Essay, Pages 9 (2231 words)
Below we will discuss a case of acute illness, how a patient is received and what efforts were made to make her better. According to NMC code of conduct (2008), i have to hide patient’s real name, for confidentiality reasons. I will call my patient as Rita. She is a 60 years old lady, who lives with her husband on a 3rd floor flat with a lift access. Professionally she works as a dinner lady in a local primary school.
Rita has a history of cardiac failure followed by a myocardial infarction 18 months ago.
She had a smoking habit of 20 cigarettes a day from last 20 years.
I choose this topic as cardiovascular diseases and Respiratory disorders are very common nowadays. We see many people in our community suffering from cardiac problems resulting in different symptoms in their daily routine. “Most patients with Myocardial Infarction are cared for in a Coronary care unit during the acute stage. It is important that the patient and family be given a brief explanation of the various kinds of monitoring equipment in use and that they be reassured of each staff member’s concern for the patient welfare” (From Frazier et al.
“Coronary heart disease is the most common cause of death in the UK, accounting for 1 in 5 deaths in men and 1 in 7 deaths in women (BHF 2008), there are marked regional variations in death rates”. (Alexander’s Nursing Practice, 4th Edition)
At the time of admission
Rita was brought to hospital in an unstable condition as she was suffering from breathlessness and was directly admitted to the emergency department.
Her attendants were very worried about her. I was the duty nurse. Her vital signs were which were not good, she was showing respiratory rate of 40 breaths per minute whereas normal is 12 to 20 breaths per minute, no doubt this was the main difficulty and wants attention at once. Her oxygen saturation is 89% on air whereas normal ratio is 95 to 100 %. Her pulse was touching 175 beats per minute which was quite high as normal measurement is 60 to 100 beats per minute. Her temperature was 36.2 degrees Celsius which is near to normal as the normal temperature of human body is 37 degrees Celsius. Rita blood pressure was 90/50 mmhg and the normal human blood pressure is 120/80 mmhg.
“The ABCDE Assessment and management tool can be applied to all deteriorating and critically ill patients. It is recognised that approximately 30% of people developing Myocardial Infarction die before reaching the hospital (Resuscitation Council (UK) 2011)”. “It is imperative that Nursing staff are aware of the seriousness of ACS and the risks it poses to life. Effective and efficient assessment together with early treatment is at the heart of improving survival. (Henderson 2010)
Three Aspects of Care
If I have to choose three main points in serving acutely ill patient in the healthcare Practice I will be emphasized on following three points:
- · Breathlessness
- · Fluid Monitoring
- · Blood Pressure
Vital standards according to book (Anatomy & Physiology, 12th Edition)
- Blood pressure Normal Adult 120/80 mmHg
- Blood pressure above 140/90 is generally considered high.
Heart rate 60 to 80 / min
Sinus bradycardia 100 / min
- Respiration rate At rest 15 to 18 / min
Tidal volume 500 mL
Dead space 150 mL
Alveolar ventilation 15 (500 – 150) = 5.25 L / min
Urine Specific gravity 1.020 to 1.030
Volume excreted 1000 to 1500 mL / day
- Glucose is normally absent, but appears in urine when blood glucose levels exceed 9 mmol / L
- Body temperatures Normal 36.8 °C : axillary
Hypethermia ?35 °C : core temperature
Death when below 25 °C
- Cerebrospinal fluid pressure Lying on the side 60 – 180 mm H2O
- Intraocular pressure 1.3 to 2.6 kPa (10 to 20 mmHg)
Hourly observations of vital sign were going on to keep a check on improvement. Atrial fibrillation is showing on ECG as a 12 lead ECG was carried out, a cardiac monitor is also attached. As it is also mentioned “Heart failure is suspected because of the patient’s history, signs and symptoms. This diagnosis is then confirmed or excluded through a 12-lead ECG, which may show left ventricular hypertrophy, ischaemia or infarction” (Alexander’s Nursing Practice, 4th Edition).
On admission to the ward and following a full assessment Rita remains breathless and is on oxygen therapy 35% via a venture mask. As mentioned in book “Practitioners must have specialist training in the equipment and processes involved in the care of patients requiring ventilation in order to deliver optimal care and recognize complications. Mechanical ventilation is the artificial support of, or assistance with, breathing when adequate gaseous exchange and tissue perfusion can no longer be maintained”. (Alexander’s Nursing Practice, 4th Edition)
Rita is very distressed as she knows why is she in hospital being a lifelong smoker, smoking 20 cigarettes a day. Smoking hazards are mentioned as “factors that influence the patient’s respiratory health status such as allergens, the environment and smoking should be identified so that potential health education strategies can be implemented. As smoking is a major cause of respiratory illness a thorough smoking history should included current and past smoking habits, with the total pack years of smoking being estimated. The number of pack years can be calculated as follows:
Pack years = (number of cigarettes smoked per day X number of years smoked) divided by 20
The patient’s present and past occupation may indicate exposure to toxic substances such as asbestos and industrial chemicals. Through identifying exposure as the causative factor of respiratory disease the patient and their family may be eligible for compensation”. Smoking hazards are also mentioned as “individuals smoking may affect the respiratory system and cause:
- · Recurrent infection in the airways
- · Damage and loss of efficiency in the lungs
- · Lungs cancer
- · Chronic bronchitis and emphysema
Fletcher & Peto (1977) demonstrated that smoking accelerates the normal decline in lung function due to aging process from about 30 mL per year to 45 mL per year. The consequence of this increased loss of lung function is that impairment occurs leading to fatigue and breathlessness which impact on the individual’s ability to perform normal activities of daily living”. Tobacco hazards are mentioned as “Tobacco smoke, which contains nicotine, tar, carbon monoxide and four thousand chemicals, is currently the leading cause of respiratory ill health and premature death”. (Alexander’s Nursing Practice, 4th Edition)
Patients with such acute critical illness should be guided emotionally and psychologically other than medical treatment. A nurse should generate a comfortable relation to talk about patient’s weaknesses and try to solve patient’s problems to satisfy his or her mental stress so that patient recover soon and taken care all the precautions in future. It may be difficult for the nurse to stop any smoker from smoking “stopping smoking requires motivation, effort, commitment and stamina to be successful; therefore it has to be right time for the smoker to make an attempt. Helping people to stop smoking are the challenge face by many nurses as it requires facilitating change and supporting patients through the process rather than actively providing care”. (Alexander’s Nursing Practice, 4th Edition)
A nurse should have complete knowledge to motivate the patient about the concerning problem. Her explanation should be technical, practical and attractive so the one may be convinced easily to quit any bad habit dangerous for his or her health such as smoking. Recovery in human body after quitting smoking can be seen in two to twelve weeks as mentioned:
· Circulation, sense of smell and taste improves ( three to nine months)
- Respiratory symptoms improve
- Nasal congestion, cough and sputum production reduce
- Risk of small cell lung cancer halved
- Lung function cannot be reversed after years of damage, however stopping smoking means that the rate of decline revert to the age decline of a non-smoker (30 mL per year) and prevents further damage
- The reduction in mucus production helps to reduce exacerbations”
(Alexander’s Nursing Practice, 4th Edition)
Rita’s blood pressure at the time of admission was also low recorded as 90 / 50 mmHg. Keeping a record of blood pressure is very important its one of very common vital sign, it shows patient’s condition and demonstrate his or her recovery sign. A good check on patient’s blood pressure helps in treatment and observing patient’s current condition extremely high blood pressure or extremely low one, both are emergency conditions in which high care is involved as both conditions are life threatening. As explained “to maintain adequate oxygenation it is likely that the respiratory rate will also increase such as:
· A systolic blood pressure below 90 mmHg (or 40 mmHg below the usual systolic pressure)
· A rising heart rate (particularly if this is over 100 beats per minute) and respiratory rate (over 25 breaths per minute)”
(Alexander’s Nursing Practice, 4th Edition)
Rita was brought with the heart rate of 175 beats per minute which shows tachycardia dangerous for heart. Her heart rate was critically observed during all her stay. Her heart was not only high as well as irregular resulting in patient’s anxiety and restlessness. “Hyperinflation of the lungs puts respiratory muscles at a disadvantage and increases the work of breathing (Porth 2011). The increased effort of breathing together with the pronounced increase in the respiratory rate, leads to the patient to experience breathlessness and difficulty in talking.” As mentioned ” Forward failure – hypotension,
- · Low systolic blood pressure for individual
- · Tachycardia
- · Fatigue
- · Reduced exercise tolerance
(Alexander’s Nursing Practice, 4th Edition)
When Rita was admitted, she was unable to speak properly and was communicating in broken sentences which were turning her attendants more concerned, worried and curious. As mentioned “There is tachycardia in older patients, atrial fibrillation and cardiac failure. Patient’s complained of general fatigue although for short spells they may become more active and find that they are restless”. (Alexander’s Nursing Practice, 4th Edition)
In emergency department a continuous cardiac monitor was attached, hourly observations of vital signs were going on and an intravenous cannula is inserted. She is administrated intravenous digoxin and furosemide in the emergency department and is catheterized to enable accurate monitoring of fluid balance. She was kept in high observation and care over there, panel of doctors were involved in her treatment, different nurses in different shifts were engage and finally it was decided to transfer her to the cardiology ward for ongoing care to monitor and stabilize her present symptoms. On admission to the ward and following a full assessment Rita remains breathless and is on oxygen therapy via venture mask. She has a peripheral oedema and its fluid overloaded. Furosemide is being administrated intravenously. She is tacky cardia and attached to cardiac monitor here as well, which is still showing atrial fibrillation between 110 to 115 beats per minute. She remains hypertensive and her urinary output is greater than 70mL per hour. She is unable to eat or drink at the moment due to her breathlessness. “The shortness of breath may be manifested by an increase in the respiratory rate together with a reduction in oxygen saturation” (Porth 2011)
Rita Fluid is monitored using Fluid Balance “fluid balance is a term used to describe the balance of the input and output of fluids in the body to allow metabolic process to function correctly” (welch 2010) due to administration of digoxin and furosemide. “When recording urine output on a fluid balance chart, it is not acceptable practice to record it as “passed urine +++” or up to the toilet. Notes such as these are uninformative and do not give a clear indication of the urine passed ( Mooney, 2007). Rita has been fully monitored using a fluid intake and loss(McMillen and Pitcher(2010); scales and Pilsworth(2008);Waugh(2007)chart. The family and Rita has also been explained how chart is filled and how to recognised any abnormalities. Rita has now been catheterised and meaning she will be at risk of Urinary tract Infection. “If a patient has a urinary catheter and output is low, it is sensible to check whether the catheter or tubing is blocked or occluded in any way (Mc Millen and Pitcher, 2010). Rita and her family has been advised she should drink plenty of fluids and monitor for dehydration ” is defined as a 1 % greater loss of body mass as a result of fluid loss, where the body has less water than it needs to function properly( Madden 2000). Symptoms of dehydration and Urinary tract infection have been explained to Rita and her family. The normal range for 24-hour urine volume is 800 to 2000 milliliters per day (with a normal fluid intake of about 2 liters per day). Oliguria is urine output < 500 mL in 24 h (0.5 mL/kg/h) in an adult.
48 hours on from admission to the ward, following the administration of loading doses of digoxin the atrial fibrillation subsided and in conjunction with the furosemide her breathing eased and the oxygen is now reduced to 24%. As mentioned “Normal breathing should be regular and appear effortless with a respiratory rate in adults between 12 and 20 breaths per minute. The majority of patients with underlying respiratory disease will have an elevated respiratory rate (>20 breaths per minute) to facilitate adequate oxygenation and ventilation. Respiratory depression (