NR 305 Week 4 Posts Discussion
NR305 Week 4 Posts Discussion
This discussion will meet the following weekly objectives:
Differentiate normal from
... [Show More] abnormal findings in the assessment of the cardiovascular and peripheral vascular systems.
Identify anatomical, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular and peripheral vascular systems.
Describe the skills and techniques required to assess the cardiovascular and peripheral vascular systems and document findings.
Develop questions to be used when completing a focused interview for the cardiovascular and peripheral vascular systems.
Discuss the focus areas related to overall health of the cardiovascular and peripheral vascular systems in the Healthy People 2020 initiatives.
In this discussion please answer the following questions for this week’s scenario:
Ms. Jackson is recovering from her mastectomy surgical procedure. She has started to experience concerning symptoms. Please address the following questions related to the scenario:
What do you suspect is the cause of the patient’s symptoms?
Describe the course of action that you will take to confirm this suspicion and prevent further decline.
What further assessments, lab values, and tests will likely be ordered for this patient and how often? If testing is to be completed more than once, please explain the rationale for doing so.
While you are caring for this patient, how will you ensure that the needs of your other patients are being met?
Collapse SubdiscussionLynne McKenna
Lynne McKenna
Nov 19, 2018 Nov 19 at 12:07pm
Dear Professor and Class,
What do you suspect is the cause of the patient's symptoms?
I would suspect that she is showing clinical signs of a possible myocardial infarction first as I would want to rule that out. The symptoms that Ms. Jackson is presenting with could be representative of other things such as tachycardia, irregular heart rate, or an electrolyte imbalance. I would have received report from the nurse going off shift regarding Ms. Jackson’s health history. I am especially interested in her smoking status, high cholesterol, hypertension, weight, past MI’s, and family history. Ms. Jackson is complaining of nausea, back pain that hasn’t been relieved, extreme fatigue, and we have a pulse rate that is very irregular. The patient is one day post op. The vital assessment shows she has a current blood pressure that is a little high, but not at hypertensive level at 132/54. Stage 1 hypertension is a systolic BP of greater than or equal to 140 or diastolic less than or equal to 90 (Jarvis, 2016). Ms. Jackson reported feeling tired. The 3 most frequently reported symptoms for acute coronary syndrome are chest pain, unusual fatigue, and shortness of breath (DeVon, Ryan, Ochs, Shapiro, 2008). Women are more likely to experience indigestion, palpitations, nausea, numbness in the hands, and unusual fatigue for acute coronary syndrome.
Describe the course of action that you will take to confirm this suspicion and prevent further decline. I would request that my patient be put on tele. Get a set of vitals, apply oxygen, and make sure we have two IV sites on Ms. Jackson per protocol. I would request that we get a 12 lead ECG after I notified the physician and listened to his/her thoughts or orders. Lab would be asked to draw for cardiac markers, (CK-MB, troponin, and myoglobin) electrolytes, and cholesterol. The ECG may change so we need to use both the lab and ECG results. Place the resident in a semi-fowlers position to keep her comfortable and enhance oxygenation. Administer nitroglycerin if prescribed or per protocol. Administer anti-dysrhythmics as prescribed. Administer thrombolytic therapy if ordered. Monitor for signs of bleeding. Monitor blood pressure, pulses and respiratory basically all the vitals to watch for changes. Assess the results of the tests and reassess. Provide reassurance to the patient and their family. Stay with the patient.
What further assessments, lab values, and tests will likely be ordered for this patient and how often? If testing is to be completed more than once, please explain the rationale for doing so. An ECG strips change and should be performed more than once (every 2-4 hours). The first set of cardiac markers may not confirm and we may have to draw another set because the markers peak at different times (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2017). Blood pressure should be continually monitored with the use of nitroglycerin and monitor for bleeding with use of thrombolytic drugs. All vital signs should be monitored and reassessed continuously due to possible changes in status.
While you are caring for this patient, how will you ensure that the needs of your other patients are being met? I would notify the change nurse immediately and ask her for assistance with delegation and gathering vitals and meeting the needs of my other patients while I deal with this potential emergent situation. The charge nurse will most likely delegate those tasks to other nurses until this situation is under control. I realize that not all facilities can absorb this with available staff. The patient may be transferred to a cardiac unit at some point during this process, but that depends on the facility and the physician’s recommendations.
DeVon, H. A., Ryan, C. J., Ochs, A. L., & Shapiro, M. (2008). Symptoms across the continuum of acute coronary syndromes: differences between women and men. American journal of critical care : an official publication, American Association of Critical-Care Nurses, 17(1), 14-24
Jarvis, C. (2016). Physical examination & health assessment (7th ed.) Philadelphia, PA: Saunders.
Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier
Collapse SubdiscussionMargo Emlich
Margo Emlich
Nov 20, 2018 Nov 20 at 3:29am
Class,
What rationale would you use to transfer the patient to telemetry versus the Intensive Care Unit? Would you transfer to telemetry or transfer to the ICU or manage her where she is?
Does having a radical mastectomy put her at a greater risk for cardiac complications?
Margo
Collapse SubdiscussionBrook Rodger
Brook Rodger
Nov 20, 2018 Nov 20 at 10:41am
Hello Margo,
I would think that a Telemetry would be best for Ms. Jackson due to telemetry being where you would want to go for any cardiac issues (especially a suspected MI). I think ICU is for critically ill patients and although we have a emergent situation if taken care of quickly and properly Ms. Jackson should stabilize. She is one day post mastectomy but not critical ill in the sense that once brought to the telemetry unit and monitored/cared for she should stabilize and hopefully recover. For these reasons, I believe Telemetry would be her best option.
I do not think there is a link between cardiac complications and Mastectomy's itself, however I do know that post-op it is certainly a top priority to get your patient moving around as soon as possible to prevent DVT's, fat embolism, and Pneumonia along with many other possibilities. I do know Cancer treatment such as radiation and chemotherapy can harm the heart. Radiation can cause many issues such as heart attack, arrhythmia, and heart failure. Chemotherapy can weaken the heart muscle. The cardiovascular side effects of cancer therapies are scary to say the least (Harvard Health Publishing, 2012).
Reference:
Harvard health Publishing. (2012, August). Cancer treatment may harm the heart. Retrieved November 20,2018, from http://www.heath.harvard.edu/heart-health/cancer-treatment-may-harm-the-heartLinks to an external site.
Collapse SubdiscussionBrook Rodger
Brook Rodger
Nov 20, 2018 Nov 20 at 12:24pm
Hello Margo,
Although I previously said I would place Ms. Jackson on telemetry floor I think I would change my mind and in fact have Ms Jackson placed on the ICU floor. The reason I am changing my mind is because with her emergent situation I feel although she is not critically ill, she is unstable and there should be a nurse that is more hands on with her until she is stable. This is serious and Ms jackson could possibly die.
There is cardiac equipment on the ICU floor and because there is usually a 1(nurse) to 2(patient) ratio I believe an ICU nurse can give more time to our patient and better all around care. I believe until she is stable she should remain in the ICU. The regular floor is a higher ratio of patients per nurse and Ms Jackson needs more hands on until she is stabilized.
Collapse SubdiscussionDenise Carranco
Denise Carranco
Nov 21, 2018 Nov 21 at 12:51am
Hi Brook,
As I read the initial question I also thought telemetry but since Ms. Jackson's symptoms have been ongoing and the interventions the prior nurse did not work which leads me to believe that the ICU is more appropriate. She is in a critical condition and she needs to be stabilized. In the ICU like you said one nurse would be working with her and another patient. More time spent with the patient to stabilize her.
Kindly,
Denise Carranco
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Osalenne Metellus
Osalenne Metellus
Nov 21, 2018 Nov 21 at 9:07pm
Hello Margo,
I would manage her on the floor. While Ms. Jackson voiced complaint of pain, tiredness and nausea, she is not in distress. She is not a candidate for ICU because it is most for critically ill patients. Telemetry probably not, if the doctor asked to transfer Ms. Jackson to ICU or Telemetry, I will do so, other than that , the patient can be treat on the floor.
Collapse SubdiscussionKarmen Crowley
Karmen Crowley
Nov 23, 2018 Nov 23 at 5:29am
Hello Margo,
Telemetry vs ICU would depend on the outcome of testing and how Mrs. Jackson proceeds to stabilize or decline in her condition in the next increment of time after our scenario. If her ECG shows AFib, she can be managed on a telemetry floor. If there is concern for a MI, she may need ICU depending on the outcome of her ECG, troponin, and how her symptoms progress or stabilize. In our hospital, nitro and anti arrhythmic drips can be managed on the telemetry floor. As others have mentioned, and in our hospital as well, ICU is saved for critically ill patients who really need to be there.
No, I don't feel that having a radical mastectomy necessarily puts her at greater risk for cardiac complications. Per this article, cardiac complications and cardiac morbidity are low in breast cancer surgery in women.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1877061/Links to an external site.
I feel that her risk for complications lies more in complications that are more common after general surgery - wound infection, non healing wound, pneumonia, and DVT.
Collapse SubdiscussionMargo Emlich
Margo Emlich
Nov 23, 2018 Nov 23 at 2:48pm
Brook, Denise, Osalenne, and Karmen
I totally agree with you fall or the most part, however, this isn’t just your basic chest pain. This is a 56-year-old black female who is post-op. Having thoracic surgery (area) puts her at a higher risk for post-op complications. It would be difficult to determine which complaints were from her surgery and which are from her cardiac status. With that being said, what signs and symptoms would occur for you to transfer her to telemetry or the Cardiac Care Unit? Is she having an evolving MI? Is she having angina? Is it just chalked-up to post-op pain?
Here is something to think about:
In an article by Zegre-Hemsey, Garvey, & Carey (2016) the 12-lead ECG remains the gold standard and initially used a diagnostic test in determining crucial information about cardiac status. It is a quick noninvasive procedure that can tell cardiac rhythm, ischemia, infarction, and other abnormalities that may be present. Usually, this test is done within ten minutes of entering the emergency room or complaints of chest pain. The longer the time that passes, the higher the chance of complications that go untreated. (Zegre-Hemsey, Garvey, & Carey, 2016, p 338)
Telemetry “is an observation tool that allows continuous ECG, RR, SpOz monitoring while the patient remains active without restriction of being attached to a bedside cardiac monitor” (Pelter, Loranger, Kozik, Fidler, Hu, & Carey, 2016 p 778).
Time is of the utmost importance in this situation. Being on a post-op floor, the patient seems to require too much care at this point, so a transfer is warranted. Post-op arrhythmias are the number one post-op complication due to electrolyte imbalance during OR because of IV fluids are given and blood loss during surgery, etc. Does the floor have adequate staff to manage this patient? Please consider her ethnicity, age, type of surgery, post-op complaints and lab work, etc.
I love all of your responses and I am not choosing one unit over the other. I am asking you to consider all of the options and chose the best based on your facts and literature information.
Let’s keep this conversation going because this is important and a situation that you may experience in your career at some point. There is no wrong or right answer until you can justify your response based on the evidence presented.
Fondly,
Margo
Pelter, M., Loranger, D., Kozik, T., Fidler, R., Hu, X., & Carey, M. (2016) Unplanned transfer from the telemetry unit to Cardiac Care unit in hospitalized patients with suspected acute coronary syndrome. Journal of Electrocardiology, 49(6) 775-783. doi: 10.1016/j.jelectrocard.2016.08.010
Zegre-Hemsey, J., Garvey, J., Carey, M. (2016) Cardiac monitoring in the emergency department. Critical Care Nursing Clinics of North America, 28(3 331-345. doi: [10.1016/j.cnc.2016.04.009Links to an external site.]
Lupe Garcia
Lupe Garcia
Nov 25, 2018 Nov 25 at 11:40am
Hello Margo and classmates;
Perhaps Ms. Jackson is just not adequately managed for her pain. A radical mastectomy is a very invasive surgery. It involves the removal of the breast, underlying chest muscle (including pectoralis major and minor) and lymph nodes of the axilla. Consideration needs to be given post-mastectomy to nerve, tissue, and/or muscle damaged causing severe pain. According to Claassens "Acute pain is particularly associated with psychological anguish, anxiety, depression, disturbed sleep and dysfunctional coping strategies" (2017). If acute pain is not properly treated, it could lead to chronic pain. Patients that were properly educated prior to surgery of the expected pain and management responded and recovered better overall post surgery.
References
Claassens, T. (2017). Nursing a patient with acute pain. Kai Tiaki Nursing New Zealand, 23(7), 15–39. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=124905674&site=ehost-live&scope=site
Julie Apuya
Julie Apuya
Nov 23, 2018 Nov 23 at 9:56am
Hi Margo,
Where this patient should go next depends on her status after all the tests have been completed, she has a diagnosis, and how much monitoring she will need afterward. The telemetry floor would be appropriate if she has been treated for the acute MI, and we would need to monitor her heart rhythm and monitor if there has been any cardiac damage that will lead to a dysrhythmia or other cardiac issues. However, if after all of her tests and treatments for the acute MI, her condition deteriorates and she is hemodynamically unstable, she might be a good candidate for ICU. ICU is for the most critically ill patients so if she needs constant monitoring that qualifies her for the 2:1 patient to nurse ratio then she should be there. Thanks for the great question Margo!
Emily Poynter
Emily Poynter
Nov 24, 2018 Nov 24 at 7:33am
Margo,
I may be biased as I work on a tele unit but I believe it would be beneficial to have Esther transferred to a tele unit. On tele units we are usually allowed to do more assessment and other things than the other floors. On my floor we have standing orders for an EKG for example. We are also able to administer certain drips that other medical floors may not be able to monitor, such as cardizem. If Esther's EKG were to show Afib with RVR then she could benefit from a cardizem drip, something the medical floor may not be allowed to perform.
D Andrew Nelson
D Andrew Nelson
Nov 24, 2018 Nov 24 at 10pm
It would depend on the results of her initial screening. If she had a NSTEMI requiring cath lab, I think CVICU would be best with all the monitoring plus 2 to 1 patient to nurse ration. CVICU may also be necessary if patient had such severe blockages that it could not be fixed in the Cath lab, and required a CABG should would definitely need the CVICU for recovery after surgery. No if patient had a NSTEMI not requiring any invasive interventions I think a telemetry or step down style unit where should be monitored regularly, and they could track her Troponins until they trend down, would be appropriate.
Collapse SubdiscussionBeth Moseley
Beth Moseley
Nov 25, 2018 Nov 25 at 10:57am
Class,
I would most likely work her up where she is to rule out cardiac complications. By report, this pt was an otherwise healthy woman prior to her surgery. Her gender, age and ethnicity place her in a higher risk category for cardiac disease, but breast removal does not create a greater risk. Presumably, she had a pre-op workup which included labs, EKG, medical history. This information Monitoring of her vital signs can be done at the bedside, including EKG, labs. She can be supported by oxygen and positioning while waiting for test results. Nausea/ malaise may be coming from anesthesia, can be treated with meds. Her back pain may be coming from her gall bladder, which is easily mistaken for cardiac pain. Her progress, once supportive interventions and assessments for cardiac complications have been started, will determine further course of treatment which might include telemetry/ CICU.
Margo Emlich
Margo Emlich
Nov 25, 2018 Nov 25 at 12:08pm
Class
Excellent discussion and rationale for your answers! There is so much to consider when assessing a patient but just take each system from head to toe and go from there. Also, never forget to listen to your patient. I have seen so many things go wrong because everyone was looking at numbers and values and never listened to the patient.
With all of the assessment knowledge and tools we have available to us now, you think it would be an easy answer but the human body is very interesting and constantly changing. Thank you for your discussion and appreciate the thought behind each of your answers. Great Job! I am impressed!
Margo
Collapse SubdiscussionD Andrew Nelson
D Andrew Nelson
Nov 24, 2018 Nov 24 at 9:36pm
What do you suspect is the cause of the patient’s symptoms?
Due to the symptoms present, the back pain, nausea, fatigue, and thready pulse I am concerned about an acute MI. While the patient is not complaining of chest pain “only 50% of women with MI complain off of chest pain” they usually present with non-typical symptoms including “overwhelming fatigue, and nausea”.(Barous, 2018, pp 1). Pt also has additional risk factors, recent surgery, could have thrown a clot, African American, and older than 55.
Describe the course of action that you will take to confirm this suspicion and prevent further decline.
I would immediately get a 12 lead ekg, at my place of employment we can perform EKGs anytime we have suspicion of change in patient cardiac status, I would have a colleague go get a doctor or page STAT, place patient on oxygen, place patient on monitor and defibrillator, check patency of IV, obtain full set of vital signs, and get ACLS drug box.
What further assessments, lab values, and tests will likely be ordered for this patient and how often? If testing is to be completed more than once, please explain the rationale for doing so.
I would anticipate a repeat EKG in 30 minutes unless patient is having an active STEMI in which case I would pull out the STEMI medication kit, call STEMI alert, and prep patient for Cath lab. I would draws lab either way including CBC, CMP, Troponin, and possibly BNP. Chest Xray. Either way if patient is not being taken to Cath lab I would expect a cardiology consult, and transferred to a cardiology floor ICU or otherwise depending on her condition. If MI is not acute she will need cardiac cauterization to obtain baseline occlusion of the arteries of her heart, and assess the need for possible stent placement. She will also need to have an ECHO done to for baseline ejection fraction or compare to a previous ECHO to see if it has declined especially in lieu of the probable cardiac event.
While you are caring for this patient, how will you ensure that the needs of your other patients are being met?
While I am addressing the needs of Ms. Jackson, I will ask another nurse to please keep an eye on my other patients, until I have got the patient caught up and settled. I would also call charge via ASCOM and update her on the situation , and that I have other patients that I need help keeping an eye on.
References:
Barous, T. R. M. F., & Oji, O. D. A. F.-B. (2018). Acute Myocardial Infarction in Women. CINAHL Nursing Guide.
Jarvis, C. (2016.) Physical examination and health assessment. (7th ed.) St. Louis, MO: Elsevier.
Katherine Lyon
Katherine Lyon
Nov 25, 2018 Nov 25 at 1:26pm
Great post! I would do the same with EKG and Troponin lab work. Also I would manage the pain with morphine and give proper oxygenation. I think in this case that she had an infection leading up to an acute MI. I believe it is very possible because someone with a weakened immune system from cancer would be more susceptible to infection and the areas around the heart could get infected from the infection. Here is a good article based on a breast cancer chemo medication and the associated cardiac risks.
www.onlinejacc.org/content/60/24/2504Links to an external site.
Camille De Leon
Camille De Leon
Nov 26, 2018 Nov 26 at 8:26am
Hi Lynne,
I definitely agree with you that putting the patient under telemetry observation is an appropriate intervention whether the result of the tests ends up to be negative. In the event that tests like EKG, troponins are positive, a cardiology consult is relevant for further evaluation. Additional diagnostic tests relevant to her presenting symptoms such as stress test, 2D echo or a TEE might be ordered by the physician. In the scenario given, no previous medical history was mentioned. It is possible that this patient has underlying cardiac problem that she is not aware of.
Collapse SubdiscussionJoyce Kariithi
Joyce Kariithi
Nov 19, 2018 Nov 19 at 7:45pm
Hello Professor and Class,
Since Ms Jackson is s/p mastectomy, I would be concerned she may have acute myocardial infarction, AFIB or Pulmonary embolism. Myocardial infarction is due to a decrease in cardiac output(output (Jarvis, 2016).MI pain for women is usually reported differently than men, Ms. Jackson is reporting back pain, which can be one of the signs and symptoms of traditional MI pain women says jaw pain, back pain, and wrist elbow, unlike men who report chest pain, left arm and jaw pain. I would also suspect a-fib due to the nursing assistant irregular heart rate. Pulmonary embolism due is a common complication postoperative.
The course of action that I will take to confirm this suspicion and prevent further decline
In this case, I would assess patient pain level of pain on a scale of 1-10, ask her to describe her pain; aching, burning, dull, sharp, stabbing. Location of the pain, and ask her what aggravates her pain and whether the pain is radiating to any other area of the body. I would also assess the patient lung sounds, ask her whether she is short of breath, assess her skin color, and also ask her whether she is feeling dizzy or vertigo. Check her oxygen level, and if her oxygen saturation is below 93%, I will start her on oxygen. It will also be necessary to auscultate the heart rate, S1 and S2 are they equal?S1, S2 are associated with systole and diastole usually heard as two different sounds. “When you notice any irregularity, check for a pulse deficit by auscultating the apical beat while simultaneously palpating the radial pulse. Count a serial measurement (one after the other) of apical beat and radial pulse. Normally every beat you hear at the apex should perfuse to the periphery and be palpable. The two counts should be identical. When different, subtract the radial rate from the apical, and record the remainder as the pulse deficit.” Jarvis 2016) Assessing Ms. Jackson brachial, radial, popliteal, posterior and dorsal pulses will also be essential. I would call the doctor for EKG STAT to order.
Further assessments, lab values, and tests that will be likely to be ordered for this patient and how often. If testing is to be completed more than once, the rationale for doing so
I would take another set of vital signs manually and check the patient chart for the current labs, medication list, and allergies. I would ask the patient whether she has a history of hypertension and family history of cardiovascular disease.” Assessment of the cardiovascular system is similar to others in that we first need to focus on asking the right questions to obtain a good history”(Chamberlin, 2018). Labs that I would expect to be done are; CMP, CBC, troponin. If the EKG indicated an MI, I would wait for a percutaneous coronary intervention (PCI) to be performed within 60 minutes. if the patient ST is elevated, fibrinolytic therapy should be started within 30 minutes. (Mennella, 2016). The troponin lab test should be repeated every 6 hours for a total of 3 results. The rationale is the peak time for this lab result is 12 hours after the heart damage occurs.
While you are caring for this patient, how will you ensure that the needs of your other patients are being
I use the chain of command and request my supervisor and charge nurse to assist with care for my patient as I take care of Ms. Jackson. Once Ms. Jackson is safe and stable, I would resume my assignment.
References
Chamberlain College of Nursing. (2018). NR305 RN Health Assessment: Week4lesson. Downers
Grove, IL: Online Publication.
Jarvis, C. (2016). Jarvis Physical Examination & Health Assessment (7th ed.). Philadelphia, PA:
Elsevier Saunders
Mennella, H. A. (2016). Core Measure: Acute Myocardial Infarction: Primary Percutaneous Coronary Intervention -- Received within 90 Minutes of Hospital Arrival. CINAHL Nursing Guide.
Osalenne Metellus
Osalenne Metellus
Nov 24, 2018 Nov 24 at 2:17pm
Hi Joyce,
Great post! It is also important when checking the vital sign, it would be also the apical pulse, checking pulse deficit, checking the capillary refill and assess skin color is very important. I enjoyed reading it.
Robert McQueen
Robert McQueen
Nov 25, 2018 Nov 25 at 1:56pm
Joyce I agree with your possible diagnosis. MI, AFIB, or PE are very rational. I think that it is very common and the right thought process to go down the worst case scenario possible. To not would probably not be very safe. It is very possible that her pain is just not managed very well. Or she is not eating or drinking much and has electrolyte disturbances. I think that she needs to be watched very close after other major diagnosis are ruled out. Good post.
Collapse SubdiscussionKarmen Crowley
Karmen Crowley
Nov 20, 2018 Nov 20 at 5:50pm
Dr. Whitman and classmates,
1. What do you suspect is the cause of the patient's symptoms?
In this clinical scenario, my first thought as to the cause of Mrs. Jackson’s symptoms is a cardiac arrhythmia. With the report from the nursing assistant of the patient’s pulse rate being “all over the place”, I am particularly suspicious of atrial fib. AFib is a more common arrhythmia and it tends to have an abrupt onset with a characteristic irregularly irregular heart rate. With the patient’s worsening back pain and nausea and her statement that “I don’t feel right”, I would also be concerned about possible MI. According to Barous and Oji (2018), women often experience less typical signs and symptoms of MI, and the symptoms this patient is having raise a red flag. Another possible differential diagnosis with a post op day 1 general surgical patient is a pulmonary embolus. I am less suspicious of this because of the lack of symptoms of shortness of breath or cough (Jarvis 2016), but it still can’t be completely ruled out.
2. Describe the course of action that you will take to confirm this suspicion and prevent further decline.
I would have the patient lie down in bed immediately and apply oxygen, obtain blood pressure and apply a pulse ox and a cardiac monitor. I would page the physician stat and report the patient’s symptoms and my findings, and obtain an order for a stat 12 lead ECG and a stat and then serial troponins because of the possible MI symptoms. I would also be looking or having someone else look to see if the patient has a history of AFib or any previous cardiac history.
3. What further assessments, lab values, and tests will likely be ordered for this patient and how often? If testing is to be completed more than once, please explain the rationale for doing so.
Depending on the findings of the tests previously ordered (ECG and stat troponin level), other tests and assessments might include a cardiology consult, CBC and metabolic panel, chest xray, echo, medications to decrease the heart rate if the patient has an arrhythmia such as AFib with RVR, or a cardiac cath if the ECG shows ST elevation or is suspicious for STEMI. Nitro and morphine may be administered if indicated for MI. Serial troponins are done at 3,6, and 12 hours in suspected MI. The indication for doing this is that troponin levels do not always elevate immediately; they are a marker for cardiac ischemia and injury and sometimes elevate over time in the presence of myocardial ischemia and necrosis. (Love and Apple, 2016.)
If a pulmonary embolus is suspected, a computed tomography angio or a VQ scan may be ordered.
4. While you are caring for this patient, how will you ensure that the needs of your other patients are being met?
Depending on the outcome of the initial assessment with Mrs. Jackson, I wouldn’t be leaving her at this point. I would be communicating with the charge nurse or clinical leader to discuss the pertinent needs of my other patients so that the charge nurse, clinical leader, or other RNs could complete or delegate these tasks so the other patients are monitored and safe, until Mrs. Jackson’s condition stabilizes or she is transferred to another floor or department.
References:
Jarvis, C. (2016.) Physical examination and health assessment. (7th ed.) St. Louis, MO: Elsevier.
Barous, T. and Oji, O. (2006 Feb, revised 2018.) Acute myocardial infarction in women. CINAHL Nursing Guide EBSCO Publishing, (Ipswich, Massachusetts), 2018 Jul 06. Retrieved from https://eds-b-ebscohost-com.chamberlainuniversity.idm.oclc.org/eds/detail/detail?vid=3&sid=89c25d4e-d716-446d-9e0c-3a3289d1444c%40sessionmgr102&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=T701513&db=nupLinks to an external site. on 11/20/2018.
Love, S. and Apple, F. (2014 May.) Cardiac troponin – serial ordering recommendations for today and tomorrow. Clinical Laboratory News. Retrieved from https://www.aacc.org/publications/cln/articles/2014/may/cardiac-troponin.aspxLinks to an external site. on 11/20/2018.
Emily Poynter
Emily Poynter
Nov 24, 2018 Nov 24 at 7:40am
Karmen,
Another option that may be warranted after ones assessment and/or testing would be what my hospital calls a Critical Assessment Team call, or other hospitals refer to them as a Rapid Response. These teams are able to give the patient a needed assessment by those typically from the ICU or ER, those that are able to give the patient a more critical assessment. In these situation it is better to air on the side of caution versus waiting to long and the patient not able to recover as well.
Camille De Leon
Camille De Leon
Nov 26, 2018 Nov 26 at 8:40am
Hi Karmen,
Healthcare is very complex, teamwork and communication is important. Proper delegation and asking assistance from the charge nurse or other nursing staff will ensure that other patient's need will be addressed. Communicating that you need help with urgent patient situation will prevent from one nursing staff from getting completely overwhelmed with a heavy workload. When we get emergencies in our floor like RRT, Code Stroke or Code blues, everyone just jump into the patient room to help the primary nurse until the emergency team arrives. We also make sure that while the others are busy in the RRT situation, that other staff covers the unit and the other patients.
Collapse SubdiscussionShirley Ramos
Shirley Ramos
Nov 20, 2018 Nov 20 at 10:42pm
Hello Professor Whitman,
What do you suspect is the cause of the patient’s symptoms?
Based on the nurse’s report, she’s 1-day post-op procedure and did not sleep well the night before, the anesthesia is wearing off and she may be suffering from
Pulmonary embolism (PE). Pain can be experienced in the chest, back, shoulder, or upper abdomen (Jarvis, 2016). The risk of thromboembolism is known to increase after major surgery, mostly on 2 days post-op (esp. orthopaedic surgery) and is highest during the first weeks of operation. Symptoms such as sharp, stabbing pain worsening with deep breaths are the common descriptions of the patient (p. 493).
Acute pain. Some degree of short-term pain is expected after any surgery but for the most people, it resolves within a short few weeks. However, some people report persistent discomfort in the longer term in the breast, chest wall, or arm following breast and axillary surgery. This can sometimes be due to nerve damage (neuropathic pain) and is often described as hot, burning, sharp or stabbing in nature. This is also called post-mastectomy pain syndrome (PMPS) and some women also report phantom nipple pain after mastectomy. Studies have shown about 20-30% of women develop symptoms of PMPS after surgery.
Anxiety. The shock of receiving a breast cancer diagnosis certainly qualifies as a major depressor and anxiety. In addition to the trauma of receiving a cancer diagnosis and the potentially anxiety-inducing of mortality it can raise, many experience anxieties as a result of radical changes in their bodies. The anxiety attack is an intense period of overwhelming fear or feeling doom over a period of short time. Symptoms are palpitations, sweating, shortness of breath, chest pain, nausea, vomiting, dizziness, numbness or tingling in the limbs or entire body, trembling, chills or hot flushes, and fear of dying. Since Ms. Jackson’s vital signs are normal and afebrile, her heart rate is found to be “all over the place” as per the nursing assistant’s report, she may be having a panic attack or anxiety.
Describe the course of action that you will take to confirm this suspicion and prevent further decline.
It is necessary to give Ms. Jackson an assurance that as her nurse in charge of her, I am available to her needs while she is in my care. I would alert the emergency team (Medical Emergency Response Team) if needed. And while waiting for the MERT, I would calm her down, instruct her to take deep breaths, give O2 supplement and put her back in bed for comfort position. I would again take her vital signs for comparison, check O2 saturation, and reassess her incisional wound and check the wound vac for any profuse bleeding. I would observe for any coughing up blood (that would rule out PE). If PE is ruled out, she will be given an anticoagulant drug and place compression stockings on her lower extremities to stop blood from pooling in the veins. I would check her blood glucose too since patients have low blood sugar post-op. I would also check her when was her last dose of pain meds, get an order from the doctor to give it to her sooner with an increased dose if needed. Though she is not complaining of any chest pain I would also get an order to draw blood for cardiac labs, an EKG test to make sure there are no pending cardiac problems.
What further assessments, lab values, and tests will likely be ordered for this patient and how often? If testing is to be completed more than once, please explain the rationale for doing so.
If she is experiencing symptoms such as tightness, squeezing, burning, or heaviness on her chest with poorly localized pain lasting 20-30 minutes to hours and does not resolve with rest as mentioned in our textbook (p. 493), then she may be having unstable angina or myocardial infarction.
Procedures such as chest X-ray, CT scan or MRI can be ordered to rule out any iatrogenic infection or disease. Iatrogenic disease is common when a patient is already under medical supervision; it can be brought upon by medication errors from doctors. She will be on EKG monitor, with IV access (KVO), a respiratory machine on site and continuous observation for fever. Her vital signs would be recorded every 4 hours for continuous comparison.
Blood tests for heart problems include lipid profile to test the amount and type of lipids in the blood. Hs-CRP detects low concentrations of C-reactive protein, a marker associated with atherosclerosis. Troponin, the most common cardiac marker, and it elevated within a few hours of heart damage and remain elevated for up to 2 weeks. Rising levels in a series of troponin tests performed over several hours can help diagnose a heart attack.
Ms. Jackson’s pain must be continuously monitored and administration should be on the clock. A PCA (patient-controlled analgesia) may be suggested for better pain management.
If she is experiencing anxiety related to her surgery or new body image, she may be given an anxiolytic drug. I will continue to monitor her for any sudden changes in mental status and would recommend to a group behavioral therapy after discharge.
While you are caring for this patient, how will you ensure that the needs of your other patients are being met?
Delegation is another important task of a nurse in a clinical or hospital setting. During the turnover of the shift, a nurse must be quick to prioritize and identify which patient she must see first. While caring for Ms. Jackson, I would ask my nursing assistant to monitor my other patients and inform me for any urgent needs. I would also inform my nursing supervisor about the situation so she can send another nurse to help me with other patients while I’m with Ms. Jackson.
https://www.breastcancerfoundation.org.nz/breast-cancer/treatment-options/surgery/side-effects-complicationsu8
breastcancer.org (Links to an external site.)Links to an external site.Links to an external site.. (2017). Treatment Side Effects List
https://www.breastcancer.org/treatment/side_effects (Links to an external site.)Links to an external site.Links to an external site.
Jarvis, Carolyn. (2016) 7th ed. Physical Examination & Health Assessment. CH. 19 Heart and Neck Vessels. PG493. Abnormal Findings. Elsevier.
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