Nursing - Mr Ben O’Brien - Central Nervous System- Assessment Answer

December 14, 2018
Author : Ashley Simons

Solution Code: 1ACDB

Question:Nursing

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Nursing Assignment

Case Scenario

Mr Ben O’Brien is a 52 year old male who presents with acute chest pain for the past 1 hour. The pain came on while he was washing the car.

Observations on presentation-

T 36.5, PR 90, RR 20, BP 130/90. Patient is complaining of crushing chest pain, radiating down left arm, pain is 4/10. GCS 15. Nil previous cardiac history, no other medical or surgical history. Patient is 20 kgs overweight and smokes 10 cigarettes per day. Patient is not on any medications.

ECG shows ST elevation in 2 contiguous leads of > 2mm. Mr Jones has been diagnosed with a MI.

Assignment Task

Choose the main ACUTE nursing aspectsfor your patient, for example the case study on pancreatitis you may need to cover the main acute nursing in the first 2 hours of care, for the pneumothorax and MI patient try and just focus on the 3 main aspects. The lectures will identify what these are, and focus on the acute nursing interventions you would provide. (Hint: A person having an MI does not want a lecture on smoking at this point- they want you to fix their chest pain

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Solution:

Introduction

The paper is based on the case study of Mr Ben O’Brien. He is a 52 years old man and has been presented to the hospital with the complaint of acute chest pain since last 1 hour. He has no history of any kind of cardiac trouble, but this time he complains about crushing chest pain, and radiating down left arm. After the ECG, Mr Jones was diagnosed with MI (Myocardial infarction). This problem occurs due to the muscular tissues of the heart. The paper will provide the physical assessment of the MI in the first part and immediate nursing care plan for the patient in the second part.

Physical assessment

Central Nervous System CNS: Myocardialinfarction(MI) is the condition where the heart muscle cells die due to the deprivation of oxygen. This heart muscle is called as Myocardium. In the patient of MI the symptoms of fatigue, malaise and chest discomfort appear before the acute event. In some of the patient the pain threshold can be high due to which they do not experience such symptoms and ST elevation can occur without warning. The CNS assessment in the case of Mr. Jones will include GCS (Glasgow Coma Score). This will help to evaluate the level of consciousness in the patient. It is also essential to assess limb power in the patient, as it will help to determine the patient’s functional capacity and condition of limb coordination & reflexes. Facial symmetry evaluation is another assessment in CNS, which is important to be done to understand the motor weakness.Some of the patients also suffer from acute headache at beginning of MI symptoms, thus it is also important to evaluate, as it can inform about bleeding tendency. With progressive symptoms patient may also suffer from fever, thus nurse should also monitors the patient’s temperature.

Cardio Vascular System CVS: The patient suffering from acute MI is presented with the complaint of acute chest pain. ST elevation (STEMI) can occur without warning in some of the patient, like in the case of Mr. Jones. The acute chest pain for over the period of 30 to 60 minutes is considered as the typical condition of MI. Under this assessment it is important to access the through medical history of patient and as well as examination of heart, peripheral arterial and venous circulations. In order to characterize the MI pain with pleuritic pain, it is important to monitor patient’s BP, palpitation and Dyspnea. Facial features and patient’s color (pale, flushed, or cyanotic) are also important to notice as they can inform about the state of blood circulation.

Respiratory System (Resp):Respiratory system is also associated with MI. The respiratory rate in the patient may increase due to pulmonary congestion and stress. As the patient Jones was washing the car, thus due to this exertion his respiratory rate may increase (Barthel et al, 2013). Also he is a regular smoker, which results in pulmonary congestion. The congestion reduces the exchange of gases and results in higher RR. In the case of Mr. Jones, RR is 20. In the old age people, there is a higher rate of morbidity associated with infracts. Pulmonarycongestion or airway obstruction can also elevate the respiratory rate, thus physical assessment should also include monitoring rise and fall of chest. Arterial pressure stats are also monitored without disturbing spontaneous breathing patter in patient.

Abdominal Assessment-Abdo: Abdominal assessment is very important for the patient of MI.In the general population it has been noticed that different kind of fats get deposited in the abdominal visceral adipose tissue (VAT). According to Diaz et al, (2015), People living in urban area are at higher risk of heart attacks or infracts due to unhealthy living. Some of the other abdominal fats are liver fats and subcutaneous adipose tissue (SAT), which increases the risk of cardiovascular diseases and MI. The adipose tissue compartments are associated with MI. It is important to do abdominal assessment to identify the presence of oesophageal spasm,gastro-oesophageal reflux disease, and acute gastritis (Diaz et al, 2015). Heart and oesophagus are in very close proximity, thus the pain could also be non cardiac. However, in the case of Mr. Jones it has been diagnosed that he has suffered MI. Abdominal pressure in the patient is also monitored to distinguish venous from arterial neck pulsation. It is important to determine circulatory function.

Renal Assessment-Renal: The impairment of the renal function increases the risk of cardiovascular disease. It is an adverse prognostic factor found in the patients with established MI. In the contemporary invasive treatment of the MI, the major growing problem is of contrast induced nephropathy. In acute MI, the presence of impaired renal function can be associated with kidney diseases, renal failure and altered effect of the drug during the procedure of the treatment (Hsieh et al, 2013). Thus, renal assessment is very essential for the patient with MI. The presence of any kind of renal disease can worsen the condition of the patient and reduce the quality of the patient outcomes. Thus, for this urine output is important. The color and quantity of the urine are important for recognition of the renal functional impairment and applying appropriate therapeutic measures and preventive interventions are very important (Gansevoort et al, 2013). The management of the renal dysfunction can only be done after the appropriate identification of the disease. The renal functions are evaluated by monitoring glomerular filtration rate (Hsieh et al, 2013). It is important to determine the presence of any kind of renal dysfunction in Mr. Jones because this would affect the future interventions. According to the study, renal dysfunction treatments in the patient with acute condition of myocardial infarction reduce the events of acute conditions. In spite of various causes the impairment of the renal functions occurs as a significant adverse prognostic factor in the patients with acute MI. Thus, regardless of the optimal management strategies, it is important to do effective diagnosis and apply therapeutic measures (Hsieh et al, 2013).

Part 2- Nursing Care

Myocardial infarction (MI) is also known as heart. It is mainly characterized by the reduced blood flow through the coronary arteries, which further results in death of the heart tissues. MI is from the category of the acute coronary syndrome, which occurs due to prolonged myocardial ischemia. The blood flow is reduced through one of the coronary artery and heart tissue die due to reduction of oxygen supply. If the treatment is delayed it can result into mortality. If the patient do not receive proper treatment within 1 hour than the chance of mortality are highest. Here, paper will present the three most important and main aspects of immediate care. The major goals of the nursing treatment in providing immediate care to the patient are to stabilize the heart rhythm, relieve the chest pain, revascularize the coronary artery, reduce cardiac workload, and preserve myocardial tissue. For this the first nursing intervention would be gaining control over chest pain.

Controlling Chest Pain

The first nursing diagnosis is of the acute chest pain in MI. The acute chest pain could be the result of the tissueischemia. Chest pain could be with or without radiation. However, in the case of Mr. Jones chest pain has resulted in radiation. Chest pain also results in restlessness and loss of consciousness. The nursing care plan for this kind of pain would require monitoring and documentation of the type of pain (Martin et al, 2014). Noting the verbal cues and non verbal reports are also important. The monitoring will also be required for Blood pressure (BP) and change in the heart rate. For Mr. Jones the initial BP reported is 130/90, which is required to be checked frequently. This intervention would also require noting the intensity and location of the chest pain. Patient should be asked to report immediately in case of alleviate increased pain. Intervention should also include calm activities, quite environment and approaching patient calmly.

Rational: The major challenge in the physical assessment of the pain could be the behavior and appearance of the patient. Most of the patient with acute MI may be distracted and focused on only pain. Identifying the verbal history and investigation the precipitation factors could be postponed till the time pain is reduces. Thus monitoring the intensity of the pain is important to take the relieving measures. Monitoring the heart rate and BP are important because due to obstruction in the airflow, respiration increases (Martin et al, 2014). It also increases due to pain, anxiety and due to the release of stress-induced catecholamines, which increases BP and heart rate. After this verbal and non-verbal reporting of pain is important, because it is a subjective experience, which is when described by the patient, provides the baseline for the treatment and appropriate therapies. The delay in reporting the pain may hinder the way of pain relief interventions. Due to the reduction in the external stimuli, anxiety may increase, which can further increase cardiac strain. The patient may difficulty in coping, thus quite and calm environment is important to help patient cope with current situation.

Ineffective Tissue Perfusion

Ineffective tissue perfusion results in the decrease of oxygen level and failure of the nourishing tissues. Blood is considered as the connective tissue that carries oxygen and transfers it to lungs and also carries nutrients from the gastrointestinal tract (McHughand Ma, 2013). The decrease in the arterial blood flow results in decreased oxygenation and nutrition in the cells. Tissue perfusion can be temporary or could also be acute that could result in destructive effects. The reduced tissue perfusion can also result in damage of the vital body organs. The nursing intervention for the reduced tissue perfusion requires improving peripheral flow of blood, removing vasoconstricting factors, reducing the metabolic demands of the body, preventing any kind of further complication and increasing patient’s participation in the treatment (Cavalcantiand Vellozo Pereira, 2014). It is required that nurse should monitor the sudden changes in the mentation. Nurse must also monitor the peripheral pulses of the patient and rate of respiration.

Rational: Cardiac output is associated with cerebral perfusion. It is also influenced by the acid base variation, electrolytes, systematic emboli and hypoxia. Systemic vasoconstriction can have adverse effects on the patient’s condition, as it can reduce the cardiac output, diminished pulses and reduced skin perfusion. Thus, it is required that vasoconstricting factors must be removed or diminished immediately (Cavalcantiand Vellozo Pereira, 2014). Respiratory distress can also occur due to the failure of the cardiac pump or ischemic pain. Continued dyspnea may also indicate the complications of thromboembolic pulmonary. The patient will be encouraged for active or passive leg exercise (isometric exercises must be avoided in patient of MI), as it will help in decreasing the risk of thrombophlebitis (Cavalcantiand Vellozo Pereira, 2014). Encouraging the patient to participate in treatment and management would encourage therapeutic relationship between nurse and patient. According to the NMBA code of conduct for the nurses, it is important to behave in a competent manner and apply appropriate knowledge and skills to reduce the risk factors.

Activity Intolerance

Activity intolerance is considered as the situation, where the patient has insufficient psychological and physiologic capability to resist or complete the important physical activities. The common characteristic of the activity intolerance is associated with weakness and weakness caused by the acute or chronic conditions (Cavalcantiand Vellozo Pereira, 2014). Such condition is mainly noticed in the older patients. Mr. Jones may also suffer from activity intolerance that could worsen his condition. Activity and intolerance is also associated with obesity, anemia and malnourishment. Mr. Jones is also obese as his weight is 20 kgs more from normal weight. The goal of activity intolerance intervention is to increase the endurance and tolerance of the activities. Activity intolerance increases the risk of imbalance between the myocardial oxygen demand and supply. This intervention requires monitoring changes in BP, heart rate and heart rhythm. The data received from such monitoring is correlated with shortness of breath and chest pain. This intervention also requires patient to rest and avoid activities based on the intensity of pain and cardiac response. The signs and symptoms of the patient’s intolerance levelshould also be identified, and should be informed to physician immediately.

Rational: Documentation and monitoring of the heart rate, heart rhythm and BP are important to identify the response of the patient and level of myocardial oxygenation. The oxygen level must be monitored, as it may require patient to decrease the activity level and take bed rest. This will also help the healthcare professionals to understand the requirement of change in medication (if required) and administering supplemental oxygen (Cavalcantiand Vellozo Pereira, 2014). Encouraging patient to take rest initially will help patient to reduce myocardial workload and consumption of the oxygen. This will further reduce the complications in the patient’s condition. The activities that involve abdominal support must be avoided, as it can result in increase in BP. Monitoring pulse irregularities, dyspnea, palpitation and changes in chest pain may indicate change required in medication.

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