This document discusses the rationales for nursing interventions in a clinical case, focusing on topics such as ECG, vital signs measurement, oxygen administration, intravenous cannulation, pain management, cardiac monitoring, and more. It provides insights on effective nursing decision making and practice.
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Nursing decision making and practice1 NURSING DECISION MAKING AND PRACTICE Student’s Name Institutional Affiliation
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Nursing decision making and practice2 The following are the rationales for the nursing interventions that would be effective for the clinical case of Mrs. Fitzgerald: 1.ECG (ELECTROCARDIOGRAM) Rationale: An electrocardiogram test is important in assessment and diagnosis of patients with an acute coronary syndrome. It is an effective tool for detecting acute myocardial infarction and assists in identifying the severity of a heart attack. It provides information of the extent of myocardial tissue damage caused by a myocardial infarction. Elevation of the T wave on performing an electrocardiogram on a patient indicates early ischemia (Hart et al, 2015). The ST wave is an important marker of the various types of coronary acute syndromes. Coronary acute syndromes include the ST-elevation myocardial infarction, non ST-elevation myocardial infarction and unstable angina. These are major causes of chest pains and an electrocardiogram performed on the patient under the case study can assist the clinician make the appropriate diagnosis and treatment plan. An ST segment elevation indicates total occlusion of a major coronary artery leading to ischemia of a significant part of the myocardium (Waters, 2016). If not corrected, the myocardial infarction can lead to ischemia and subsequent heart failure. The ST-elevation myocardial infarction is indicated by an elevation of the ST segment is greater than 2mm in two contiguous leads. The affected leads can guide the clinician to the affected parts. On the other hand, a non ST-elevation myocardial infarction represents a more mild form of acute myocardial infarction and is indicated by ECG recordings of an ST segment depression in several contiguous leads.Jensen, (2018) statesit occurs
Nursing decision making and practice3 when a coronary artery is partially blocked and its recording is often indistinguishable from unstable angina. 2.MEASURE VITAL SIGNS Rationale: Measuring vital signs is an important nursing intervention for emergency situations. Mrs. Fitzgerald’s vital signs as measured by SAAS included a BP of 170/95, a pulse rate of 105 bpm, and a respiratory rate of 24 breaths per minute, a temperature of 36.8 and an SPO2 of 96%. Vital signs are important in that they give the clinician and nurse an overall analysis of a patient’s current condition. As the name suggest, they are characteristics of any patient that should be treated with immediate urgency in case of any deviation from the normal physiological states. Mrs. Fitzgerald primary complaint involved severe chest pains. When compared with the vital signs, a nurse can be able to come up with an accurate diagnosis and better manage the condition. The blood pressure levels of the patient in this scenario are higher than the normal levels of 120/80mmHg. The blood pressure readings indicates that the patient has a high blood pressure (hypertension). This can be explained by an increase in either cardiac output or blood vessels peripheral resistance. Hypertensive states are matters of emergency and predispose patients to other cardiac related conditions including an acute myocardial infarction (Douw et al, 2015). The chest pains experienced by the patient might therefore be signifying an underlying cardiac condition such as an acute myocardial infarction that can be linked to an increase in blood pressure levels over time.
Nursing decision making and practice4 The normal pulse rate level of a person is 60-100 beats per minute. The heart rate of the patient was significantly higher than normal. The breathing rate was also higher than the normal range of 12-20 breaths per minute. The cause of this state can be explained by the fact that the patient was suffering from a cardiovascular disease. An acute myocardial infarction results from a cut off of oxygen supply to the heart muscle (Doenges, Moorhouse & Murr, 2016). In order to compensate for the limited oxygen supply, the body reacted by increasing oxygen demand. The physiological response was therefore an increase in breathing rate so as to assist increase oxygen levels that are at demand. The heart rate also increased so as to increase oxygenated blood supply to the parts of the heart affected. Measuring vital signs and time to time monitoring of these signs is important as it provides information on the progress of the patient and assists measure the effectiveness of other prior nursing interventions. 3.OXYGEN ADMINISTRATION Rationale: The body requires adequate oxygen supply for normal physiological and metabolic processes. When the oxygen saturation levels are low, it becomes an emergency that needs to be corrected with the utmost attention. Respiration is dependent on oxygen and a small decrease in the level of oxygen supply can lead to multiple organ failure (Douma et al, 2016). The case of Mrs. Fitzgerald indicates a significant increase in the patient’s respiratory rate than normal levels. This suggests that the patient is not receiving adequate oxygen supply within the body. The patient is experiencing chest pain that might be associated with a heart attack thereby suggesting that there is oxygen deficiency to the heart muscle.
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Nursing decision making and practice5 There is need to administer oxygen so as to boost the level of oxygen supply to the heart muscle as well as other body tissues. This is an important step as it helps alleviate the symptoms of chest pain caused by limited oxygen supply to the heart muscle. In addition to this, inadequate oxygen supply can lead to necrosis and an eventual heart failure which is fatal. There is therefore need to administer enough oxygen to prevent worse outcomes. Measurement of SPO2 levels is important to detect the level of oxygen saturation in the body as well as how much oxygen levels should be administered to alleviate hypoxic states (Tang, 2018). An SPO2 of less than 95% is alarming and should be managed with administration of oxygen for longer periods. 4.PERFORM INTRAVENOUS CANNULATION Rationale: Intravenous cannulation is an important nursing intervention that involves connecting a tube to a patient’s vein so that infusions can be inserted directly into the patient’s bloodstream (Sanders, 2017). In this clinical case, this can be used to provide medication that require intravenous route of administration. Intravenous nitroglycerin is an example of a medication that can be administered to patients with an acute myocardial infarction. Intravenous cannulation can also be used for administration of fluids to patients with low blood volume. In this case, the patient can be assessed for signs of dehydration and isotonic fluids administered to increase blood volume. 5.PAIN MANAGEMENT Rationale: The patient under study was suffering from pain. On being asked to rate the pain she was experiencing, she stated it was a 7/10. This indicates the pain was severe and
Nursing decision making and practice6 needed to be alleviated. Administration of morphine which is an opioid can be quite helpful to manage the pain experienced by the patient. Morphine acts by decreasing pain transmission to the brain. According toSchaeffer et al. (2018),it does so by causing activation of descending fibers that come from the mid brain and medulla that control the endogenous opioid containing interneurons within the dorsal horn of the spinal cord. It is therefore effective for pain management. Since opioids have an anesthetic effect in addition to analgesia, it is important to monitor the patient carefully and administer the correct amount of medication. Pain assessment after morphine administration is also important in order to monitor progress. 6.SEND BLOOD FOR TROPONIN TEST AND CREATININE KINASE. Rationale: Cardiac muscle injury can be indicated by testing cardiac enzymes such as troponin and creatinine kinase in blood. These enzymes can be useful to determine the extent of heart damage caused by myocardial infarction and other cardiac related diseases (Ford et al, 2018). They are called cardiac biomarkers and are usually released into blood when myocardial necrosis occurs. Their levels are therefore elevated incases of cardiac damage caused by necrosis and provide useful information on the progress of a patient suffering from myocardial infarction. In this case study, this nursing intervention would provide information on any damage caused to the heart muscle that leads to chest pains. 7.CONSTANT CARDIAC MONITORING AND ATTACHED DEFIBRILATOR TO TREAT SUDDEN CARDIAC ARREST Rationale:
Nursing decision making and practice7 Constant cardiac monitoring for a cardiac disease patient is important as it enables the nurse to understand and gauge the effectiveness of other nursing interventions and medication administered to the patient (Larson-Lohr, 2017). It is also important as it assist prevent future recurrences of a similar disease. The patient under case study can be monitored by constant ECG monitoring to ensure there are positive changes as the patient is undergoing treatment. For a patient with a history of heart attacks, it is important to attach a cardiac defibrillator to treat sudden cardiac arrest. A defibrillator can be useful in that it ensures a steady heart rhythm is maintained thereby preventing occurrence of cardiac arrhythmias and other changes in rhythm that can lead to sudden cardiac arrest. 8.MAINTAIN SEMI-FLOWERS POSITION FOR PROPER BREATHING Rationale: Maintaining a patient in a semi flowers position allows for improved breathing and feeding states. It is an important nursing intervention that assists patients with respiratory distress. The flowers position involves sitting the patient in an upright position in bed. In the case of a semi-flowers position, the patient lies in bed in supine position with his or her body 35-40 degrees in the air. In this clinical case, the patient had a significantly increased breathing rate implying signs of respiratory distress. The semi- flowers position helps keep the airway pathway open and encourages easy breathing. 9.ADMINISTER GTN (IV) (IF PAIN IS NOT REDUCED) Rationale: Administration of glyceryl trinitrate (IV) if pain is not reduced is a significant nursing intervention. As stated byLevin et al. (2018),this drug is useful for the
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Nursing decision making and practice8 management of heart failure, hypertension and is used to treat chest pains that result from inadequate blood flow to the heart as in the case of angina. It therefore has multiple effects that help manage pain caused by cardiac related problems. As opposed to morphine which is analgesic GTN (IV) targets the various underlying pathologies of a heart attack.
Nursing decision making and practice9 REFERENCES Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016).Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis. Douma, M. J., Drake, C. A., O'dochartaigh, D., & Smith, K. E. (2016). A pragmatic randomized evaluation of a nurse-initiated protocol to improve timeliness of care in an urban emergency department.Annals of emergency medicine,68(5), 546-552. Douw, G., Schoonhoven, L., Holwerda, T., van Zanten, A. R., van Achterberg, T., & van der Hoeven, J. G. (2015). Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review.Critical Care, 19(1), 230. Ford, T. J., Corcoran, D., Oldroyd, K. G., McEntegart, M., Rocchiccioli, P., Watkins, S., ... & McConnachie, A. (2018). Rationale and design of the British Heart Foundation (BHF) Coronary Microvascular Angina (CorMicA) stratified medicine clinical trial.American heart journal,201, 86-94. Hart, P. L., Brannan, J. D., Long, J. M., Brooks, B. K., Maguire, M. B. R., Robley, L. R., & Kill, S. R. (2015). Using combined teaching modalities to enhance nursing students’ recognition and response to clinical deterioration.Nursing Education Perspectives,36(3), 194-196. Jensen, S. (2018).Nursing health assessment: A best practice approach. Lippincott Williams & Wilkins. Larson-Lohr, V. A. (2017). Nursing and Hyperbaric Medicine. InTextbook of Hyperbaric Medicine(pp. 511-521). Springer, Cham.
Nursing decision making and practice10 Levin, S., Toerper, M., Hamrock, E., Hinson, J. S., Barnes, S., Gardner, H., ... & Kelen, G. (2018). Machine-learning-based electronic triage more accurately differentiates patients with respect to clinical outcomes compared with the emergency severity index.Annals of emergency medicine,71(5), 565-574. Sanders, W. (2017). Implementating a Chest Pain Screening Tool in a Primary Care Setting. Schaeffer, C., Teter, C., Finch, E. A., Hurt, C., Keeter, M. K., Liss, D. T., ... & Ackermann, R. (2018). A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics. Contemporary clinical trials,65, 53-60. Tang, C. J., Zhou, W. T., Chan, S. W. C., & Liaw, S. Y. (2018). Interprofessional collaboration between junior doctors and nurses in the general ward setting: A qualitative exploratory study.Journal of nursing management,26(1), 11-18. Waters, J. (2016). 22 Chest Tube Placement (Assist).AACN Procedure Manual for High Acuity, Progressive, and Critical Care-E-Book, 178.