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Client Case Study

Annie Kownack

Old Dominion University

Client Case Study

D.F is a 68-year-old male with a history of myocardial infarction and mechanical aortic/mitral valve replacement. He also has a long medical history of cardiac issues including cardiomyopathy, valvular heart disease, coronary artery disease, and chronic congestive heart failure. He is a full code with no known drug allergies. He was on vacation in the outer banks when he suddenly fell out of a recliner and hit his head. The emergency medical squad found him apneic and pulseless with ventricular fibrillation. He was defibrillated 3 times and given 3 doses of epinephrine with 300 milligrams of amiodarone. He was flown into Norfolk Sentara after being intubated in the field with possible aspiration pneumonia and reintubated upon arriving at the emergency room. His blood levels were drawn in the emergency room showing a Troponin level of 0.26 indicating that he had heart muscle damage. His chest x-ray revealed heavy infiltrates in bilateral lung fields and interstitial edema. He was admitted to the ICU and is currently on hospital day 28 in the PVSU.

His condition is relatively stable now and his prognosis looks good. He was cardioverted from atrial fibrillation and tolerated it well. His cardiac catheterization showed normal coronaries and normal prosthetic valve function. He is on telemetry and in sinus bradycardia with 58 beats per minute. He is conscious, oriented times four, and does not have any focal weakness. He showed signs of acute respiratory failure so he was kept on the vent for two weeks and now has a tracheostomy, which he is being weaned off of. He has been coughing up blood and blood has also been coming out of his tracheostomy, but it is believed that this is because of his heparin drip. His breath sounds are clear to coarse. He completed his bedside swallow test so his NG tube was removed and he is now on a puree diet. He failed his voiding trial so he still has a foley catheter in with good output. He has full range of motion but is very weak symmetrically. He requires maximum assistance and does not have any restraints. His skin is intact but he does have some scrotum swelling and bruising on his lower legs. He is on isolation for stenotrophomonas moro in his sputum. His daughter and wife are constantly at the bedside and have been staying onsite. He is a little depressed and anxious about his health and hospital stay. He is being consulted by internal medicine, speech, cardiology, and pulmonary/critical care doctors. Once he is able to tolerate it, an internal cardiac defibrillator will be surgically placed in his heart to fix any arrhythmias or irregular heart rates he may experience after being discharged. He is most likely going to be discharged sometime in the next week and will require follow up care afterwards.

The scope of this paper will include medical diagnosis, nursing diagnosis, outcomes, interventions, evaluations, and nursing research that apply to this patient.

Medical Diagnosis

D.F was admitted to the ICU because he was in acute respiratory failure after his myocardial infarction and could not be taken off the ventilator. His admitting diagnosis was acute respiratory failure related to a cardiac arrest. “A heart attack happens if the flow of oxygen-rich blood to a section of heart muscle suddenly becomes blocked and the heart can't get oxygen” (Gibbons, 2013, p. 5). This could be related to the fact that D.F already had coronary artery disease and congestive heart failure. He also had valvular disease with mechanical aortic/mitral valve replacement, which put him at risk. The most likely cause of his heart attack was his coronary artery disease. “Coronary artery disease is when plaque builds up in the coronary arteries that usually supply oxygen rich blood to the heart” (Gibbons, 2013, p. 7). If the plaque buildup is too severe it can clot and cause a blockage and the oxygenated blood cannot be circulated. If the blockage isn’t fixed quickly the heart tissue will start to die and will cause a heart attack or myocardial infarction, which is what D.F experienced.

The most common signs and symptoms that are related to having a heart attack include chest pain or discomfort, upper body discomfort in your shoulders, jaw, neck, back, or arms, and shortness of breath. Other symptoms include diaphoresis, feeling unusually tired, nausea, lightheadedness, and dizziness. These symptoms can develop slowly over weeks or hit you hard at once. Diagnosing a heart attack includes looking on an EKG for T wave inversion, ST elevation, or Q waves. These signify cardiac ischemia, injury, and infarction. Troponin levels are drawn to check for cardiac muscle injury. An elevated troponin level signifies that cardiac muscle has been injured and means you have had or are having a heart attack. The treatment for a heart attack consists of aspirin to prevent clotting, nitroglycerin to dilate the blood vessels, oxygen, and morphine for pain. The only way to completely get the blockage out is by going in through cardiac catheterization and removing the clot to restore blood flow. If the heart attack has already occurred and the patient is unconscious like D.F was found, cardiopulmonary resuscitation can be performed to stimulate the heart. If the patient is in ventricular fibrillation a defibrillator may also be used to provide a shock that will hopefully correct the arrhythmia.

D.F was having a left bundle branch block heart attack with ventricular fibrillation. When the emergency medical squad got to him he was unconscious, pulseless, and apneic. They performed cardiopulmonary resuscitation on him and defibrillated him to get his heart beating in normal rhythm again. Prolonged resuscitation can cause damage to the body and having a heart attack takes a huge toll on the body so he was admitted to the ICU for follow-up and further care.

Nursing Diagnosis

There are multiple nursing diagnoses that go along with D.F and his post myocardial infarction care and recovery. Inadequate tissue perfusion is huge since his body was not able to get oxygen while his heart was not pumping. Another nursing diagnosis is impaired gas exchange. His blood was not oxygenated and wasn’t being pumped through his body. Therefore his lungs were also suffering from lack of oxygen and tissue perfusion. This is why he was intubated for so long and now requires a tracheostomy to help him get adequate oxygenation. Activity intolerance evidenced by generalized weakness is expected from being in bed resting and intubated for so long. He does not have much strength and it is difficult for him to even sit up on his own or lift his hand to his mouth to eat food. He is also experiencing some anxiety and depression related to a change in his health status and not being able to perform his regular day activities. This is evidenced by him expressing verbal concern about his outcomes, crying, and his uncertainty about if he is getting better or not. His family and him have been referred to chaplain services in order to discuss their feelings and beliefs on the rough situation they are going through. He is originally form New York and talks a lot about how he just wants to go home. Lastly, he is at risk for excess fluid volume from decreased organ perfusion and urine retention. This is evidenced by him failing his voiding trial, plus two edema in his extremities, and pulmonary edema.

The priority nursing diagnosis for D.F is that he has inadequate tissue perfusion. In order for him to perform day-to-day activities and to survive his body needs to be oxygenated. A nursing theory that goes with this is Orem’s theory of self-care deficit. This theory states that human beings have varying abilities to care for themselves during illness and nurses use different approaches based on the patient’s ability to care for themselves. A key concept of this theory is that activities an individual performs themselves contributes to their continuing health and well being. If D.F is weak and tired from his blood not being perfused correctly then he will have difficulty in performing self care. It is important that the nurse works to promote his self-care and well being to aid him in his recovery. The nurse can do this by allowing him to assist her in his activities of daily living like brushing his teeth, bathing him, taking his medications himself, and feeding himself. In order to help him not feel weak or tired the nurse can spread these activities out and gradually increase the amount of active time he has.

Outcomes

The top priority nursing diagnoses for D.F include inadequate tissue perfusion and activity intolerance. It is important for his tissues to be perfused and for him to be able to perform daily tasks. Appropriate outcomes for tissue perfusion include being able to demonstrate adequate perfusion. For example his skin should be warm and dry, peripheral pulses should be able to be palpated and strong, and his vital signs should be within his normal limits. He should also have a balanced input and output. Lastly he should not have edema and should be free of pain or discomfort. These should all be attained before the patient is discharged.

Activity intolerance can be occurring because of an imbalance between his myocardial oxygen supply and demand or because of ischemic myocardial tissues that make it harder for him to complete daily tasks without tiring out. D.F exemplifies this because he is too weak to do anything and he requires maximum assistance. An outcome for him includes demonstrating an increase in tolerance for activities by his heart rate, rhythm, and blood pressure not increasing when he exerts himself. Another outcome would be no complaints of pain or angina with activity. A good outcome would be for him to be able to pull himself up in bed and sit up without help within a week. Now that he is able to eat food orally he should be regaining more energy and will be able to perform more tasks without tiring.

Interventions

In order to achieve these outcomes, interventions must take place to aid the patient in progressing forward. For activity intolerance documentation of vital signs before, during, and after activity can help mark trends in the patient’s response to the activity and can indicate if the patient needs to take a break or decrease the activity level. Rest should be encouraged so that the patient does not overexert themselves and be at risk for another myocardial infarction. The patient should increase his activity gradually by sitting up in bed, feeding himself, walking to a chair to sit in it, walking around his room, and walking around the unit. Progressive activity provides a controlled demand on the heart, increasing strength and preventing overexertion. According to the AACN standard for interventions, they should be delivered in a manner that minimizes complications to the patient. Therefore, it is important for the activities to be progressive to not overexert the patient too much. The patient may need to be referred to a rehabilitation program after discharge where he can regain his strength and be able to perform even more activities. This continued support will help him return to baseline quicker and promote his wellness. The family and patient need to be taught about possible signs and symptoms of overexertion and possible oncoming heart attack so they are prepared in such a circumstance. D.F is a bigger, Italian man who loves to eat and has personally stated that his culture loves to eat and does not exercise as regularly as they should. He should be encouraged to go on walks everyday once he is able to tolerate it and to eat a healthier diet. All of these interventions should help improve his activity tolerance.

There are also many interventions that could help D.F reach his outcomes for his inadequate tissue perfusion. The patient should be assessed for changes in mental status that could indicate his cerebral perfusion is not adequate. This could be as a result from decreased cardiac output so it is important to look out for. The patient should also be assessed for pallor, cyanosis, skin temperature, and peripheral pulses. Making sure the skin is warm and that the patient has strong pulses bilaterally proves that the patient is being perfused well. Monitor intake and outtake to make sure the patient is still making urine. If the patient has a decreased urine output it could be a sign that his kidneys are not getting a good amount of blood flow. The patient should perform leg exercises to enhance his venous return and decrease his risk for getting a clot. Medications can also be administered if needed to reduce the risk of clots forming and blocking oxygenated blood flow. D.F is on a heparin drip which is an anticoagulant used to reduce the risk of getting a blood clot. There are specific policies and standards for patients on heparin drips that he needs to be informed of because it puts him at an increased risk for bleeding and he will bruise more easily. D.F is also getting an internal cardiac defibrillator so if he is having an arrhythmia and the blood is not being perfused, the device will shock him and hopefully fix the rhythm so that blood will be pumped correctly. According to AACN standards of practice, the patient and family participate in implementing the plan according to their level of participation and decision-making capabilities. In order for these interventions to work, the patient and family must actively participate to perform the actions. All of these interventions will help D.F with his tissue perfusion and promote his well-being.

It is clear that adequate tissue perfusion is very important for patients after having a myocardial infarction and D.F needs to have it in order to recover. The nursing journal “Reperfusion Therapy for ST Elevation Acute Myocardial Infarction in Europe” is interesting because it talks about patient access to reperfusion therapy and primary percutaneous coronary intervention in European countries. The journal showed a lack of organized PCI networks in countries there but most European countries use it. It was interesting to read about the way they handle myocardial infarctions in a different country.

The article “Impaired Microcirculation Predicts Poor Outcome of Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock” talks about a study done to test the relationship of perfused capillary density to measure tissue perfusion in patients after a heart attack. The study revealed that decreased perfused capillary density is related to poor outcomes in these patients including multiple organ failure. This is relevant to D.F since he suffered a heart attack and one of his priority diagnoses is about tissue perfusion. It would be good to measure this in him to predict possible decreased perfusion to his organs and prevent organ failure.

Another article called “Physical activity levels, ownership of goods promoting sedentary behavior and risk of myocardial infarction” discusses the relationship between physical activity and the risk of having a myocardial infarction. The results of the study revealed that mild-to-moderate physical activity was associated with a reduced risk but not heavy physical labor. Since D.F has activity intolerance at the moment, this will have to be something he works up to when he is able to tolerate activities more. It is important for him to prevent future attacks in any way possible.

Evaluation

It is important to evaluate D.F’s progress towards his outcomes to make sure that he is achieving them. “Evaluation is systemic and ongoing using evidence-based techniques and instruments” (Bell, 2008, p. 564). His activity tolerance can be evaluated by his increased ability to handle activities. He should be progressing and be able to sit up by himself in a chair by the end of the week. Evaluating his vitals, respirations, pain level, and muscle strength are good indicators of if he is tolerating the activity well. His heart rate and respirations should not dramatically increase with activity and his pain level should not rise either. If he is not able to tolerate the activities then an additional plan could be to refer him to a rehabilitation center.

D.F also needs to be evaluated to make sure his tissue perfusion is adequate. His progress can be evaluated by checking for increases in pain. He did not complain of any pain throughout my evaluation. He has a foley catheter in and his input/output ratio are good so this shows his kidneys are getting perfused. His peripheral pulses were present and strong, his skin was warm and dry, and his capillary refill was less than three seconds showing that his skin was being perfused. All of the evaluation results are documented so any change in the patient’s state can be seen. If the evaluation were to show that he was not being perfused well then a change in medication may be needed. It is also possible he could need a stent or balloon to keep his vessels open so that blood can flow through them more freely. Currently his perfusion is adequate and all of the results are within normal limits.

Conclusion

The assessment and care of this patient has helped educate me on cardiac health and the effects a heart attack can have on a patient and their family. It is interesting to me how the heart has such an effect on every single organ in the body, which is why D.F started having issues with breathing after having a myocardial infarction. When the heart isn’t pumping correctly, no organs can get the right amount of oxygenated blood and the whole body suffers. I learned about different treatment options for patients who have had heart attacks and different prevention factors that can be done so another heart attack does not occur. I would love to learn more about the internal cardiac defibrillator and how it works to correct the arrhythmias the heart can experience. Overall, my experience with this patient completely broadened my knowledge on cardiac and critical care and I am thankful to have been a part of his recovery.

References

Bell, L. (Ed.). (2008). AACN Scope and Standards For Acute and Critical Care Nursing Process.

American Association of Critical Care Nurses.

Gibbons, G. What Causes a Heart Attack? (2013, December 17). Retrieved October 4, 2015,

from

Luscher, T. (n.d.). European Heart Journal. Retrieved October 4, 2015, from



Impaired Microcirculation Predicts Poor Outcome of Patients with Acute Myocardial Infarction

Complicated by Cariogenic Shock. (2010). Retrieved October 3, 2015, from

eurheartj.content/31/24/3032.short

Physical Activity Levels, Ownership of Goods Promoting Sedentary Behaviour and Risk of

Myocardial Infarction. (2012).

Vera, M. (2014, February 27). 7 Myocardial Infarction (Heart Attack) Nursing Care Plans –

Nurseslabs. Retrieved October 4, 2015

NURS 451 Client Case Study

Grading Criteria

Student: __________________________ Score: __________

|Grading Criteria |Points |Faculty Comments |Points |

| | | |Awarded |

|Introduction | | | |

|Pt. Overview |2 | | |

|Scope of paper |1 | | |

|Medical Diagnosis | | | |

|Dx for ICU adm. |2 | | |

|Patho |4 | | |

|Related S/S |4 | | |

|Nursing Diagnosis | | | |

|5 NANDA (1+ psych/soc) |5 | | |

|Priority with theorist support |10 | | |

|Outcomes for top 2 NDX |#1 #2 | | |

|Appropriate for NDX |2.5 2.5 | | |

|Attainable within timeframe |2.5 2.5 | | |

|Interventions for top 2 NDX |#1 #2 | | |

|Interventions with rationale |6 6 | | |

|SOP /Clinical Path |2 2 | | |

|Patient/family teaching |2 2 | | |

|Critical Thinking |2 2 | | |

|Cultural Considerations |3 | | |

|Evaluation |#1 #2 | | |

|Progress toward outcomes |5 5 | | |

|Additional/alternative plan |1 1 | | |

| | | | |

|Conclusion | | | |

|Review of learning |3 | | |

|Grading Criteria |Points |Faculty Comments |Points |

| | | |Awarded |

|Sources | | | |

|5+ sources |1 | | |

|3+ primary nursing research | | | |

|Study results reviewed/applied |3 3 3 | | |

|Study poorly reviewed/applied |1 1 1 | | |

|Research omitted |0 0 0 | | |

|APA Format (Cover page, headings, margins, type | | | |

|size) | | | |

| | | | |

|Format conforms to APA Format |3 | | |

|Format includes 1-3 APA errors |2 | | |

|Format includes 4-6 APA errors |1 | | |

|Format includes >6 errors |0 | | |

|APA- References/Reference Page | | | |

| | | | |

|Conform to APA Format |4 | | |

|Include 1-3 APA errors |3 | | |

|Include 4-6 APA errors |2 | | |

|Include >6 APA errors |1 | | |

|Do not conform to APA format |0 | | |

|Writing Style (Grammar, spelling, punctuation, | | | |

|language) | | | |

| | | | |

|Logical, organized, without errors |3 | | |

| | | | |

|Logical, organized minor errors (5) |1 | | |

| | | | |

|Lacks logic / organization AND major spelling / | | | |

|grammar / errors (>5) |0 | | |

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