Table of Contents
INTRODUCTION
In the nursing management of chronic conditions among the elderly population, cardiovascular diseases are considered to be the major contributor to the health issues at old age (Torpy, 2010). Based on the scenario presented, the diagnostic procedures, management and nursing care services provided is focused on promoting safe and quality healthcare services so as to attain the desirable health outcomes. The nurse conducts an assessment of the patient through gathering objective and subjective data so as to identify the health problems being experienced by the patient. In the nursing management of the patient, the first priority health problems that can be identified include the management and complications associated with acute coronary syndrome. The second patient problem that is also of priority in the nursing management of the patient is the poly-pharmacy management after discharge from the hospital. In the nursing management of elderly patients, complication that are associated with cardiovascular disease is among the leading problems that cause prolonged hospital stay that increases the risk of acquiring nosocomial infection as well as deterioration of the patient’s quality of life (Timmis, 2015). On the other hand, treatment regimen management such as poly-pharmaceutical approach to the management of heart disease whereby the health practitioners subscribe different drugs to the patient is considered to be a major patient problem due to the increased possibility non-adherence to medication.
Furthermore, in undertaking an immediate emergency assessment and management of life threatening clinical complications associated with acute coronary syndrome, the A-E assessment approach is used. The initial step in the assessment of Violet involves the evaluation of the life threatening airway complication so as to provide interventions that ensure patency of the airways for respiration (Thim et al., 2012). The second step in the management of Violet involves the evaluation of life threatening breathing problems such as auscultating for breath sounds, respiratory secretions, blood oxygen saturation and respiratory rate so as provide treatment interventions to ensure effective breathing patterns are establish throughout the period of care. The third step in the assessment approach involves the evaluation of the circulatory systems through investigations such as the heart rate and blood pressure so as to assess the competency of the circulatory system. The forth step in the assessment involves investigating the disability being experienced by Violet due to acute coronary syndrome whereby the investigations conducted include assessing for alertness or responsiveness to voice and pain. This step in the assessment is important in evaluating violet consciousness. The fifth step involves the investigating signs of trauma or intravenous application used on Violet. Apart from ABCDE-assessment, the NEWS approach is also used in the assessment of the patient. The NEWS approach to the management of the patient facilitates the identification of early warning signs of deterioration that ensure effective nursing interventions undertaken (Bilben, Grandal and Sovik, 2016). In the nursing management of Violet, a score is assigned to the vital signs upon assessment and compared over time so establish whether her condition is improving or deteriorating during her hospital stay. In the assessment of Violet lamb the scores are assigned to the airway patency, blood pressure, blood saturation of oxygen, pulse, pain, disability after surgery and the condition of the IV lines. The NEWS-assessment approach is important in determining the prognosis of the Violet whereby a score of 0 indicated progress while a score of 3 indicates deterioration. Based on the results from the assessment, the nursing problems that are identified should be addressed based on the best available evidence so as to enhance the safety and quality of care offered to Violet.
On the other hand, the SBAR tool can be used to communicate the health problems being experience by Violet within the multidisciplinary team involves in her care throughout the period of stay at the hospital. The SBAR tool is important in managing complications that are associated with multidisciplinary communication such as ambiguity of instructions (Cudjoe, 2016). Therefore in describing the current situation of the patient to the multidisciplinary team, the nurses will state, “Mrs Violet Lamb is complaining of shortness of breath, frothy sputum and cough. Her assessment reveals a respiration rate of 32 breaths per minute, an oxygen saturation of 88%, heart rate of 90 beats per minute, blood pressure of 130/72 mmHg and a temperature of 36 °C. Violet is currently on prescribe Metformin 1000mg BD, amlodipine 5mg OD, atorvastatin 40mg Nocte and aspirin 75mg OD.” Furthermore in describing the background of the nurse will state, “Mrs Violet Lamb is75 years old and was admitted due to acute coronary syndrome and she has underwent percutaneous coronary intervention and stent due to occlusion of the coronary artery.” The communication of the assessment undertaken will state, “Mrs Violet Lamb is experiencing complication of acute coronary syndrome.” Lastly the recommendation will be states as, “Mrs Violet Lamb is to be scheduled for another cardiovascular review.” Therefore the importance of SBAR in the multidisciplinary communication includes effective transition of care during the handing over activity that ensures continuity of care.
DISSCUSION
In the nursing assessment of Mrs Violet, the first priority health problems that can be identified is the complications associated with acute coronary syndrome. The nursing process involved in the management of acute coronary syndrome is focused on reducing the life threatening complications that are associated the impairment of coronary artery blood supply through diagnostic and nursing care approaches (Torpy, 2010). Acute coronary artery syndrome is associated with conditions such as atherosclerosis that limit the blood supply to the coronary artery that supplies the entire cardiovascular tissue. The complications that are associated with acute myocardial syndrome involve a sudden reduction in the volume of blood that flows into the myocardium resulting in alteration of the function of the myocardial tissues (Sheeler, 2013). These complications include reversible ischemia and myocardial infarction due to complete and prolonged impairment of the coronary artery blood flow to the myocardium that ultimately result in myocardial tissue necrosis which is the permanent loss of function of the myocardium.
The occlusion of the coronary artery results in the alteration of the electrical conduction activity of the myocardial tissue causing atrial fibrillation as seen through the evaluation of the electrocardiograph (Wilkerson, 2012). Mrs Violet experiences atrial fibrillation due to the alteration in the function of the myocardium that is caused by the occlusion of the coronary artery due to conditions such as atherosclerosis. Due to Mrs Violet age and underlying chronic condition such as diabetes, arteriosclerosis is a major risk factor. This is because with age, the amount of fats in the body increases while the activity level of a person reduces thus creating an increased risk of circulating fats occluding the coronary artery (Wang and Zhong, 2016). Also due to chronic diabetes state, the amount of blood sugar is constantly elevated therefore causing bruising of the inner linings of the arteries that result in the development of an atherosclerotic plaque that occludes the coronary artery thus increasing the risk of coronary artery syndrome (Sheeler, 2013). Due to the occlusion of the coronary artery the signs and symptoms of the complications associated with acute coronary syndrome that the nurse should assess include tachycardia due to the compensatory mechanism of the heart to relieve ischemia (Wilkerson, 2012). In the event of occlusion of the coronary artery, the heart compensates for the reduced blood flow through the coronary artery through an increased heartbeat so as to ensure that sufficient blood volume is provided to the myocardial tissues to relieve the ischemic effect caused by coronary artery syndrome.
Based on the health problem, the management and nursing care of Mrs Violet is therefore focused in reversing the impairment of the coronary artery so as to ensure that sufficient volume of blood flows through the artery to the myocardial tissues to relieve ischemia. In the management of Mrs Violet, surgical intervention such as percutaneous coronary interventions are undertaken in the cardiac laboratory so as to relieve the occlusion causes reduced flow of blood in the coronary artery (Torpy, 2010). Also apart from PCI, the surgeons also relieved the occlusion through the placement of stents so as to ensure that the patency of the coronary artery is maintained so that sufficient volume of blood flows through the coronary artery (Fuster, Topol and Nabel, 2015). Apart from surgical intervention, the health problem is also addressed through the provision of pharmaceutical therapy that involves the provision of atorvastatin 40mg to reduce the amount of circulating cholesterol and low density lipoprotein that are produced in the liver to reduce the risk of clot formation that occludes the coronary artery resulting in coronary artery syndrome (Hogan et al., 2013). Also amlodipine 5mgs OD is used in the pharmacological intervention to cause a relaxation of the coronary artery so that blood can easily flow to the myocardial tissue (Finkel et al., 2015). Furthermore, in the management of arteriosclerosis due to clotting of blood, aspirin 75mg which is anticoagulation medication is administered to the patient. Due to the pharmacologic management of the complication associated with acute coronary syndrome, the nurse should ensure that the patient adheres to the treatment regimen management throughout the period of care as well as conducting periodic assessments for possible drug interactions and side effects (Henry, 2013). Also, the nurse should assess the surgical sites and intravenous sites for signs of inflammation such as reddening, pain or discharge which may indicate infection of the wound due to invasion of microorganisms.
The second patient problem that is also of priority in the nursing management of the patient is the poly-pharmaceutical management after discharge from the hospital. In the nursing management of elderly patients with comorbid conditions or chronic illnesses, poly pharmacy is a major problem and often patients complain that the medications are a lot and therefore it is difficult to adhere to the treatment regimen management. In the management of Mrs Violet the problem is caused by the existence of diabetes, coronary syndrome and high blood cholesterol level. Therefore, Mrs Violet is taking several medications concurrently that is, metformin 1000mg BD, aspirin 75mg – OD, amlodipine 5mgs OD atorvastatin 40mg –Nocte, bendroflumethiazide 2.5mg OD, amiloride 5mg OD and bisoprolol 5mg OD so as to manage her condition. Poly-pharmacy especially in old age is among the major health problems to the patient because of the psychosocial issues that are associated with chronic illness in old age such as anxiety regarding medication and depression due to alteration in social patterns sue to hospitalization or care home (Maher, Hanlon and Hajjar, 2013). Based on the scenario, the impact of poly-pharmacy in the management of Mrs Violet can be seen through the difficulty of the client to understand the medication administered as well as non-adherence to the treatment regimen management due to the numbers of drugs that she has to take on a daily basis. The pharmaceutical intervention used in the management of the patient is therefore ineffective sue to the non-adherence to the medication provided.
The problem of non-adherence to the poly pharmaceutical regimen is caused by factors surrounding the use of drugs in chronic and comorbid conditions. These factors include non-adherence to medication regimen due to the adverse reaction that is experienced by the patient upon use of the poly pharmaceutical therapy (Hajjar, Cafiero and Hanlon, 2007). In the administration of medication to patient with chronic conditions or comorbid disorders, the healthcare professional should ensures that the pharmaceutical regimen is tested for adverse reaction. This is to ensure the safety as well the comfort for the patient throughout the period of care because the patient will take the medication with least adverse effects. Also poly pharmacy is a problem in the management of the patients because of the increased tendency to skip doses by the patient because of factors such as difficulty in swallowing the drugs or lack of understanding regarding the significance of taking all the medications (Woodruff, 2010). Therefore the efficacy of the management of the patient is highly likely to be compromised mainly due to the non-adherence tendency to treatment. In the management of the patients, the effectiveness of poly pharmacy can be enhanced through identifying the concerns of the patient that result in skipping of doses (Woodruff, 2010). Also the elderly patient experience challenges when refilling their medication because due to poly pharmacy, the cost of medication especially among the uninsured resulting in missed doses.
In the management of problems associated with poly pharmacy, the healthcare team should ensure that the patient understand all the medications that are included in the prescription form (Woodruff, 2010). In planning the discharge of the patient, the nurses should ensure that the patient understand the dosages, role and names of the medications that are prescribe through conducting an effective discharge education. This is because through educating the patient regarding the various medications that are administered, the patient is empowered and is now able to effectively adhere to the treatment regimen (Mortazavi et al., 2010). Other nursing interventions that can be used include providing a colour coding of the medication to serve as an aid in assisting the elderly patients to understand the medication as well as to keep up with the dosages accurately. Also coding of the medications is effective in assisting the patient to know which medication is over and needs to be refilled so that the therapy is not interacted due to missing of drugs or taking the wrong drugs (Cantlay, Glyn and Barton, 2016). Therefore in planning the discharge of Mrs Violet Lamb, the nurse should ensure that education regarding the management of poly pharmacy therapy is undertaken so as to enhance her adherence to the medications. The nurse should also work with Mrs Violet to identify the reasons for skipping the medication so that in case of adverse reactions or side effects to the drugs, the nurse can recommend an alteration in the type of drugs so as to enhance tolerance and adherence.
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CONCLUSION
In the nursing management of patients with acute coronary syndrome, the nurses should assess the patient to gather valuable data regarding the various systems and communicate the findings to the multidisciplinary team. In the nursing process, among the methods of assessment that can be used include the A-E assessment and the NEWS tool for gathering valuable information regarding the health needs of the patient. The information obtained through assessment of the patient is communicated within the multidisciplinary team using SBAR to ensure continuity of care through the period of stay in the hospital. Furthermore, upon establishing the health problems that the patient is experiencing, the nurses should seek a collaborative approach through collaboration with the multidisciplinary team so as to identify the relevant interventions. The interventions undertaken in the management of the patient should be based on the best evidence possible so as to promote the safety and quality of care. Thereafter the nurse should follow up on the interventions so as to identify other health needs that might affect the effectiveness of the interventions. Lastly, the nurse should prepare a discharge plan for the patient to ensure that the patient benefits from the interventions that were provided during the period of care.
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