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NSB231 Integrated Nursing Practice

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NSB231 Integrated Nursing Practice

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NSB231 Integrated Nursing Practice

2 Downloads8 Pages / 1,912 Words

Course Code: NSB231
University: Queensland University Of Technology

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Country: Australia

Question:
Discuss about the Randomized Trial of Preventive Angioplasty.
 
 
Answer:
Introduction:

In the simulation, the scenario of Mr. Harry bright has been focused. Mr. Harry Bright is a 65 years old male, undergoing an angioplasty recently. He has the history of hypertension and type 2 diabetes. He had 3/12 history of angina during the household works, like working in garage or watching TV. The nurse attending him needed to look after other patients, thus she handed Mr. Bright over me during simulation. I thoroughly underwent his post angioplasty assessment. As he has reported chest pain during post angioplasty period, assessment should be done carefully, as chest pain is considered as significant PCI related complication.
In this context, we have reviewed articles to analyze the effectiveness of the assessment done for Mr. Bright. Royelly et al., (2011) provided a set of nursing clinical practice guidelines for individuals undergoing percutaneous coronary interventions (PCIs). The authors highlighted the need for the assessment of vital signs of the patient, which is crucial for PTCI care. Here the authors indicated the assessment of ST segment elevation in ECG to detect the acute ischemic changes. This is important for Mr. Bright, as doctors identified the PTCI procedure difficult for him along with a risk of ischemia. In this context, authors also highlighted the need for cardiac enzyme level measurement followed by the ECG, especially the level of troponin, as its rise indicates ischemia. They also revealed the need for monitoring the signs of localized puncture site complications, i.e. bleeding, swelling, hematoma and limb circulation (Khan et al., 2011). All of these assessments were done properly in simulation assessment of Mr. Bright. As the femoral puncture causes hematoma or haemorrhage, which can lead to significant blood loss, thus, I have significantly assessed Mr. Bright for the absence of ooze, redness, warmth and absence of bleeding.
These assessments are included in the category “wound assessment”. Authors also highlighted the importance for peripheral pulse measurement, which was done in the simulation, by monitoring Mr. Bright’s dosalis pulse. Another guide provided by the author is to manage pain, including chest pain and surgical site pain during the removal of sheath. For controlling the post PTCI vascular complications, strategies are depicted by the authors to achieve haemostasis (Roffi et al., 2015). In case of chest pain, authors guided to change patients’ position and to elevate the head of the bed to 30°, which I did, when Mr. Bright reported his chest pain (Royelly et al., 2011). In regards to the secondary prevention of post angioplasty complication, author’s guidelines showed the use of nitrate in the action plan. The recommendation of nitrate usage is given for not only during hospitalization, rather even after patient’s discharge, besides seeking emergency medical assistance. In case of Mr. Bright, he was admminsitered with nitroglycerin spray x 1, which significantly resolved his pain (Gallagher et al., 2011). Therefore, it can be said that post angioplasty wound and chest pain assessment were significantly done during simulation.
However, according to the article provided by Chang et al., (2016), the neurovascular assessment was not done properly in the simulation. I have attempted and completed several factors in Mr. Bright’s neurovascular assessment, but missed the assessment of two feet. It has been revealed by the author that femoral bleeding can lead to hematoma formation, which may compress the femoral nerve and detection of which is crucial to reduce the risk of ischemia (Bonati et al., 2012). This damage can be detected through proper neurovascular assessment including capillary refill, skin colour, dorsalis pulse, pain, discomfort, sensation and motor function observation (Blair & Clarke, 2013). Though I have monitored colour, dorsalis pulse and pain adequately; I missed the assessment of capillary refill, skin colour and discomfort assessment. Moreover, Mr. Bright has the history of type 2 diabetes, which reduces the rate of surgical wound recovery, while influencing the femoral bleeding and related nerve damage. In this context, though his BGL was normal, i.e. 10 mmol/l, I didn’t check whether the medications were withdrawan or not, as these symptoms, combining altogether may lead to damage to his kidney, assessment of which was also missed (De Luca et al., 2013). Therefore, these missed diagnosis and insufficient assessment may increase the severity of his condition. I would improve my skills in these areas in further (Rear, Bell & Hausenloy, 2016).
 
I have undergone ISBAR format to communicate Mr. Bright’s case with other nurses, especially while handing him over to other nurses, after my shift. Here, I am going to reflect about Mr. Bright’s case and information I have provided to the doctor, when he complained chest pain, through the ISBAR format.
Indentify- Mr. Bright is a 65 years old male, who have been admitted to the surgical ward of QUT hospital, after he had undergone an angioplasty. I am looking after Mr. Harry Bright in this shift and about to inform you regarding Mr. Harry Bright’s chest pain. His details are as follows:
Situation- Mr. Bright reported angina several times, prior his angioplasty. However, after undergoing angioplasty and transferring him from the operation theatre to his bed in male surgical ward, he reported severe chest pain, which is also radiating from his left side of law to his legs, which is followed by nausea. The pain is now started to radiate towards back.
Background- Mr. Harry Bright is a 65 years old male, who has medical history of hypertension and type 2 diabetes, which he revealed during pre-admission assessment. His medical issues are controlled by medications; i.e. for hypertension, he has been administered with metropolol, which is a beta blocker and helps to control his blood pressure. On the other hand, he is administered with metformin, for controlling his blood sugar and combat with his type 2 diabetes. On the other hand, he has also been administered with aspirin regularly, for dealing with his previous episodes of angina; simvastalin is administered daily for lowering blood cholesterol level and reduce the chance of cardiovascular complications associated with high cholesterol, type 2 diabetes and hypertension. However, the patient does not have any allergy.
From his medical history, it has been revealed that he used to a chain smoker, smoking 20 cigarettes per day and consuming alcohol on regular basis. Recently he has been experiencing some transient episodes of unstable angina.  He reported in his pre-admission assessment that he usually experienced the episodes of angina or chest pain while doing regular work, i.e. watching TV, gardening or working in garage. Every time, he experienced the pain radiating from left arm to left jaw. As he was experiencing unstable an transient episodes of angina, physicians decided to perform a PTCI and admitted to QUT hospital. During admission, his BP was high, 150/90 and BGL was around the normal range, 10.7. He was brought to the operation theatre after undergoing initial diagnosis and blood tests. During the surgery, his right femoral artery was punctured and through 6 french sheath and a drug eluting stent was placed in right coronary artery, with 10 % residual stenosis at the site. The process was difficult to perform and may lead to cardiac ischemia, for which continuous ECG monitoring was required. In his recovery, his right femoral surgical wound was removed, followed by which he reported chest pain. It was noticed by the physician and he administered nitroglycerin spray x 1 to Mr. Bright and his pain was resolved. He transferred to the ward at 1650 hours, while he was conscious and alert.
Assessment- After he was transferred to the surgical ward, I assessed his vital sign, surgical site and further episodes of chest pain. No pain, swelling or hematoma was observed. I observed only little ooze and bruising of the surgical site. I monitored is dorsalis, which showed normal sign. His fluid chart shown he was on normal saline IV line with a rate of 100 ml/hr back (Benner, Hooper-Kyriakidis & Stannard, 2011). His ECG was done after chest pain reported, which was normal. I am observing his vital signs over every 30 minutes. At 1527 hours, he reported chest pain and I measured the pain score, which was 6 out 10 in a 1 to 10 pain scale. His heart rate was 112 and respiratory rate was 26 with a body temperature of 37.3. The wound assessment showed no hematoma, change in colour or pain at surgical site. He reported his pain radiating to back.
Recommendation
As the doctor and RN advised not to order another ECG and only administer his medication; I will administer nitro-glycerine spray and complete his neurovascular assessment. I will help Mr Bright to lay down with a maximum 30 ° angle with the bed, for promoting his airway passage. As I have the order for his medications, i.e. morphin and metoclopramide, I would assess his status prior administering the medication. As the patient has undergone chest pain, there is a chance of haemorrhage or bleeding; thus further tests are recommended to be ordered including ECG, Doppler and cardiac enzyme, i.e. troponin level testing and doctor’s visit (Abid et al., 2015).
 
Reference List
Abid, S., Shuaib, W., Ali, S., Evans, D. D., Khan, M. S., Edalat, F., & Khan, M. J. (2015). Chest pain assessment and imaging practices for nurse practitioners in the emergency department. Advanced Emergency Nursing Journal, 37(1), 12-22. doi: 10.1097/TME.0000000000000048
Benner, P. E., Hooper-Kyriakidis, P. L., & Stannard, D. (2011). Clinical wisdom and interventions in acute and critical care: A thinking-in-action approach. Springer Publishing Company.
Blair, V., & Clarke, S. (2013). Neurovascular assessment post femoral nerve block: Nursing (RN) implications on fall prevention. International Journal of Orthopaedic and Trauma Nursing, 17(2), 99-105. doi: 10.1016/j.ijotn.2012.05.007
Bonati, L. H., Lyrer, P., Ederle, J., Featherstone, R., & Brown, M. M. (2012). Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. The Cochrane Library.
Chang, C. C., Chen, Y. C., Ong, E. T., Chen, W. C., Chang, C. H., Chen, K. J., & Chiang, C. W. (2016). Chest pain after percutaneous coronary intervention in patients with stable angina. Clinical Interventions in Aging, 11, 1123.
De Luca, G., Dirksen, M. T., Spaulding, C., Kelbæk, H., Schalij, M., Thuesen, L., … & Chechi, T. (2013). Impact of Diabetes on Long-Term Outcome After Primary Angioplasty. Diabetes Care, 36(4), 1020-1025.
Gallagher, K. A., Meltzer, A. J., Ravin, R. A., Graham, A., Shrikhande, G., Connolly, P. H., … & McKinsey, J. F. (2011). Endovascular management as first therapy for chronic total occlusion of the lower extremity arteries: comparison of balloon angioplasty, stenting, and directional atherectomy. Journal of Endovascular Therapy, 18(5), 624-637.
Khan, N., Dodd, R., Marks, M. P., Bell-Stephens, T., Vavao, J., & Steinberg, G. K. (2011). Failure of primary percutaneous angioplasty and stenting in the prevention of ischemia in Moyamoya angiopathy. Cerebrovascular Diseases, 31(2), 147-153.
Rear, R., Bell, R. M., & Hausenloy, D. J. (2016). Contrast-induced nephropathy following angiography and cardiac interventions. Heart (British Cardiac Society), 102(8), 638-648. doi:10.1136/heartjnl-2014-306962
Roffi, M., Patrono, C., Collet, J. P., Mueller, C., Valgimigli, M., Andreotti, F., … & Gencer, B. (2015). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European heart journal, ehv320.
Rolley, J. X., Salamonson, Y., Wensley, C., Dennison, C. R., & Davidson, P. M. (2011). Nursing clinical practice guidelines to improve care for people undergoing percutaneous coronary interventions. Australian Critical Care, 24(1), 18-38.
Wald, D. S., Morris, J. K., Wald, N. J., Chase, A. J., Edwards, R. J., Hughes, L. O., … & Oldroyd, K. G. (2013). Randomized trial of preventive angioplasty in myocardial infarction. New England Journal of Medicine, 369(12), 1115-1123.

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