., López-de-Sá, E., & López-Sendon, J. L. (2013). Obstructive Sleep Apnea and Coronary Artery Disease: From Pathophysiology to Clinical Implications. Pulmonary Medicine, 1-9. doi:10.1155/2013/768064Henry, N. E., McMichael, M., Johnson, J., DiStasi, A., Ball, B., Holman, H. C., . . . Lemon, T. (2016). RN Adult medical surgical nursing. ATI Nursing education.Pérez, E. Z., Lluch Canut, M. T., Pegueroles, A. F., Llobet, M. P., Arroyo, C. M., & Merino, J. R. (2015). Critical thinking in nursing: Scoping review of the literature. International Journal Of Nursing Practice, 21(6), 820-830. doi:10.1111/ijn.12347 ................
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