Quality and Safety Education for Nurses



**Used only by the instructor. Supplies:Pillow to show obesityWig to show agePack of cigarettesSpray bottle with water for sweatGurneyOxygen maskNitroAspirinMorphineECG wiresIV kitPressure dressing**Students begin assessing the patient by interviewing him as a large group, and then discuss which assessment data they would like to know (what is his BP? What were his lab results? Etc).Patient: Mr. SmithAge: 55 years oldChief Complaint: blurry vision that first started several months ago and has gotten worse latelyPMH: no known medical history. He has not had a primary doctor in years and before last week has not had a checkup in over 10 years because he says he feels fine and there is no need. However, he came to the clinic last week because of his blurry vision and was told his BP was high. Since HTN cannot be diagnosed after 1 blood pressure reading, he was told to come back to the clinic today for a recheck. Smoker: pack a day for 30 years. Alcohol: denies Home meds: noneFamily Hx: mother: HTN. Father: high cholesterol, HTN, and heart diseaseAssessment: BP 172/98. HR 94. RR 20. T 98.8F. O2 sat 98% on RA. Weight: 280lbs (BMI 38 kg/m2)Labs: BUN high. Creatinine high. Creatinine clearance decreased. Lipids (LDL, TG, and TC) high. Glucose normalECG normal Retinal exam shows small hemorrhagesNo symptoms except for blurry vision** Stop the interview/assessment and review assessment findings.What are the risk factors for him developing HTN? AgeMale genderObesity, esp central obesityFamily HistorySmokerDyslipidemiaAre any complications of HTN present?Renal Insufficiency (High BUN and creatinine, decreased creatinine clearance)Retinal damage (blurry vision and retinal hemorrhages seen on exam)Physician diagnoses Mr. Smith with HTN and prescribes hydrochlorothiazide (a thiazide diuretic) and lisinopril (an ACE inhibitor). Interventions: (3 small groups are each assigned one of the following teaching topics and then actually perform the education to the patient in front of the large group)Teach lifestyle modifications: Weight reduction: calorie reduction and moderate exercise at least 30min per day more than 4 days per week. Smoking cessationRegular checkups: BP checks, labs and tests to assess complicationsDASH diet for HTN: decreased sodium, fats, and sweets. Increased fruits, vegetables, and whole grains. Low fat dairy products. Fish, beans, seeds, and nuts are good choices to incorporate. Heart Healthy diet for cholesterol: Decreased saturated fats and cholesterolIncreased complex carbs (whole grains, fruits, vegetables) and fiberDecreased red meats, egg yolks, whole milkIncreased Omega-3 fatty acidsTeach medication knowledge: check BP daily. Know s/s of orthostatic HTN and teach ways to avoid (slow position changes)Teach signs of HTN complications and when to seek medication attention.Hypertensive Heart Disease- development of chest painCVA and TIAsPVDEvaluation: performed at follow up appoints. Evaluate BP, weight, smoking status, etc), follow up labs, etc**Students begin assessing the patient by interviewing him as a large group, and then discuss which assessment data they would like to know (what is his BP? What were his lab results? Etc).Patient: Mr. SmithAge: 56 years oldChief Complaint: “I am here to follow up on my BP and labs and also I have started having chest pain when I walk up the stairs to my apartment.” Assessment: BP 140/80. HR 82. RR 20. T 98.6F. O2 sat 98% on RA. Weight: 280lbs (BMI 38 kg/m2)Labs: LDL high, Triglycerides high, Total Cholesterol high, Glucose normal. BUN, Creatinine, and creatinine clearance all unchanged from the last visitLifestyle/social history: tried to stop smoking after the last visit, but just couldn’t do it. Began walking for exercise, but only gets 20min once a week. Did not make changes to his diet, so still eats lots of fast food, red meats, does like fruit but does not eat many veggies. PMH: Every time I walk up the stairs to my apartment, I get this bad pain in my chest, right in the middle. It’s like this heavy tight feeling. It scares me and I get pretty nervous when it happens. It sometimes makes me feel like I can’t breathe. When I get to the top of the stairs, I go into my apartment and rest on my couch. It always gets better and goes completely away after about 5 minutes. (no radiation of pain, no other symptoms like nausea, dizziness, diaphoresis, etc)** Stop the interview/assessment and review assessment findings.What are the risk factors for him developing CAD? Which are modifiable? Which are non-modifiable?Age (non-modifiable)Male gender (non-modifiable)Family History (non-modifiable)Smoker (modifiable)Obesity (modifiable)HTN (modifiable) (his HTN has been managed since beginning treatment at last visit, but we will still consider it a risk factor for CAD since it is a diagnosis and since the damage has been done prior to beginning therapy)Physical inactivity (modifiable)Physician diagnoses Mr. Smith with CAD and Angina Pectoris and prescribes nitroglycerin (short-acting nitrate), aspirin (antiplatelet), and clopidogrel (antiplatelet), and simvastatin (a statin).Interventions: : (2 small groups are each assigned one of the following teaching topics and then actually perform the education to the patient in front of the large group)Teach medication knowledge: NTG: Give SL (tablet) or by sprayIf no relief in 5 min, call EMSIf some relief, repeat every 5 min for a max of 3 dosesPatient TeachingCan be used prophylacticallyAspirin and Clopidogrelgiven to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow through the coronary arteriesbleeding precautions and monitorings/s of bleeding (bruising without trauma, bleeding gums, blood in stools or urine, low BP, high HR, decreased Hgb or HCT)Apply pressure to site of any needle puncture for longer than normalAvoid IM injections if possibleAvoid tissue injury from devices such as continuous automated BP cuffs, etcSimvastatin:Serious adverse effects of these drugs are rare, but include liver damage (hepatotoxicity) and myopathy that can progress to rhabdomyolysis (the breakdown of skeletal muscle). Monitor for severe muscle pain or leg cramps and report to provider. Liver enzymes are initially monitored and rechecked with dosage changesTeach disease process, modifications, and complications/when to seek medical helpLack of blood getting to heart tissue due to blockage in coronary vesselsWith stable angina, the pain is predictable, so determine the level of activity that the patient can safely perform, and at what point symptoms begin. Even though the pain is predictable, the patient may not have ever thought it through all the way. Verbalizing it and discussing activities may be the first time the patient realizes known triggers of the angina. Plan activities and rest periods as needed.Balance activity with restFollow prescribed exercise regimenAvoid exercising in extreme temperaturesUse resources for emotional support (counselor)Avoid over-the-counter medications that may increase HR or BP before consulting with a health care providerStop using tobacco products (nicotine increases HR and BP)Diet low in fat and high in fiberFollow up with health care providerReport increase in S&S to providerMaintain normal BP and blood glucose levelsEvaluation: performed at follow up appoints, assessing if nitro has relieved pain, lack of further progression of chest pain.**Students begin assessing the patient by interviewing him as a large group, and then discuss which assessment data they would like to know (why is the patient presenting for surgery? What are his current vitals?)Patient: Mr. SmithAge: 56 years oldChief Complaint: “I am here to have a stent placed in my heart. I am very nervous about the procedure and don’t remember much about what the doctor said the procedure was for ” Assessment: BP 130/80. HR 86. RR 20. T 98.6F. O2 sat 98% on RA. Weight: 275lbs (BMI 38 kg/m2)Interventions: (one small group provides preop teaching to the patient in front of the large group)Teach the patient about the procedure preop:PCI is performed in interventional cardiac catheterization laboratories (cath labs). Done on outpatient basis for recurrent chronic stable angina IV contrast dyes are injected to visualize the coronary circulation and identify to location and extent of the blockage.During this procedure, a catheter with an inflatable balloon tip is inserted into the appropriate coronary artery through a distal site (femoral or radial arteries). When the blockage is located, the catheter is passed through it, the balloon is inflated, and the atherosclerotic plaque is compressed, resulting in vessel dilation. This procedure is called balloon angioplasty or PTCA (percutaneous transluminal coronary angioplasty). Intracoronary stents are often inserted in conjunction with balloon angioplasty. Stents are used to treat abrupt or threatened abrupt closure and restenosis following balloon angioplasty. Stents are expandable meshlike structure designed to keep the vessel open by compressing the arterial wall. Because stents are thrombogenic, anticoagulants are used during PCI to help prevent the abrupt closure of the stents (ex: heparin). After PCI, the patient is treated with dual antiplatelet agents (clopidogrel (plavix) and aspirin) until the intimal lining can grow over the stent and provide a smooth vascular surface.Many stents are drug-eluting stents. This type of stent is coated with a drug that prevents overgrowth of the new intima, the primary cause of stent restenosis. Patients with this type of stent may be on antiplatelet drugs for 12 months or longer.The most serious complications from stent placement are abrupt closure and vascular injury. **The patient lies on a stretcher and is wheeled to “surgery” and then returns to the post-op unit.Post op interventions: (1 small group assesses the patient post-op in front of the large group)Once the patient arrives to the medical-surgical unit, they must remain flat (HOB no greater than 30 degrees) for approximately 4-6 hours to prevent bleeding from access (sheath) site or hematoma formation. If radial site was used, remain on bed rest for 2 hours and may sit up in bed.Nursing assessment must include assessment of access site- (see section in ch 25, pages 703-705) Do not remove the dressing that is in place, but visualize the site and surrounding region.Assess for color, temperature, swelling, or possible hematoma formation. Assess peripheral pulses distal to access site, cap refill (q15min x1hr, q30min x1 hr, q1hr x4hrs). Compare to unaffected extremityAssess for pain, numbness, or tinglingAssess cardiac rhythm and vital signs (BP, HR). Vasovagal response due to distended bladder or pain from manual pressure during sheath removal can occur and cause bradycardia, hypotension, nausea. If occurs, elevate lower extremities above heart, infuse bolus of IV fluid, and may need dose of atropineAssess for recurrent angina. After any invasive cardiac procedure, there is the potential for restenosis of the blocked vessel. Chest pain is an indicator that this has occurred.Immobility and bed rest may cause discomfort or pain. Administer prescribed analgesics and use nonpharmacological pain techniques. Patients resume self-care and ambulate unassisted after the first few hours.The day after the procedure, the site is inspected and the pressure dressing is removed. Teach patient new home medications administration (anticoagulants) and how to monitor site for bleeding or hematoma formation.**Students begin assessing the patient by interviewing him as a large group, and then discuss which assessment data they would like to know (what is his BP? What are his lab results? Etc).Patient: Mr. SmithAge: 56 years oldChief Complaint: “My chest is hurting really bad and my nitroglycerin did not work this time. I feel like I can’t breathe and like I am going to pass out.” (he is pale and diaphoretic)Assessment: BP 182/90. HR 112. RR 26. T 98.6F. O2 sat 86% on RA. Weight: 280lbs (BMI 38 kg/m2).12 lead: ST- segment elevationPMH: Usually my chest pain goes away after I rest on my couch. But today, it started when I was just sitting around watching TV. I was already here in the hospital visiting a friend, and I only had one nitro with me. I took it but it didn’t help at all. Its hurting so bad I can hardly talk. I feel like I can’t breathe. It starts in the middle of my chest, goes all the way down my arm, and even up my neck into my jaw. I am so scared. **Students should recognize the patient is in ACS***Interventions: (remaining small group should perform the protocol interventions in front of the large group)I: IV accessM: morphine (reduces preload and afterload. Relieves anxiety and pain) and monitor (obtain a 12-lead and start continuous tele)O: oxygen (2-4L/min to keep sats >95%. Position in upright position)A: aspirin (chewable 325mg)N: nitro (SL nitro)S: statin (within 24 hrs)**Instructor discusses following key points of basic med-surg care of patients in ACS-prepare for PTCA. PTCA is first line treatment for STEMI. Must be done within 90min of arrival to ED.-after STEMI, patients are transferred to ICU after treatment and invasive procedures. Once the patient is transferred back to the floor, teaching and further interventions begin:Slowly advance diet from sips of water and clear liquids, to full liquids, to soft foods, then to cardiac diet (low salt, low cholesterol, low saturated fat)Cardiac rehab is the restoration of a person to an optimal state of function in 6 areas of health : physiological, psychological, mental, spiritual, economic, and vocational. All patients need to be referred to a cardiac rehab program.Physical activity usually involves low-level exercise stress tests before discharge to assess level of tolerance. Teach patients to listen to their bodies and not to try to do too much too soon.Teach patients to take pulse and instruct them on their maximum HR allowedSexual activity is another hard topic that patients can feel embarrassed about discussing. You can bring it up by telling that patient that resuming sex is a common area of hesitation for many patients after ACS. Ask if they are concerned about this.Sexual activity for middle-aged men and women is no more strenuous than climbing 2 flights of stairs. It may help to discuss sexual activity from a physical activity standpoint.Erectile dysfunction is common after MI and should be expected to disappear after several attempts. ED drugs are contraindicated with nitrates. It is common for a patient who experiences chest pain on physical exertion to experience angina during sex. They may take a NTG prophylactically. Avoid anal intercourse as it has the potential for stimulating the vasovagal response which can lead to an unsafe drop in HR or BP.Typically ok to resume sex 7-10 days post MI or when patient can safely climb 2 flights of stairs. ................
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