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HSNS 365 Case Study Report Marking Criteria Method

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Question:

These criteria select from the 5 possible scores (representing strong, proficient, satisfactory, weak or unacceptable respectively). The paper presented will address all elements of this assessment rubric will be considered when allocating each question grade.
 
 

Answer:

Introduction: 

The comprehensive patient assessment helps in the recognizing and identifying the care needs of the target patient groups, understanding the particular preferences of the patients and their family members, along with providing a benchmark for proper continual monitoring system for the progress that the patient is making in response to the care being provided (Estes, 2013). This essay will attempt to implore on comprehensive assessment and based upon the analysis, discuss the case presentation, pathophysiology, pharmacological treatment and prioritised plan of care, with respect to the case study of Mrs Catherine Morrison. Catherine is an 83 year woman who presented to the facility with the complaint of atypical chest pain indicating at a likelihood of chest infection, although the sharp pain began in her right arm, from elbow radiating into jaw. Her past medic al history includes asthma, diabetic on insulin for 16 years, arthritis at back, gout, hiatus hernia, hypertension, and high cholesterol.

1. Analysis of the assessment and diagnosis made:

The first section emphases on a thorough discussion of the assessment that has been carried out for the patient, explore and evaluate the steps that have been taken for the assessment, and comment on the diagnosis that has been performed. In this case, a thorough comprehensive assessment has been carried out for the patient taking the assistance of a systematic framework or template, which is needed to be appreciated. Elaborating further on the selection of the assessment framework, the comprehensive health assessment template has been adapted from Estes et al. (2016). The assessment template designed by esteemed nursing and health care researcher, and the assessment template encompasses a varied range of domains, in turn providing an extended and meticulous scope for assessing each and every interrelated factors associated with the health condition of the patient. From the analysis, it is clear that Catherine had many interrelated anomalies which required a meticulous and extensive assessment; hence, it can be stated that the choice of the assessment framework is apt and appropriate given the scenario.

Exploring the effectiveness of the interpretation of the assessment data and the preliminary diagnosis made, it can be stated that there are certain errors that is needed to be highlighted. First and foremost, discussing the signs and symptoms, Catherine presented in the facility with the complaint of atypical chest pain, which was immediately pegged as chest infection related pain, which had not been a correct clinical decision. Ricci et al. (2016) has stated that atypical chest pain in women is often underdiagnosed or misdiagnosed, where in reality it indicates at acute coronary syndrome. Moreover, the assessment data also revealed the fact that the patient was woken in the middle of the night with the pain, and as she visited the washroom a sharp pain started in the her right, and it radiated from the elbow to her jaw, which is considered a tell-tale sign of atypical angina pectoris. Considering the past medical history of the 83 year old woman, she had diabetes, hypertension, hypercholesterolemia, and arthritis, all of which indicates at possibility of coronary arterial disease. Similarly, the patient also had a family history of her father, mother and sister having coronary arterial conditions. Hence, from the above data, it can be inferred that she is at risk of an ischemic heart disease major event and is suffering from acute coronary syndrome, thus rejecting the primary diagnosis made in the presentation.

2. Pathophysiology:

The next question focuses on discussion of the pathophysiology of the disease that the patient is suffering from with relation to the final diagnosis made. In this case, it has to be mentioned that the patient is suffering from an atypical chest pain which also radiated to the right arm, elbow and even to the jaw, which indicates at the chances of developing atypical angina. As discussed by Ibáñez et al. (2015), angina develops as a direct result of myocardial ischemia, which in turn is generated when the coronary blood flow is insufficient and cannot effectively meet the myocardial oxygen demand. As a result the body instantly switches to anaerobic metabolism, and there is a progressive impairment of metabolic, mechanical, and electrical functions. As discussed by Sanghavi and Gulati (2015) the result of the series of events of myocardial ischemia, the angina pectoris, typical or atypical, develops in the patient. Elaborating further on the exact pathophysiology of development of myocardial ischemia in the patient, it can be stated that myocardial ischemia is a direct result of dynamic or fixed epicardial coronary artery stenosis, which in turn is facilitated by the process of atherosclerosis (Reed, Rossi & Cannon 2017). Atherosclerosis is endothelial dysfunction of the large and medium sized muscular arteries due to the vascular inflammation and accumulation of lipids, cholesterol, calcium, and cellular debris in the vessel wall or intima. In this case, the patient already had hypertension, hypercholesterolemia, and diabetes, which are all risk factors for the development of ischemic heart diseases. Moreover, the patient had also been an active smoker in the past and also occasionally consumed alcohol, which in turn accelerates contributes to the process of atherosclerosis (Heusch & Gersh, 2016).

One complication in Catherine’s case had been the accompanying symptoms of angina, sweating and shortness of breath had been absent in her case. Although, many authors have highlighted the fact that acute coronary symptoms in manifested differently in women than in men. In this case, her heart rate at vital sign assessment had been 73 BPM, which can be considered low to average. Although, as discussed by Wong et al. (2015), angina at low heart rate is indicative of imminent myocardial infarction. In this case, it can be inferred that she is presenting with NSTEMI elevation after the acute coronary syndrome, where she has myocardial ischemia, which if left untreated, can lead to myocardial infarction leading to a heart attack.

 

3. Pharmacological treatment:

In terms of pharmacological treatment, she would require immediate attention with respect to clearing her blockage and avoiding the chances of myocardial infarction. First and foremost, as her nursing attendant, it would be imperative to perform an electrocardiogram or echocardiogram to confirm the diagnosis before commencement of the medication to ensure utmost safety. Based on positive diagnosis, the patient should be prescribed aspirin, a blood thinner, which will attempt to reduce obstruction of the coronary arteries, which was already given to her. Next medication to be prescribed to Catherine would be nitrate, for dilating the arteries and improving coronary blood flow. In her order to relax her blood vessels and improve coronary blood flow, she would be administered calcium channel blockers, such as Amlodipine and Angiotensin-converting enzyme or ACE inhibitors, such as captopril. Lastly, she would require cholesterol lowering medication to dissolve the blockage and widen the arteries further. As patient had allergies to atorvastatin, Pravastatin or Pravachol can be administered (Heusch & Gersh 2016).

Considering pharmacodynamics of the prescribed medication and existent hypersensitivity interaction in the patient. The assessment indicated that the patient had allergy to atorvastatin, a cholesterol lowering medication. Hence, the drug-drug interaction has to be taken into consideration for the pharmacological treatment provided to the patient. Aspirin also reacts with ACE inhibitors and disrupts their functionality, hence the dosage calculation has to be completed effectively (Santos et al. 2017). ACE inhibitors also tend to interact with calcium channel blockers, hence in this case as well, Amlodipine and captopril have a minor interaction, although it is not of sufficient extend to harm the patient (Russo, Petrucci & Rocca 2016).

4. Plan of care:

Nursing problem or issue

Nursing Goal

Interventions

Rationale

Myocardial ischemia  

The atypical angina pectoris will be reduced and the atherosclerosis will be reduced. The patient will be free from risk of myocardial infarction  

Nurse will need to perform a thorough assessment involving either electrocardiogram or echocardiogram.

 

 

Administer blood vessel dilating medication such as calcium channel blockers, ACE inhibitors to dilate the vessels and anti-anginals such as nitro-glycerine.

This will provide a preliminary analysis of the exact condition of the patient.

 

 

 

The medications will dilate the blood vessels and will in turn help in improving the coronary blood flow (Fors etv al. 2015).

Activity intolerance  

The patient will report progressive increase in tolerance for activity and will report reduction in angina frequency with activity.  

Documenting the heart rate, rhythm and changes in the blood pressure and heart rate, before, during and after activity.

 

 

Instructing the patient to rest with evidence based explanation along with instructing the patient to avoid abdominal pressure.

 

 

 

 

 

Engaging the patient in cardiac rehabilitation program and reviewing the signs and symptoms reflecting intolerance of present activity level.

 

 

 

 

The trend in response of the patient to different activities will determine the myocardial oxygen deprivation requiring reduction in activity level.

 

This will help in reducing the myocardial overload and oxygen consumption, along with exploring whether Valsalva maneuver can lead to bradycardia and rebound tachycardia with elevated BP (Ibáñez et al. 2015).

 

Palpitations, pulse irregularities, development of chest pain, or dyspnea will help in indicating necessity for changing exercise regimen or medication.

Risk for decreased cardiac output  

The cardiac output of the patient will be improved and care the cardiac load will be decreased.  

Cholesterol reducing medication such as Pravachol will be administered.

 

 

 

 

 

 

Auscultating the breathing sounds and noting the development of S3, associated with HF.

The cholesterol lowering medication will in time help in reducing the extent of atherosclerosis Catherine had, and in turn will reduce the risk of myocardial infarction (Reed, Rossi & Cannon 2017).

 

Help in understanding whether or not the patient is at imminent risk of congestive

Anxiety and Discomfort

The patient will be free from anxiety.

Assessing the signs and symptoms of anxiety and fear in the patient and assessing the perception of threat in the patient.

 

Compassionate and empathetic communication with the patient to assure the patient and provide comfortable physical environment to her.  

Verbal or nonverbal signs of anxiety will indicate signs of discomfort and anxiety in the patient (Fors etv al. 2015).

 

The compassionate communication will help in calming the patient and reducing the stress of the patient as well, so that she feels comfortable (Fors etv al. 2015).

Conclusion: 

On a concluding note, this paper helped understand the exact importance of comprehensive assessment in understanding the exact factors associated with condition that the patient is presenting. The essay in 4 sections helped in exploring and evaluating the assessment and rejecting the erroneous assessment or diagnosis made for the patient, evaluate the exact pathophysiology, pharmacodynamics for medication to be administered to provide symptomatic relief and lastly, a thorough care plan. In terms of outcome of the analysis, it can be stated that the assessment initially made had been erroneous, and making the correct diagnosis helped me understand the impact of nursing diagnosis and related care for the patients. It can be hoped that in the future this thorough exercise will help me make correct diagnosis and be able to provide adequate care interventions to help the patients.

 

References:

Estes, M. E. Z. (2013). Health assessment and physical examination. Cengage Learning.

Fors, A., Ekman, I., Taft, C., Björkelund, C., Frid, K., Larsson, M. E., ... & Swedberg, K. (2015). Person-centred care after acute coronary syndrome, from hospital to primary care—a randomised controlled trial. International Journal of Cardiology, 187, 693-699.

Heusch, G., & Gersh, B. J. (2016). The pathophysiology of acute myocardial infarction and strategies of protection beyond reperfusion: a continual challenge. European heart journal, 38(11), 774-784.

Ibáñez, B., Heusch, G., Ovize, M., & Van de Werf, F. (2015). Evolving therapies for myocardial ischemia/reperfusion injury. Journal of the American College of Cardiology, 65(14), 1454-1471.

Jin, W. Y., Zhao, X. J., & Chen, H. (2016). Decreased Diagnostic Accuracy of Multislice Coronary Computed Tomographic Angiography in Women with Atypical Angina Symptoms. Chinese medical journal, 129(18), 2191.

Malecki-Ketchell, A. (2017). Pathophysiology, assessment and treatment of coronary heart disease in women. Nursing Standard (2014+), 31(40), 51.

Reed, G. W., Rossi, J. E., & Cannon, C. P. (2017). Acute myocardial infarction. The Lancet, 389(10065), 197-210.

Ricci, B., Cenko, E., Varotti, E., Puddu, P. E., & Manfrini, O. (2016). Atypical Chest Pain in ACS: A Trap Especially for Women. Current pharmaceutical design, 22(25), 3877-3884.

Russo, N. W., Petrucci, G., & Rocca, B. (2016). Aspirin, stroke and drug-drug interactions. Vascular pharmacology, 87, 14-22.

Sanghavi, M., & Gulati, M. (2015). Sex differences in the pathophysiology, treatment, and outcomes in IHD. Current atherosclerosis reports, 17(6), 34.

Santos, T. R. A., Silveira, E. A., Pereira, L. V., Provin, M. P., Lima, D. M., & Amaral, R. G. (2017). Potential drug–drug interactions in older adults: A population?based study. Geriatrics & gerontology international, 17(12), 2336-2346.

Wong, Y. K., Stearn, S., Moore, S., & Hale, B. (2015). Angina at Low heart rate And Risk of imminent Myocardial infarction (the ALARM study): a prospective, observational proof-of-concept study. BMC cardiovascular disorders, 15(1), 148.

OR

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