Q1: Prioritizing patient care will help to complete nurse’s shift duties without any adverse patient complication. Prioritizing will help to plan out the day and in managing the cases in the most effective way (Alfaro-LeFevre 2014). The best path to plan care for the patient with different medical and surgical priorities is to set timed objectives and meet the discharge goals based on the urgency of the medical or surgical condition. The handover from the staff of the previous shift provided the information for 4 patients, of which Lucy’s condition is more of an emergency that will be considered first. The patient needs an emergency appendectomy. Her temperature is already high and her conditions need to be optimized quickly so that the surgery can be performed. When compared to Lucy, the other three patients are relatively stable. The second patient in the list will be Steve and the third patient will be Ronald. The fourth priority will be provided to Claire.
Lucy has a ruptured appendix and needs several peritoneal normal saline washes to reduce the contamination from contents that spilled into the peritoneum. The ruptured appendix could prove fatal if not attended to. Her temperature is already high which suggest an underlying inflammation. She is already on intravenous antibiotic therapy. There is no treatment for this condition, other than an emergency surgery. There is no sufficient time for a detailed post-operative assessment in this emergency (Solomkin et al. 2010). The order and procedure planned for this patient will be prioritized. The patient is in severe pain and her temperature is high. The order to administer metronidazole and Perfalgan will be executed. Her vital signs and respiratory function will be monitored. The normal concern in ruptured appendicitis cases is peritonitis, the psychosocial aspect of care and surgery (Craig, 2015). The nurse has to coordinate activities with the surgical team to get the patient treated at the earliest.
The second patient on the priority list is Steve. He is presented to the emergency department with rapid Atrial Fibrillation. Though the patient is cardioverted, he complained of chest pain in the previous shift. He is already with fluid resuscitation and his heart function is being monitored. His blood test and ECG are due at 1000hrs. So after looking into Lucy’s case, I will prioritize Staves case.
The other two patients: Ronald and Claire are relatively stable and well past their emergency situation. Ronald complains of nausea and mild right shoulder pain. There are no orders for this patient. The nurse can look into the positioning of the patient and offer psychosocial support. The mild pain can be managed with the patient’s assistance. The reason for nausea can be looked into. This symptom could be just a procedure associated mild side effect that will subside with time. Mild pancreatitis is common in patient undergoing endoscopic retrograde cholangiopancreatography. Pain due to the surgical wound may return when sedation levels wear down. Bloating and nausea can occur for a short time following the procedure (Endoscopic Retrograde Cholangiopancreatography). The fourth priority will be provided to Claire. Her condition is stable and her vital signs are in the expected range. She is due for Ventolin nebulizer at 10. 00hrs. Claire is a medical case and was admitted a week ago. She is showing improvement in her condition.
The pathway for nursing care of medical and surgical cases are slightly different. In medical cases, the nurses are provided orders on interventions that are needed to stabilize the patient on admission. Once the condition is stabilized, the care is focused on controlling symptoms of the disease. When the patient’s condition is improved and is ready for self-care or care by another person, he/she is discharged. On the other hands, surgical nursing plan pathway, involves pre-operative care, surgery, and post-operative care. (Shepperd et al. 2013)
Q2. Bloating and nausea may occur for a short time following the endoscopic retrograde cholangiopancreatography procedure (Loperfido, 2015). This is normal. But if the patient complains of nausea becoming worse, the nurse can promptly alert the physician. Pancreatitis is a complication associated with endoscopic retrograde cholangiopancreatography (Loperfido, 2015). Nausea is an uneasiness that is felt in the stomach and is usually felt before vomiting. The symptom is not harmful in itself. It can prevent the patient from having oral fluid and taking rest. Normally, the sign of nausea is observed for 24 hours and physician is only alerted, if it still persists after 24 hours.
As I don’t see an antiemetic in the medication list, I will call the physician and ask for his directions of this case. When there is severe nausea and vomiting, the patient is nourished on intravenous fluid and no oral fluids are provided. Antiemetic are prescribed to treat nausea. The nursing priorities while treating patients who underwent endoscopic retrograde cholangiopancreatography for removal of gallstones are: to relieve pain and to promote rest. The surgery was done with sedation and the patient begins to sense pain when sedation begins to wear away. In addition, symptoms of nausea are also preventing the patient from taking rest. The patient needs to be maintained on fluid and electrolytes, as he is still not ready to take fluid orally.
Most patients who do not have a complication will be able to take oral fluids within 24 hours. Preventing complications are the third priority in caring for the patient. The final priority is to provide the physician information about diseases prognosis and treatment needs. Having taken care of the first three priorities, I see that the patient needs medicines for pain and nausea. This treatment need will be communicated to the physician. Prolonged vomiting can restrict oral intake of nutrient causing nutrient and electrolyte deficiency. The patient can be discharged only when the pain is relieved and complications are minimized. For these reasons, the worsening symptom of nausea has to be taken seriously and communicated to the physician.
Q3: On entering Steve’s bed, he looks grayish and does not have a palpable pulse. Steve’s condition is a medical emergency and the cardiac resuscitation team will be alerted. Cardiogenic shock is a condition where the heart is unable to contract and pump blood efficiently (Warise 2015). There is insufficient blood circulation and oxygenation in the body. The grayish coloration and low temperature of the patient is a sign of this. Cardiogenic shock results from a severe heart attack and the mortality rate associated with this condition are very high (Warise 2015). The patient is in need of immediate medical attention. Old age and history of heart failure are risk factors for cardiogenic shock. Steve is 85 years old and is admitted for atrial fibrillation, and thus, this emergency situation is to be expected.
Symptoms of acute cardiac failure are: angina pectoris, dysrhythmia, diminished heart sound, a sudden drop in blood pressure, weak pulse, diminished cardiac output, the urine output is also lower than 30 ml per hour. There is shortness of breath and the patient skin is cool and pale. It is also moist from sweating. If the patient is not treated immediately, there could be complications from damage to the brain, kidney, and multiple organs. Cardiogenic shock is diagnosed based on blood pressure and electrocardiogram. Cardiac enzyme test will also help to diagnose cardiogenic shock. In some patient, coronary angioplasty may be required for diagnosis. Atrial fibrillation is a sign of underlying disease. Unless the primary disease is corrected, the interventions to restore cardiac output will not be effective. (Ren, 2015)
Decrease in cardiac contractibility will decrease cardiac output and stroke volume. This will cause decreased coronary perfusion, again impeding cardiac contractibility. Low cardiac out and stroke volume can decrease systemic perfusion and cause pulmonary congestion. My immediate response, in this case, would be to intubate and start fluid resuscitation and correct hypovolemia and low blood pressure. Fluid resuscitation is contraindicated in pulmonary edema. Ringers lactate, normal saline or dextran are commonly used for fluid resuscitation. The second thing I would do is intubation and mechanical ventilation. Hemodynamic monitoring is very important in understanding the prognosis.
The patient was stabilized on admission. When the patient was admitted, the goal of the nursing intervention was to restore the cardiac output. In atrial fibrillation, the cardiac output decreases. The desired outcome of this intervention is noticed in 30 -60 minutes. Following this, the patient is placed under 24 hours’ observation. The cause of atrial fibrillation is still not known. In order to know the cause of atrial fibrillation, it is necessary to monitor the electrical conduction of the heart. Normally, electrical signals start in the atrioventricular node and is conducted to Sino ventricular (SV) node. In atrial fibrillation, there is overwhelming of SV node due to signals arising from other regions in the heart. The atrial fibrillation can occur for a number of reason. Heart attacks, coronary artery disease, stress, hypertension, are the common cause of atrial fibrillation in the elderly population. (Ren, 2015)
During 24 hours’ observation, the cardiac monitor will access the patient heart rate and rhythm. The patient is also assessed for chest pain, blood pressure and increasing heart rate. This is done to diagnose heart failure. I would also suggest monitoring the patient oxygen level. The patient did have chest pain and his blood enzyme and ECG report were due. If the patient’s condition does not improve, he will be again recommended for transmission to ICU. Treatment modalities will vary with the patient to patient. On admission, cardioversion was done to optimize cardiac cycle. The rationale for this procedure is to restore the sinus rhythm. The patient complained of angina and was due for ECG. His blood samples were sent for cardiac enzyme test. Ideally, patients with heart failure should be followed up with a specialized team that focuses on heart failure (Berti et al. 2013). It is not safe to admit patients in the medical ward with other patients who need emergency care. Cardiogenic shock is to expect in the patient. As the patient is connected to a cardiac monitor, the nurse will be alerted when variation in heart rate or rhythm is noticed. (Gulanick, Myers 2011)
The nurse role in the management of the patient with cardiogenic shock are: monitoring the hemodynamic and assess the patient’s vitals; maintaining patency of arterial lines; administering prescribed medicines at the correct time; checking the IV infusion site for bleeding or other allergies, and monitoring urine output and kidney function. In order to prevent complication, the nurse will notify the physician promptly when there are changes in hemodynamic and vital status. The nurse can also notify the physician when there are changes in breathing sound and cardiac rhythm. (Gulanick, Myers 2011)
References
Alfaro-LeFevre, R. (2014). Applying nursing process: The foundation for clinical reasoning. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Berti, D., Hendriks, J. M., Brandes, A., Deaton, C., Crijns, H. J., Camm, A. J., . . . Heidbuchel, H. (2013). A proposal for interdisciplinary, nurse-coordinated atrial fibrillation expert programmes as a way to structure daily practice. European Heart Journal, 34(35), 2725-2730. doi:10.1093/eurheartj/eht096
Craig, S. (2015, December 27). Appendicitis Treatment & Management. Retrieved August 30, 2016, from http://emedicine.medscape.com/article/773895-treatment
Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and outcomes (7th ed.). Missouri: Elseivers.
Loperfido,, S. (2015). Patient information: ERCP (endoscopic retrograde cholangiopancreatography) (Beyond the Basics). Retrieved August 30, 2016, from http://www.uptodate.com/contents/ercp-endoscopic-retrograde-cholangiopancreatography-beyond-the-basics
Ren, X. (. (2015, December 13). Cardiogenic Shock. Retrieved August 30, 2016, from http://emedicine.medscape.com/article/152191-overview
Shepperd, S., Lannin, N. A., Clemson, L. M., Mccluskey, A., Cameron, I. D., & Barras, S. L. (2013). Discharge planning from hospital to home. Cochrane Database of Systematic Reviews Reviews. doi:10.1002/14651858.cd000313.pub4
Solomkin, J., Mazuski, J., Bradley, J., Rodvold, K., Goldstein, E., Baron, E., . . . Bartlett, J. (2010). Diagnosis and Management of Complicated Intra‐Abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clinical Infectious Diseases CLIN INFECT DIS, 50(2), 133-164. doi:10.1086/649554
Warise, L. (2015). Understanding Cardiogenic Shock. Dimensions of Critical Care Nursing, 34(2), 67-78. doi:10.1097/dcc.0000000000000095
