Integrated Nursing Practice 2

Assessment Task 1

Question 1: (approx. 600-700 words)

 

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 bleeding.

You are 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 researched articles.

 

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.

 

Answer.

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 & Zanini, 2017).

 

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 al., 2015).

 

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 words)

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.

Identityà

Mr. Harry Bright of age 67years, male in the out surgical facility/ unit is under the recovery room nurse care in the cardiology recovery ward.

Situationà

Mr. Harry 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 consistent observation.

Backgroundà

§  Mr. Harry Bright (67) male having a history of DMII and hypertension controlled with diet and medications was admitted for angioplasty.

§  He is a smokerà 20 cigarettes daily.

§  No known allergy.

§  He had undergone angioplasty for right coronary artery placing the drug eluting stent.

§  There was 10% residual stenosis at the site and cardiac monitoring during the placement indicated certain myocardial ischaemia.

§  Sheath was removed in recovery with minimal wound ooze and no bruising.

§  During recovery, he developed certain chest pain 6/10 and MO was contacted immediately.

§  Pain was resolved with Nitroglycerin spray sublingually x 1 and no firther treatment ordered.

Assessmentà

§  RTW at 1650hrs.

§  Initial set of post procedure observations were in normal range.

§  To conduct obs every 15 minutes.

§  Small wound ooze is present with no haematoma or swelling and even no pain at site.

§  N/Saline (1000ml) IVT infusion @ 100ml/hr.

§  Routine post angioplasty ECG and was normal.

§  Mr. Bright is connected to monitor.

§  Immediately post-operation, chest pain as 4 on 10 rating, but now no such complaints.

§  BGL 10mmol/l.

Recommendationà

§  Conduct the post-op observations of Mr. Bright every 15 minutes and document in the chart.

§  Contact MO immediately if he reports chest pain as it was reported during recovery also.

§  Consistently observe Mr. Bright for verbal and non-verbal cues.

§  Assist Mr. Bright with re-positioning techniques to assist in alleviating pain.

References

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), 1234-1244.

 

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