Integrated Nursing Practice 2
Question 1: (approx. 600-700
The simulation scenario involved Mr Bright who had just
undergone an angioplasty. A potential problem related to this procedure
includes impaired tissue perfusion related to haematoma formation or
required to find five (5) contemporary, valid research journal articles (no
older than 7 years) relating to the care of the patient undergoing angioplasty.
Read the articles focusing on the assessment elements of care required post
procedure. (Don’t forget to link your assessment reasoning to anatomy and
physiology and pathophysiology).
Reflecting on the simulation, you are
required to identify CORRECT nursing assessment performed on Mr Bright relating
to the problem stated above. Justify your discussion using evidence from your
Reflecting on the simulation, you are now
required to identify those elements of nursing assessment that were NOT performed
on Mr Bright relating to the problem stated above. Justify your discussion
using evidence from your researched articles.
Nursing assessments elements performed CORRECT
The very first assessment element
in hematoma formation or bleeding is to monitor Mr. Bright’s vital signs,
certainly HR (heart rate) and BP (blood pressure). It is to look for the signs
of the orthostatic hypotension. In this case, vital stats have been measured
post procedure and are within normal range (Elgendy, Huo, Bhatt & Bavry, 2015).
The next set of observations is to be conducted within next 15 minutes. This
assessment is necessary because hypotension and tachycardia are the first
compensatory mechanisms which are generally notified with bleeding (Underwood,
Duran, Dighe, Elbarouni, Bagai, Buller & Graham, 2015). Orthostatsis
indicates decreased circulating fluids. Orthostasis means the drip of 20 mmHg
in the systolic BP or about 100 mmHg drip in the diastolic BP when it changes
from supine towards the sitting position (Elgendy et al., 2015).
The nurses also conducted the
assessment of Mr. Bright’s skin and mucous membranes for finding the signs of
bruising, hematoma formation, petechiae, pr blood oozing. This is evident in
post-operation form when the nurse during clinical handover reported that the
observations are normal, but he is bit cold (Underwood et al., 2015). Even
while giving the clinical handover, the nurse asked the patient and made the
other nurse see the wound to define any bruising or hematoma formation. The
nurse also reported that there is little bruising seen (Nikolsky & Mehran, 2016).
This assessment is mandatory as the patient having decreased platelet counts or
clotting impaired factor activity might experience tissue bleeding which is out
of proportion to the injury. Due to skin trauma areas or surgical incision,
prolonged blood oozing is possible linked with coagulation abnormalities
(Underwood et al., 2015).
Nursing assessments elements NOT performed
The sign of decreased tissue
perfusion was to be assessed which is missing in the case. It is because
particular clusters of the signs and symptoms usually occur with the differing
causes. This evaluation is necessary as it gives the baseline for the future
health comparison (Izzo, Rosiello, Lucchini, Tomasi, Mantovani, Lettieri &
It was necessary to review the
laboratory data including ABGs, platelet count, fibrinogen, activated
coagulation time (ACT), bleeding time, creatinine, BUN, electrolytes,
prothrombin time, international normalized ratio, or partial thromboplastin
time in case the anticoagulants are being used for treatment (Smits,
Abdel-Wahab, Neumann, Boxma-de Klerk, Lunde, Schotborgh & Hambrecht, 2017).
In this case, the nurse on the shift change clearly stated that Mr. Bright is
being given anticoagulant to relive his chest pain. This assessment is
necessary for impaired tissue perfusion because blood clotting studies
suggested that clotting factors stay quite within the therapeutic levels (Izzo
et al., 2017). The irregularities in the coagulation can occur due to the
impact of therapeutic measures. It is also a necessary nursing assessment as
blood clotting cascade is the integral system in need of extrinsic and
intrinsic factors. The disarrangements in the above defined factors can impact
the clotting capability. These tests are essential for getting imperative data
regarding patient’s coagulation status and potential of bleeding (Underwood et
The evaluation of Mr. Bright’s
use of medications affecting hemostasis like anticoagulants, NSAIDs,
salicylates, etc. The nurses did not evaluate the affect of medications which
was necessary (Izzo et al., 2017). It is because the drugs which interfere with
the platelet activity or clotting mechanisms increase the risk for hematoma or
bleeding. NSAIDs and salicylates inhibits cyclooxygenase 1 (COX)-1 which
is an enzyme promoting the platelet aggregation (Nikolsky & Mehran, 2016). Smits
et al. (2017) stated that warfarin which is an oral anticoagulant is
responsible for inhibiting the synthesis of vitamin K into the liver.
This decreases the levels of various subsequent factors of clotting. Even Heparin
which is a parenteral anticoagulant is responsible for inhibiting thrombin action
and avoids the formation of fibrin clot (Underwood et al., 2015).
Another nursing assessment important is to monitor heatocrit
(Hct) and haemoglobin (Hgb). This is not seen in the nursing assessment
post-angioplasty. This assessment was essential as when bleeding is invisible,
reduced Hct and Hgb levels may be the early indicator of the internal bleeding (Nikolsky & Mehran, 2016).
Question 2: (approx. 300-400
National Safety and Quality Health Service Standards for
Clinical Handover recommend that communication of patient information should be
conducted in a standardised format using a structured process in order to
transfer relevant patient information. In the simulation, ISBAR was the
structured format used to communicate patient information.
Reflect on the simulation at the point
in time when Mr Bright complained of chest pain. Using the ISBAR format,
dot point your structured verbal handover to the doctor advising of the
patient’s chest pain.
Harry Bright of age 67years, male in the out surgical facility/ unit is under
the recovery room nurse care in the cardiology recovery ward.
Bright admitted to the ward after angioplasty. Admitted for the angioplasty due
to 3/12 unstable angina history. I am on way to shift my duty and one of my
post-angioplasty patients need post-op care. Currently, he is stable, but under
Harry Bright (67) male having a history of DMII and hypertension controlled
with diet and medications was admitted for angioplasty.
is a smokerà
20 cigarettes daily.
had undergone angioplasty for right coronary artery placing the drug eluting
was 10% residual stenosis at the site and cardiac monitoring during the
placement indicated certain myocardial ischaemia.
was removed in recovery with minimal wound ooze and no bruising.
recovery, he developed certain chest pain 6/10 and MO was contacted immediately.
was resolved with Nitroglycerin spray sublingually x 1 and no firther treatment
set of post procedure observations were in normal range.
conduct obs every 15 minutes.
wound ooze is present with no haematoma or swelling and even no pain at site.
(1000ml) IVT infusion @ 100ml/hr.
post angioplasty ECG and was normal.
Bright is connected to monitor.
post-operation, chest pain as 4 on 10 rating, but now no such complaints.
the post-op observations of Mr. Bright every 15 minutes and document in the
MO immediately if he reports chest pain as it was reported during recovery
observe Mr. Bright for verbal and non-verbal cues.
Mr. Bright with re-positioning techniques to assist in alleviating pain.
Elgendy, I. Y., Huo, T., Bhatt, D. L., & Bavry, A. A.
(2015). Is Aspiration Thrombectomy Beneficial in Patients Undergoing Primary
Percutaneous Coronary Intervention?: Meta-Analysis of Randomized Trials. Circulation:
Cardiovascular Interventions, 8(7), e002258.
Izzo, A., Rosiello, R., Lucchini, G., Tomasi, L., Mantovani,
P., Lettieri, C., ... & Zanini, R. (2017). Relationship between early
administration of abciximab and TIMI flow in STEMI patients undergoing primary
angioplasty: findings from a large regional STEMI network. Journal of
Cardiovascular Medicine, 18(6), 398-403.
Nikolsky, E., & Mehran, R. (2016). 26 Bleeding
Complications in Patients Undergoing Percutaneous Coronary Intervention:
Prognostic Implications and Prevention. Mechanical Reperfusion for
STEMI: From Randomized Trials to Clinical Practice, 240.
Smits, P. C., Abdel-Wahab, M., Neumann, F. J., Boxma-de
Klerk, B. M., Lunde, K., Schotborgh, C. E., ... & Hambrecht, R. (2017).
Fractional flow reserve–guided multivessel angioplasty in myocardial
infarction. New England Journal of Medicine, 376(13),
Underwood, G., Duran, C., Dighe, K., Elbarouni, B., Bagai,
A., Buller, C. E., & Graham, J. J. (2015). USE OF PROGLIDE PERCLOSE®
VASCULAR CLOSURE DEVICE IN PATIENTS UNDERGOING CORONAR