Nursing process is an essential phase of any treatment. The success of whole treatment depends on this stage and deep understanding of this process is the way to quality in medical care and to better outcomes of treatment. The nursing process is a problem solving process consists of elements assessment, planning, implementation, and evaluation (Tanya McFerran et al 2008)
With this essay I’ll try to elucidated nursing process according to the certain case study, outline some critical points, problems that can emerge at any stage of nursing process. The case study I’ve chosen, concerns one the most important medical problems in the world for now, – coronary artery disease and its acute form-myocardial infarction. Coronary artery disease (CAD) is the most common type of heart disease. It is the leading cause of death in the United States in both men and women.
The patient: Mr. Ronald Jones, 55 year old, male. He presents with acute chest pain for the past 2 hours. Patient is complaining of crushing chest pain, radiating down left arm, pain is 4/10. This pain came on while physical activity (he was mowing the lawn). I’m to start with assessment of the patient’s condition: primary survey(ABCDE) and systems assessment, touching upon principal links of pathophysiology of emerged disease; going further I will talk about the plan of nursing care: define principal nursing diagnosis, discuss nursing interventions I will provide.
The primary survey is a process carried out to detect and treat life-threatening conditions. Patient is alert, awake, and oriented to person, place and time. Chief complaints: crushing chest pain, radiating down left arm, pain is 4/10.
Ensured open airways, no potential obstruction, no need for adjuncts to maintain airway. Chest wall movements are inadequate, RR=20(tachypnoe), shallow breath. These are the indications for immediate oxygenation with supplementary oxygen. The pathophysiological background for this procedure is improvement of blood oxygen saturation. Supplemental oxygen helps to improve cardiac function by increasing available oxygen and reducing oxygen consumption. The goal of oxygenation is to maintain patient’s oxygen saturation at 93% or above further on. So oxygen is started per nasal canulla at 5L\min
Pulse is present at both radial arteries, it’s symmetric, rate 90, weak, fast, regular. Cyanosis, cool moist skin and prolonged capillary refill time could be seen.
Glasgow Coma Scale is 15(minor brain damage). No evident signs of trauma or injuries. Assessing pain: it’s typical “coronary”, so an analgesic as ordered immediately performed. Pain management is critical during MI and pain relief should be provided immediately. Pain of AMI is very severe and places enormous stress on the patient’s autonomic nervous system-stress that may contribute to complications (Nancy L. Caroline 2007). These are the factors that propel peripheral vasoconstriction, blood flow “centralization” with ineffective tissue perfusion. Constant “catecholamine attack” on heart and coronary arteries, provokes continuation of ischemia. Morphine sulfate was indicated in this case. Nitrates were not appropriate in this cause due to hypotension!
Also, 12-lead ECG was started, laboratory analysis for cardiac troponin I and T, CK, clinical blood count, arterial blood gas and chemistry panel were administrated. Central and peripheral lines were inserted. ECG showed ST elevation in 2 contiguous leads of > 2mm. Mr. Jones has been diagnosed with a MI.
History: Mr. Ronald Jones is a 55 year old male who presents with acute chest pain for the past 2 hours. The pain came on while he was mowing the lawn. Patient is complaining of crushing chest pain, radiating down left arm, pain is 4/10. Pain was not relieved by rest or intake of nitroglycerine, antacids. No allergies were reported by the patient. Mr. Jones father died at the age of 47 of AMI. Mr. Jones doesn’t take any medications.
During examination pale moist skin due to diaphoresis revealed. Facial mask of pain was evident. Cyanosis of wrists and feet, mottling, nails’ beds were detected. Coolness of wrists’ and feet’s skin was evident. Turgor of skin was adequate. Skin and breath odor was not pathological. Capillary refill was prolonged for more than 3 seconds.
There were no limitations in moving with head or shruging the shoulders against resistance. Carotid pulse was adequate, strong and regular. During auscultation of the carotids while having the patient hold his breath no bruits were revealed. Thyroid gland was intact. Pre- and postauricular lymph nodes, occipital, cervical, and submental lymph nodes were intact, no signs of abnormality. Body temperature was 35.5°C.
Joint stability and muscle strength with full contraction and full relaxation were present. No signs of inflammation (heat, redness, swelling) of joint or region were detected. Tenderness wasn’t revealed during full length palpation of spine.
Central nervous system
The patient did not describe any previous history of seizures, loss of consciousness, anesthesia, paresthesia neuralgia, twitches, tremors, personality changes, memory deficits, mental deterioration, nervousness, anxiety. No history of psychiatric problems was revealed.
Patient’s speech was clear, coherent, and spoken at an appropriate rate. Restlessness was present. No evidence of memory, orientation, perception or attention disorders. Cranial nerves’ function was normal.
Pulse was present at both radial arteries, symmetric, pulse rate is 90, weak, fast, regular, pulsus arterans. Blood pressure measured at both arms was 100/60. The apex beat was in the fifth intercostal space in the left mediclavicular line. No thrills of heavies during palpation were found. Auscultation disclosed an S3 and paradoxical splitting of S2, and decreased heart sounds. Holosystolic murmur at mitral valve which correspondents to mitral insufficiency. Liver and spleen had no signs of growth or tenderness.
Smoking: 16 pack\years. Respiratory rate was 20 per minute with shallow breath. Chest movements were symmetric, corresponding to breathing but with accessory muscle use. Chest wall is elastic, not painful. During auscultation vesicular breath sounds with coarse crackles more evident in the dependent areas of the lungs.
Patient didn’t perform any abdomen pain, vomiting, nausea, heartburn or problems with a sore mouth, tongue, or throat. Patient presented loss of appetite. No gastrointestinal problems were revealed in the patient’s history.
The mouth and throat hadn’t any sores, irritations, or any other conditions that could affect the intake of food and liquid. The tongue is dry with white debris. Unusual breath odor was not detected.
Abdomen is soft and rounded with a sunken umbilicus. Abdomen contour is symmetric, abdominal aorta pulsation wasn’t clear. Peristalsis is registered during the auscultation. No vascular abdomen sounds were heard. During percussion tympani was revealed.
The patient hadn’t history of UTIs, hematuria, hesitancy, urgency, renal or urethral calculi. Inspection, palpation was without any abnormalities. The patient hadn’t urination for 4 hours, decreased urine output is possible.
There were no data concerning any abnormalities in history of the patient, during inspection and palpation.
Based on ECG changes (ST elevation in contiguous leads of more than 2mm), cardiac necrosis markers (troponin T and I), considering episode of crushing chest pain lasting for the past 2 hours, radiating down left arm, pain is 4/10, Acute myocardial infarction with ST elevation (STEMI) was diagnosed. ABGs results for oxygen were 94%. Mr. Jones had no contradictions to thrombolytic therapy and was a appropriate candidate for such type of reperfusion. Intravenous alteplase(T-PA) was given by bollus(15 mg), then followed by intravenous infusion of alteplase (50 and 35 mg) and heparin(4000 IU-bollus, 1000 IU per hour). Immediate transfer to the Coronary Care Unit was organized. Monitor continuous ECG as appropriate was obtained.
The initial morphine sulfate dose reduced pain from 4 to 3 balls. Supplementary oxygen improved respiratory rate to 16, skin color. Thrombolytic therapy reduced pain to 2. No indications of bleeding were noted. Reperfusion was indicated by relief of chest pain, return of ST to baseline, early peaks of CK levels and transit PVCs registration.
An actual nursing diagnosis is “supported by defining characteristics (manifestations, signs, symptoms) that cluster in patterns of related cues or inferences” (Glossary of Terms Used by NANDA 2003)
Base on assessment I indentified nursing diagnosis: 1) Decreased cardiac output,2) Acute pain and 3)Ineffective tissue perfusion: cardiopulmonary, 4) Ineffective protection related to the risk of bleeding secondary to the thrombolytic therapy.( Hegner 2007)
- Rate chest pain as 2 and lower
- Maintain an adequate cardiac output and tissue\organs perfusion during and after thrombolytic therapy
- Prevention of internal and external bleeding
- Risk of cardiogenic shock
Common medications included antiplatelet therapy, diuretics, ACE inhibitors, statins, anticoagulants, inotropic agents should be given. Nursing task is to administer medication as prescribed, noting response and watching for side effects and toxicity. Also possible parameters for withholding medications should be clarified with physician.
Maintaining pain: Recording the severity of pain, location, type, and duration of pain. Proper analgesics is performed. Nitroglycerin (NTG) is administer sublingually for complaints of angina with BP control. After thrombolytic therapy, administration of continuous heparin is performed, besides, monitoring the partial thromboplastin time every 6 hours, and monitoring the patient for evidence of bleeding should be available.
Maintaining adequate ventilation and perfusion, as in the following: patient in semi- to high-Fowler’s position. This reduces preload and ventricular filling. Later on patient is placed in supine position. This increases venous return, promotes diuresis. Administration of humidified oxygen as ordered (canulli or mask) is appropriate with ABGs control
Maintaining hemodynamic parameters and Tissue perfusion at prescribed levels:
Monitoring and recording the patient’s ECG readings, blood pressure, temperature, heart and breath sounds. ECG strips are recorded when new arrhythmias are documented, chest pain occurs, or at least every shift change. Treating arrhythmias according to medical orders or protocol and evaluating response, antiarrhythmic drugs should be readily available. Both tachyarrhythmias and bradyarrhythmias can reduce cardiac output and myocardial tissue perfusion. If invasive adjunct therapies are indicated (e.g., intraaortic balloon pump, pacemaker), nurse should maintain within prescribed protocol.
Control for crackles, tachypnea, and edema, as signs of left-sided heart function worsening. Titration of inotropic and vasoactive medication within defined parameters to maintain adequate contractility is essential, pre/afterload and blood pressure control.
Control for symptoms of cardiogenic shock, if shock is present, PAWP and increased systemic vascular resistance are measures. Maintaining of optimal fluid balance(intake and output), daily weight should be performed also., because fluid overload increases the workload of the heart and decreased cardiac output which can cause a decrease in perfusion to the kidneys. Control of laboratory data closely (ABG’s, serial enzymes, electrolytes, B-type natriuretic peptide, serum creatinine) is to be hold.
Maintain physical and emotional rest, as in the following:
Restriction of activity, that reduces oxygen demands, is vital. Nurse should provide quiet, relaxed environment, emotional support, organize patient care to maximize periods of uninterrupted rest.
Monitor sleep patterns; administer sedative if it is indicated. Rest is important for conserving energy. A stool softener is facultative to prevent straining during defecation, which causes vagal stimulation and may slow heart rate. Also, straining for a bowel movement further impairs cardiac output.
A low-cholesterol, low-sodium diet, without caffeine-containing beverages, may be ordered. If the patient is immobilized turn him often. Give antiembolism stockings to prevent venostasis and thrombophlebitis.Order small sodium restricted diet (sodium restriction helps to avoid fluid overload). Assess for the presence of depression (depression is common after acute MI and can result in increased mortality).
Refer patient to cardiac outpatient program and support groups. Assist with organizing cardiac rehabilitation efforts post discharge in future. With stabilization of haemodynamics and LV function activity shouldn’t be delayed, the patient is allowed to use a bedside commode and should be given as much privacy as possible.
Myocardial infarction is the leading cause of death in the United States and in most industrialized nations throughout the world. Approximately 450, 000 people in the United States die from coronary disease per year (AHA statistics, 2009). The survival rate for U.S. patients hospitalized with MI is approximately 95%( H. Michael Bolooki, Arman Askari). So it’s obvious that thousands of lives could be saved if there is adequate medical care. Having a case of study concerning AMI, I’ve tried to elucidate principal stages of nursing process, problems that may occur during nursing care, possible variants of disease flow. It should be also stressed that dealing with AMI is not only the issue of professional knowledge but also a problem of rapid situation assessment, dispatch in actions. “Time is muscle” as it was revolutionary said 35 years ago by Eugene Braunwald, MD, MACC
With this case of study I’ve tried to give a concrete example of nursing process as a “combining the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method.”(Shore, 1988)
1. Nancy L. Caroline; Nancy Caroline’s Emergency Care in the Streets: Trauma Medical, 2007
2. Glossary of Terms Used by NANDA ,2006 <http://www.hepfi.org/nnac/pdf/nanda_glossary.pdf>
3. American Heart Association. Cardiovascular disease statistics. Available at <http://www.americanheart.org/presenter/> (accessed March 2, 2009).
4. Acute Myocardial Infarction H. Michael Bolooki ,Arman Askari, <http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/acute-myocardial-infarction/#bib5>
5. Shore M.D. < http://www.lifenurses.com/nursing-process/> 1988
6. Tanya McFerran and Elizabeth Martin, “A Dictionary of Nursing” 2008.
7. Hegner, “Outlines & Highlights for Nursing Assistant: A Nursing Process Approach” 2007