Medical Surgery Nursing: Clinical Presentation, Priorities, And Management

Clinical Presentation

Discuss about the Medical Surgery Nursing?

Initial Assessment of Sylvie

The first thing that will be expected is that the patient will be fatigued and restless because the patient is unwell from a very long time and has been having other health problems. Cardiovascular system abnormality is very common in Down syndrome. The patient will have difficulty in breathing and will have disease, which has to be diagnosed. The patient has peripheral edema which means swelling of the tissues which usually happens in the lower limbs. This happens due to the fluid accumulation. The patient is having this problem because of her age but there can be many other reasons to it which has to be founded if the patient has trauma, altitude sickness, hypertension, alcoholism, etc. The treatment of peripheral edema depends on the control of underlying cause; swelling can cause a total damage of the nerves which may result to the peripheral neuropathy. The patient has congenital heart disease with the Down syndrome which is a problem with the structure of the heart. An initial physical exam is to be done along with heart tests to examine the congenial heart defects. A treatment is to be done depending on the severity of the defect. It is also seen in the case study that the patient is also suffering from cyanosis which is the blue or purple coloration of mucous membrane because of the tissues near to the surface of the skin is having saturation of low oxygen.

Nursing priorities of Sylvie

The first thing is to be done is to diagonose the ABC’s of the treatment, i.e. Airway, Breathing and Circulation. Firstly it has to be seen that if there are possible obstructions or not. Wheeing will indicate lower obstruction in airway. Then the effectiveness of the breathing has to be assessed and also the respiratory rate is to be examined. Flaring of nostrils and intercostals recession is to be checked. Another cause for concern is if the tachypnoea is at rest. Cyanosis is pre-terminal or late. It has to be checked if the mental status is impaired or not because Sylvie is forgetting things lately. Finally the volume of the pulse is to be examined. Advance shock leads to absence of peripheral and weak central pulses

In this case when Sylvia was brought to the hospital it has to be seen that has peripheral edema which may lead to trauma. Firstly the trauma team members have to be prepared so as to deal with any sort of injury. The learning details of the injury will help them forecast the combinations and types of injury information so that it helps the attending nurse and the team members to plan an effective care. It has to be seen that the oxygen level is appropriate or it has dropped. The case study mentions that Sylvie has been commenced with oxygen of 2 litres/minute settings. It lasts for approximately two hours. The patient was also having breathing problem which means that she will need perfect amount of oxygen. So two oxygen concentrators are to be combined and given using a “Y” connection. If there is insufficient oxygenation then the flow rate of oxygen is to be increased eventually.

Nursing Priorities

Assessment and monitoring Sylvie’s cardiac function and strategies to improve her condition

Cardiac function is the consequence of the interaction of four autonomous factors which are heart rate, contractility, preload and afterload. The heart rate can easily be quantified but the estimation of preload has traditionally depended on the persistent pressure measurements, both pulmonary artery wedge and central venous (Arakawa, Tatsumi and Nishimura, 2013). The measurement of afterload and contractility is difficult and so in clinical practice the bedside evaluation of the cardiac function is characterized by cardiac output. Correct evaluation and monitoring of the cardiac function in the ICU is essential because the heart is the common organ which fails during unfavorable illness. The failure of heart can be no longer regarded as the simple disease or the contractile disorder (Hall and Burton, 2010). The clinical symptoms are the consequences of the changes to the heart’s molecular and cellular components and to the medium that steer homeostatic control. The general acceptance when the heart disease progresses is that it proceeds to HF, the size of the heart increases, with the deterioration of cardiac function and the symptom of failure becomes evident. The aim of the therapeutic interventions is to correct the reduced blood flow or low cardiac output which gives symptomatic relief or improvement in cardiac function (Hosseini and Ahmadi, 2012). This does not really slow the progression of failure or reduce the mortality.

Tachycardia is the disease where the heart rate becomes faster than 100bpm which results from many other cardiac mechanisms. So a right medicine has to be chosen to recognize the source of the disease. One of the strategies can be cardiac remodeling which can be described as the molecular, genome expression, cellular and the interstitial changes that are demonstrated clinically as the changes in the shape, size and function of the heart after surgery. Process of cardiac remodeling is impacted by the hemodynamic load, activation of neurohormonal and other factors which is still under examination (Lindsay, 2013).

Strategies to reduce Sylvie’s cardiac workload and myocardial dysfunction

Heart failure is the condition which is described by the myocardial dysfunction which leads to performance of the impaired pump or abnormal circulatory congestion (Maeder and Hunziker, 2009). The congestion of venous circulation may be the consequence to peripheral edema, congestion of the pulmonary circulation may also be the cause for peripheral edema. The failure of the pump usually occurs in the left ventricle which is damaged but may also occur in the right ventricle. The advancement is the therapeutic and diagnostic techniques have highly improved the notion of the patients with the heart failure syndrome but the prognosis of the same is still depending on the cause and response to the treatment. The following should be done to reduce the cardiac workload:

Electrocardiography: This is to examine if atrial hypertrophy, ischemia, axis deviation and patterns of damage are present or not. Permanent segment of ST-T abnormalities and reduced QRS amplitude may also be found.

X-ray of chest: This will show the enlarged shadow of the cardiac which will reflect the chamber dilation or the deviation in the blood vessels and increased pressure on pulmonary veins.

Nursing Management – Assessment and Monitoring of Cardiac Function

Sonograms: This will show the enlarged dimensions of the chamber, alterations in the valvular structure and the extent of ventricular dysfunction.

Pulse oximetry: Here the saturation of oxygen may be low, when acute heart failure has occurred.

The important strategy of the drug therapy in the early stage of acute myocardial infarction is to recover the demand or the supply ratio of the heart (Matsuki, 2013). Reduction in this particular ratio occurs when the coronary flow is bargained. The sole reason when the cardiac function is impaired which is result to the clinical implications that is associated with myocardial infarction. There are two strategies to enhance this coronary demand or supply ratio is decrease the myocardial consumption of oxygen and restores the normal coronary flow of blood (McMullen, 2014).

The management of pain is another important concern where anxiety and pain stimulates the sympathetic activity which can be hazardous to the heart. Thus drugs like morphine are often prescribed to reduce the acute pain. Myocardial infarction occurs usually due to coronary artery disease where most of the patients are prescribed to be on long-term therapy of anti-platelet. In addition to this post-infarct patients are under the treatment of beta-blocker since they have revealed to reduce cardiac remodeling and decrease the mortality which is followed by the infarction (Murakami et al., 2014).

Nursing responsibilities associated with administering medications and monitoring Sylvie’s response

Cardiac glycoside is the organic compound which contains the glycoside or sugar which acts on the contractile force of cardiac muscle. Glycosides can be discovered as secondary metabolites in many plants as well as also in some insects. In this contemporary world of treatment the purified portions or the synthetic analogues of few of the compounds have been personalized for the cure of congestive heart failure and the cardiac arrhythmia. The utility of this component is to increase cardiac output by increased force of contraction. The digitalis of the adjustment of dosage should be made so as to keep away from toxicity (Pai, 2012).

ACE inhibitor or angiotensin-converting-enzyme inhibitor is a drug which is mainly used for the treatment of the congestive heart failure and hypertension. The nurse should prescribe this to Sylvie because it gives relaxation to her blood vessels along with the reduced volume of blood which will lead to the reduction of blood pressure along with increased demand of oxygen from the heart. For treating the heart disease this inhibitors are used with a medication which includes beta-blocker. It is a standard treatment for the failure of heart with being beneficial to the patients who are suffering from the cardiovascular mortality or morbidity. It helps the heart failure patient which includes preload and afterload reduction through lowering of blood pressure which was indeed needed for Sylivie (Piotrowski, 2013).

Diuretic is the substance which promotes the production of the urine. This also includes forced dieresis. It increases the excretion of the water from the bodies. Clinically a diuretic is used to treat heart failure, hypertension, liver cirrhosis, etc. These are also called water pills which help in increase the water loss and salt from the body which can be done through different steps which depends on the drug. Sylivie was prescribed this to get rid of the excessive fluids in her body and also to treat high blood pressure. So reduction in the fluid amount in the blood vessels will help decreasing the blood pressure. Excessive fluid content in the body which builds up, leads to the failure of heart which is initially treated with diuretics. If any patient is suffering from the congestive heart failure their heart isn’t effectively circulating blood which results into accumulation of fluids throughout the entire body which is also known as edema.

Nursing Management- Reducing Cardiac Workload

Patient reading topics appropriate for Sylvie

Sylvie is a patient with heart disease which has been creating problems for a long time. So the common medications as also mentioned above should be followed by the patient. Beta-blockers should be taken by the patient to slow down the rate of the heart and decrease the rhythm problems, which makes the heart stronger along with lowering the blood pressure. ACE inhibitors widen the blood vessels which makes the heart pump more blood through the blood vessels. Vasodilators are also prescribed so that Sylvie’s blood vessels relax and there is a decrease in the cardiac workload. Diuretics are referred to reduce the excess water in the kidneys and also the salt from the body. It will reduce the fluid in the lungs and help the patient breathe properly. Sylvie has reported that she was gaining weight without even eating. The water pills will help her reduce the fluid from her legs, belly, feet and hands, which is increasing her weight (Shuster, 2012).

Sylvie is also having myocardial dysfunction so she is prescribed to have antiplatelets and anticoagulants which prevent clotting of blood. Coumadin, Heparin, ReoPro will reduice the stickiness of the blood which will be fewer clots. If any unusual bleeding happens she should immediately report to the doctor (te Slaa et al., 2014). Imdur, Nitro-Bid, Isodril is prescribed to treat the chest pain and open the narrow blood vessels. Morphine may be taken if the chest pain increases. Sylvie is advised to have at least five segments of various vegetables and fruits, which may include frozen, fresh and dry (Tezuka, Sasaoka and Isobe, 2014). She must not eat foods with saturated fats and also reduce the salt intake.

Sylvie’s rights are in relation to making decisions about her care

Sylvie is entitled to take her care apart from the nurse who is on duty. As a registered nurse it should examine the patient and the family’s status of health. She should build an individual procedure to care for Sylvie so that she can improve in time, manage pain, and provide education on medicines and strength to cope with the strategies. She should assure that the treatment goals of Sylvie are met (Thomas, 2009). She should provide health teaching and promote health awareness. The discharge of any patients starts the time they are admitted which does not mean that they will be relieved the next day (Ramchandra, 2014). The authorities chalk out the best way to that the discharge is a successful one which starts by gathering valuable information about the patients and their families. On Sylvie’s part she should ask about any information about her treatment to the nurse so that she is aware of the surgery or the medicines prescribed to her. She should mention the location of her accommodation and the facilities that are available nearby so that the nurse can note down if any extra care from the hospital is needed. Sylvie should tell them everything about her health and keep them updated so that the nurses can provide immediate medication in case of emergency (Sharma, 2007). 

References:

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Hall, A. and Burton, H. (2010). Legal and ethical implications of inherited cardiac disease in clinical practice within the UK. Journal of Medical Ethics, 36(12),

pp.762-766.

Hosseini, S. and Ahmadi, A. (2012). Peripheral Edema Occurring during Treatment with Risperidone Combined with Citalopram. Case Reports in Medicine, 2012, pp.1-3.

Lindsay, C. (2013). ESC Congress 2013: advances in cardiac treatment. Br J Cardiac Nursing, 8(10), pp.474-477.

Maeder, M. and Hunziker, P. (2009). Sepsis-associated myocardial dysfunction: from bedside to bench. J Org Dysfunct, 5(2), pp.79-90.

Matsuki, T. (2013). Diagnosis and Treatment of Cardiac Failure in DPC/PDPS. Journal of Cardiac Failure, 19(10), p.S127.

McMullen, M. (2014). It is unlikely that the drinking of cold and room temperature water decreases cardiac workload. Acta Physiol, 213(1), pp.3-4.

Murakami, T., Takeda, A., Takei, K., Tateno, S., Kawasoe, Y. and Niwa, K. (2014). The cardiac blood supply–workload balance in children. Heart Vessels.

Pai, R. (2012). On Early Detection of Myocardial Dysfunction in Asymptomatic Severe Mitral Regurgitation. Echocardiography, 29(3), pp.265-266.

Piotrowski, (2013). Tomotherapy: Implications on Daily Workload and Scheduling Patients based on Three Years’ Institutional Experience. Technology in Cancer

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Ramchandra, D. (2014). Informed Consent: A Myth of Ethical Spirit and Legal Paradigm in Medical Profession. Medico-Legal Update, 14(1), p.86.

Sharma, A. (2007). SEPSIS-INDUCED MYOCARDIAL DYSFUNCTION. Shock, 28(3), pp.265-269.

Shuster, J. (2012). ISMP Adverse Drug Reactions - DRESS Syndrome Associated With Deferasirox Treatment; Recurrent Stress Cardiomyopathy Induced by

Over-the-Counter Phenylephrine; Angular Cheilitis After Selective Serotonin Reuptake Inhibitor Treatment; Chemotherapy-Induced Spontaneous Orgasms;

Liraglutide-Induced Acute Kidney Injury; Peripheral Edema Associated With Risperidone; Risk of Bleeding With Concurrent Use of Antibiotics and Warfarin. Hospital

Pharmacy, 47(4), pp.264-269.

te Slaa, A., Dolmans, D., Ho, G. and van der Laan, L. (2014). Treatment strategies and clinical aspects of lower limb edema following peripheral bypass surgery.

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