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Approaches used for the diagnosis and treatment of Myocardial Infarction

Discuss about the Role Of Care Nurse In Assisting The Patient With Myocardial Infarction In Emergency Department.

Background of the problem

Mycardial infraction (MI) is a pathological condition which is defined as myocardial death caused via prolong ischemia. In MI, an portion of myocardium is permanently destroyed due to plaque rupture and the subsequent thrombus formation causes complete occlusion of the artery which eventually leads to acute coronary syndrome (ACS). According to the elctrocardiographic criteria, there two different kinds of acute MI (AMI) based on the therapeutic differences and these are AMI with strongly uneven ST segments and AMI without strongly uneven ST segments (O'Gara et al., 2013). Therapy for AMU without strongly uneven ST is identical with the therapy for instable angina. AMI individuals with strongly uneven ST are treated with precutanous transluminal coronary angioplasty (PTCA) and with thrombolytics. On the other hand, the length o the reperfusion therapy is mainly modulated in case treating AMI with strongly uneven ST (O'Gara et al., 2013). Levine et al. (2016) is of the opinion that arterial recanalization applied at the right point of time is beneficial for the maintenance of the ventricular function and sustainability. In relation to this, Deaton et al. (2017) have stated that all these contemporary approaches that are used for the diagnosis and the treatment of AMI have revolutionized the role and responsibilities of the nurses in the emergency department of the coronary care unit. Deaton et al. (2017) have further argued that the treatment and care for the patients with AMI who are admitted in the emergency department is not solely dependent on the role and performance of the doctors. The present cardiovascular setup in the healthcare organisation demands close working association among the nursing professionals, physicians and other allied technical professionals who assist in stabilizing the overall condition of the patients and they work in unison towards successful procurement of the care plan. Deaton et al. (2017) highlighted that the registered nurses in the cardiovascular unit have varying roles in the care process of the patients with MI in the emergency department and this mainly includes nurse-initiated thrombolytic, patient education and adoption and subsequent procurement of the primary health interventions upon admission to the emergency unit. However, the role and scope of responsibilities of the specialist nurse in assisting the patients with MI in emergency department is not well-defined.

The aim of the research is to analyse and describe the roles and the responsibilities of the registered nurses in providing care to patients with MI in emergency unit.

  • What are the roles of the nurses in managing patients with MI in emergency unit?
  • How this nurse specific roles and responsibilities help in the improvement of the overall patient’s outcome?
  • How the roles of the nurses can further be improved in order to reduce the chances of hospital readmission due to MI?

Importance of close working association among nursing professionals, physicians and other allied technical professionals

According to the Department of Health Australia (2016), cardiovascular disease is the leading cause of death along with disease burden in Australia. The total number of people living with cardiovascular disease in Australia is increasing because of increase in the percentage of the aged population in the Australian sub-continents. Among the cardiovascular disease, one of the most common names is myocardial infarction which is regarded as one of the major form of the coronary heart disease leading to stroke or heart attack. However, as per the reports published by The Department of Health Australia (2016), in Australia, the level of survivors of MI is gradually increasing due to improved fibrinolytic therapy and advanced precutaneous coronary interventions. However, patients with myocardial infarction and the rates of hospital admission is a persistent problem in Australia because of the unhealthy lifestyles. The hospital admission is mostly common among the older adults and risk of mortality is also significantly high in this population due to their age related associated pathological complication. Furthermore, this group of population also encounters high rate of hospital readmission due to their unhealthy lifestyles (Kim et al., 2013). Meisinger et al. (2013) are of the opinion that the proper treatment and immediate actions in the emergency unit help in reducing overall mortality and morbidity rate of the patients with MI. Research undertaken by Meisinger et al. (2013) highlighted that nurse-based case management may influence the overall health outcomes of the patients with MI in the emergency department (ED). So the proper analysis of the roles and the responsibilities of the nurses in the cardiovascular emergency unit will help to stringently define the nurses’ roles in managing MI and thereby helping to improve the interventions associated with the nurse-based case management in MI.

The study conducted by Hunger et al. (2015) is based on the background that older adults who suffer from the acute MI often lack the adequate support to continue with the process of rehabilitation after getting discharged from the hospital. They conducted a randomised control trial (RCT) over 329 patients between the age group of 65 to 92 years in order to study that whether hoe-based case management programme conducted by the trained nursing professionals can help in the improvement of the overall physical functioning, atherogenic risk factors and mental health of the patients who are in their first year of MI prognosis following their discharge from the medical hospital. The results of their randomised control trail lead to the elucidation that test group of population showed significant improvement in the blood cholesterol level, blood pressure maintenance, nutritional balance, cognitive status and nutritional level in comparison to the placebo group who received no  interventions. Thus the RCT study conducted by Hunger et al. (2015) showed that nurse-based case management of patients with MI help in providing improved level of outcomes. However, the study had certain limitations like the study was conducted over the patients based on single hospital and in this one year follow-up study, there was a high rate of drop out these two factors might lead to the generation of the biased results. However, this study though conducted over the patients post discharge highlighted the importance of the proper  nursing intervention in maintaining the proper health outcomes in case of MI. Effective improvement of the cognitive function may not he significant with the scope of the current study as it mostly centres on the MI patients of ED, but the proper maintenance of the vital parameters like cholesterol, blood pressure showed that how proper nursing roles and responsibilities is helpful in managing the health related risks associated with MI.

Nurse-based case management in Myocardial Infarction

The study conducted by Grosmaitre et al. (2013) highlighted that in the ED, early diagnosis of ST-MI following hospital admission is the principal parameter in providing eligible patients with reperfusion therapy immediately. Chest pain is the common sign leading to suspicion of MI in ED. Upon admission to the ED upon suspected case of MI, immediate electrocardiogram (ECG) is recommended in order detect the condition of the heart. However, in case of older adults, the positive predictive parameter of chest pain associated with MI diagnosis is significantly low. This is because, the prevalence of MI in aged individual is mostly represented via atypical symptoms which is devoid of chest pain. This atypical symptom leads to delayed diagnosis of MI among older adults (Grosmaitre et al., 2013). The retrospective multicentre study conducted by Grosmaitre et al. (2013) showed that the atypical symptoms of MI are severe and common among the older adults of ED. Proper education of the nurses and defined nurse roles and responsibility help in the early diagnosis of MI and subsequent hospital admission. This early diagnosis of MI is mostly related with the rapid provision of an electrocardiogram to all elderly patients irrespective of their cardiovascular symptoms (Grosmaitre et al., 2013). This review support the purpose of the study as it mainly deals with the importance of proper nursing education and role of nurse towards early diagnosis of MI upon ED admission.

The qualitative study conducted by Cherlin et al. (2013) highlighted that apart from early diagnosis and prompt interventions in treating the patients of MI in the ED, proper planning of hospital discharge is also essential for the ED patients in order to maintain the health and safety. This quality discharge planning mainly deals with the disease related education to patient and their family members in the domain of maintenance of healthy lifestyle. This education will in turn restrict hospital re-admission on the same cause within smaller interval. The qualitative study conducted by Cherlin et al. (2013) over the nursing and the administrative staffs of the US hospitals having provision for percutaneous coronary interventions showed that it is the role of the nursing professionals to ensure a detailed follow-up plan with the physician before discharge while providing proper education to the patient and their family members about patient’s health and follow-up. Though their study is not comprehensive but it lead to the elucidation that nurses play an important role in ED department towards treating patients with MI in ED (Cherlin et al., 2013). However, the study mostly concentrated on the importance of nursing intervention in planning the discharge plan and failed to conduct an analysis on the overall nursing roles and the responsibilities. However, they conducted study from the perspective of the nursing professionals which is one of the strength of the study which helped to get the insight of care plan from the nurses.

Early Diagnosis in Emergency Department

Thus the main gaps in the research is though the importance of the nursing interventions in managing the patients with MI has been studies, but there was though detailed insight about roles and the responsibilities of the nurses which help in early diagnosis of MI upon ED admission along with better disease outcomes and less frequent re-admission. However, it can also be said that the review is not comprehensive as the research failed to access adequate journals due to the lack of time and resources.

According to Bernard (2011), the research design mainly constitutes the methods that will be employed in order to conduct a research.

According to Bergh and Ketchen (2011) there are different types of research philosophies namely positivism, interpretivism and realism. In this research, the researcher will follow Interpretivism research philosophy will help in the in-depth analysis of the small samples, something that is best suited for qualitative research.

The main research approach that will be suitable for the research is inductive research approach. Inductive research approach mainly deals with generation of new theories from the emerging information. Moreover, it helps to narrow down the scope of the study which is best suited for qualitative research (Crowther & Lancaster, 2012).

This study will mainly employ qualitative descriptive style research design in order to explore the roles and the responsibility of the nurses in managing MI patients in ED. Descriptive type research design is suitable because it will help in elaborate description of the importance of roles and responsibility of nurses in caring MI patients via establishing close relationship with the participants and the study (Sandelwoski 2000).

Sample is a subset of population chosen to participate in the study (Polit, Beck & Polit, 2010). The researcher will use random sampling. The researcher will choose a sample size of 10 to 15 registered nurses operating the ED of cardio-vascular unit of state run hospital in Australia. The selection criteria that will be taken into consideration include registered nurses working more than 5 years in the ED of the cardiovascular unit. This is because experienced nurses are best candidate to comment on the importance of nursing role in patient care in MI.

There are two types of research design qualitative and quantitative research design (Truscott et al., 2012). Here the author will follow qualitative research design. The reason for the selection of qualitative research design is it helps to carry forward the research work under natural settings which help to understand the underlying phenomenon from the perspective of the people who are inherent to the required system (Sandelowski, 2000). Moreover, qualitative research design will help in-dept understanding of the research process (Cresswell, 2013).

Hospital Discharge Planning

The qualitative data collection will be done via designing 10 open ended questions which is will used as main weapon of the semi-structured interview among the RN in this qualitative study (questionnaire provided in the appendix portion). Semi-structured interview is important for the social and health care research because it proved avenues towards generation of new ideas during the interview sessions (Galetta, 2013). The main instruments that will be used for the data collection will be audio tape recorders. The recorded data will be transformed into written transcript via a professional transcriber. The written transcript generated will be evaluated by the respondents themselves in order to check the validity and reliability of the data collection tool and procedure.

In case of conducting a research, the researcher is required to abide by certain ethical consideration as proposed by the Data Protection Act of 1998. The ethical principles along with the guidelines will help the researcher to conduct the research in an authentic manner (Brinkmann 2014). At first the researcher will take consent from the concerned hospital in order to access the RN. An official letter will be sent to the administrative head seeking permission to contact with the RN of the ED. After getting permission of from the concerned authority, a letter will be disseminated to the prospective RN stating the purpose of the study, and who their participation will help to enrich the study, the letter will also contain that the entire research work will keep their identity confidential and their participation is subject to their own approval. The letter will also contain the contact details of the researcher so that the interested nurses can contact the researcher directly in case of any query. Upon the approval from the RN via the signed consent form, the interview session will initiate and this will occur within the hospital permission as per time opted by the nurses so that the interview session might not harm their duty hours. The RN will be allowed to leave the interview session at any point of time without any prior notice. The names and the identification details will not be disclosed in the study and the survey questionnaire will avoid personal question so that it might not hurt the emotions and feelings of the participants (Brinkmann 2014). The written transcript and the soft cope of the recorded audio file will be stored in locked shelves secured USB respectively under high confidentiality. 

The researcher is also required to be aware of the biasness and about the protection of the collected data so that the privacy and confidentiality issues are not bridged. The researcher also needs to avoid data manipulation so that the work can be authentic.

Conclusion

Study limitation

The main limitation of the study is, its low sample size. However, due to the lack of proper funding and time, the researcher is required to restrict the study design within low sample size. This low sample size might generate a bias response (Marshall et al., 2013).

Potential impact of proposed study on wider community

The study is extremely beneficial for the wider community that is the adults or the older adults suffering from recurrent myocardial infarction. This is because, proper elucidation of the nursing roles and responsibilities in patient care and management in ED will promote quality patient outcome and fast recovery.

Summary 

Thus from the above research proposal, it can be said that ED admission of patients with MI requires prompt diagnosis and immediate application of therapy. In this emergency recovery plan of MI, nurses play an important role. However, there are no significant research defining nurse roles and responsibilities in managing MI in ED. This research will conduct a survey via open-ended questionnaire over 10 to 15 nurses in order to ascertain the roles and responsibilities of nurses in managing MI in ED.

References

Bergh, D., & Ketchen, D. J. (2011). Research methodology in Strategy and Management, 1st ed. Bingley: Emerald Group Publishing Ltd

Bernard, H. R. (2011) Research Methods in Anthropology: Qualitative and Quantitative Approaches. 5th ed. Plymouth: London. Alta Mira Press.

Brinkmann, S., 2014. Interview. In Encyclopedia of critical psychology (pp. 1008-1010). Springer New York.

Cherlin, E. J., Curry, L. A., Thompson, J. W., Greysen, S. R., Spatz, E., Krumholz, H. M., & Bradley, E. H. (2013). Features of high quality discharge planning for patients following acute myocardial infarction. Journal of general internal medicine, 28(3), 436-443.

Creswell, J. W. (2013). Qualitative Inquiry and Research: Choosing Among Five Approaches. 3rd editions.

Crowther, D., & Lancaster, G. (2012). Research Methods, 2nd ed. London: Routledge

Deaton, C., Johnson, R., Evans, M., Timmis, A., Zaman, J., Hemingway, H., ... & Cramer, H. (2017). Aligning the planets: The role of nurses in the care of patients with non?ST elevation myocardial infarction. Nursing open, 4(1), 49-56.

Galletta, A., (2013). Mastering the semi-structured interview and beyond: From research design to analysis and publication. NYU press

Grosmaitre, P., Le Vavasseur, O., Yachouh, E., Courtial, Y., Jacob, X., Meyran, S., & Lantelme, P. (2013). Significance of atypical symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments. Archives of cardiovascular diseases, 106(11), 586-592.

Hunger, M., Kirchberger, I., Holle, R., Seidl, H., Kuch, B., Wende, R., & Meisinger, C. (2015). Does nurse-based case management for aged myocardial infarction patients improve risk factors, physical functioning and mental health? The KORINNA trial. European journal of preventive cardiology, 22(4), 442-450.

Kim, E. S., Sun, J. K., Park, N., Kubzansky, L. D., & Peterson, C. (2013). Purpose in life and reduced risk of myocardial infarction among older US adults with coronary heart disease: a two-year follow-up. Journal of Behavioral Medicine, 36(2), 124-133.

Levine, G. N., Bates, E. R., Blankenship, J. C., Bailey, S. R., Bittl, J. A., Cercek, B., ... & Khot, U. N. (2016). 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Journal of the American College of Cardiology, 67(10), 1235-1250.

Marshall, B., Cardon, P., Poddar, A., & Fontenot, R. (2013). Does sample size matter in qualitative research?: A review of qualitative interviews in IS research. Journal of Computer Information Systems, 54(1), 11-22.

Meisinger, C., Stollenwerk, B., Kirchberger, I., Seidl, H., Wende, R., Kuch, B., & Holle, R. (2013). Effects of a nurse-based case management compared to usual care among aged patients with myocardial infarction: results from the randomized controlled KORINNA study. BMC geriatrics, 13(1), 115.

O'Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., De Lemos, J. A., ... & Granger, C. B. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), e78-e140.

 Polit, D., Beck, C. & Polit, D. (2012). Resource manual for Nursing research. Philadelphia: Wolters Kluwer Health/lippincott Williams & Wilkins

Sandelowski, M. (2000). Focus on research methods-whatever happened to qualitative description?. Research in nursing and health, 23(4), 334-340.

The Department of Health Australia. (2016). Cardio Vascular Disease. Access date: 20th June 2018. Retrieved from: https://www.health.gov.au/internet/main/publishing.nsf/content/chronic-cardio

Truscott, D. M., Swars, S., Smith, S., Thornton?Reid, F., Zhao, Y., Dooley, C., ... & Matthews, M. (2010). A cross?disciplinary examination of the prevalence of mixed methods in educational research: 1995–2005. International Journal of Social Research Methodology, 13(4), 317-328.

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