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Advanced nursing consultation and decision making in Acute Coronary Syndrome a case study.
An Advanced Practice Nurse (APN) is a highly qualified and experienced nurse with post-graduate education that prepares them for highly specified roles (White, 2010). One of the advanced roles of ANPs (the consultation and decision making), will be explored in this case study, which presents details of a patient whose care was attended by an APN. However, it is necessary to mention that in Iran, where this case happened, there is lack of autonomy among nurses even in at advanced levels. In other words the parental attitude is dominant among doctors, therefore the diagnosis and care planning and treatment would usually be ordered by them or in a few cases, in a joined form with nurses. Another criticism is the lack of shared decision making. According to Sheridan et al (2004), Share decision making is a process that involves active partnership between nurses and the clinician to clarifying and evaluate acceptable medical alternatives and adapting to a preferred option of care (Sheridan et. al. 2004 pg 57).
The aim of this paper is to understand the condition of Acute Coronary Syndrome (ACS) by analyzing a case study, exploring normal heart physiology and pathophysiology in addition to consultation and assessment based on a selected consultation model. This paper is set based on Driscoll`s (1994) Model of reflection because the flow of the case study fits properly and logically in the framework.
Literature Search Strategy
This case study involved research on the condition (ACS) through comprehensive literature research on books and clinical experiences. Literature search uses credible academic and medical books, some journals and involves limited use of search engines and internet. Through the application of the research and clinical information on ACS, the diagnosis and treatments included in this study are purely objective.
Acute Coronary Syndrome is a term that describes a range of cardiovascular disorders that include myocardial infarction and unstable angina. The disorders included by the term are those caused by the same underlying problem of abrupt or impulsive blood flow reduction in heart muscle parts (O`Connor et al. 2010). This underlying problem may be caused the formation of a blood clot on an atheroma patch especially within the coronary artery. In presenting this case study, the choice of the patient was determined by the quest to understand the condition of Acute Coronary Syndrome. To study Mr. Ali Bahmani`s case, we applied the Calgary-Cambridge consultation model which is appropriate for the case as compared with other models.
Patient Case Study
The patient under study is a 42 year old Ali Bahmani who lives with his 38 year old wife. Ali has been a relatively healthy and happy man who has had a lovely childhood being brought up by able parents. He is a responsible family man who spends most of his free time with his family. Together with his wife, he has been able to raise their three children as he is a banker and the wife a high school teacher. It is worth noting that Mr. Bahmani has not had a difficult work history since his white collar job is at an office located near his home. However, he admitted driving in the workplace rather than walking, despite being near his place of residence.
Mr. Bahmani has no medical history of note, apart from the case he was presenting at the nurse`s office. In addition, he has a very supportive family that accompanies him whenever he is concerned with his health. As a school nutrition teacher, his wife has maintained a good nutrition for the family, but it is worth noting that he eats junk food a lot. This happens while at work and out for lunch with colleagues by eating fast foods.
Normal Heart Physiology
The heart is a fist-sized special muscular organ located between the lungs and above the diaphragm behind the sternum and surrounded by the pericardium. Weighing about 250-300 g, the center is served by great vessels: inferior and the superior vena cava, the pulmonary vein and artery and the aorta (Phibbs, (2007). Generally, the heart receives deoxygenated blood from the body via the veins, pumps it to the lungs for oxygenation and then to the body via the arteries on receipt from the lungs. To perform this, the physiology of the heart has four compartments: the left and right atria and ventricles respectively. In addition, for perfect functioning, the heart has four valves the tricuspid valve, the mitral valve, the pulmonary valve and the aortic valve all of which control the flow of the blood to and from the heart to veins and aorta. Just like any other body muscle, the muscles of the heart require a good supply of blood which is done by the coronary arteries (Patient, 2014).
The key coronary arteries to the heart muscles branch off from the aorta, which is the large artery transporting oxygenated blood to the body from the heart chambers. From the main coronary arteries, blood is taken to all parts of the heart muscle by smaller arteries that divide into smaller branches from the main coronary artery (Patient, 2014). Therefore, for a properly functioning heart, blood flows smoothly from the coronary arteries to the muscles and returned to main veins that take deoxygenated blood back to the heart.
Heart Pathophysiology ACS occurrence
Acute Coronary Syndromes (ACS) occur either as unstable angina to Myocardial Infarction (MI) depending on the effect of the blockage of the coronary artery on the part of the heart muscle affected. Myocardial Infarction occurs in two main types based on what is depicted on the heart tracing (electrocardiograph or the ECG). The two main MI types are the non-ST elevation (NSTEMI) and the ST elevation MI (STEMI).
The case of unstable angina of ACS occurs when the blood clot blockage leads to reduced blood flow (White, 2010). This leads to loss of oxygen and blood to the part of the heart muscle that is served by the blocked artery or branch. This situation risks the affected part of the heart muscle to die off, unless the blockage is timely removed. This is what gives the word infarction it meaning. It means the death of part of a tissue caused by a blocked artery, which blocks the flow of blood past the blockage. This is called coronary thrombosis or commonly referred to as a heart attack (Porth, 2011). In addition to infarction, the majority of cases of heart dysfunction is due to narrowing of the blood vessels supplying the heart, which may happen due to Atheroma, when fatty plaques or patches develop within the artery lining.
Consultation and Assessment
The process of consultation and assessment on Mr. Ali Bahmani was done by the AP nurse using the Calgary-Cambridge model. This model was used because it provides a guideline of studying the patient while carrying out the process (Patient, 2014). The model was preferred because the interviewing process of Mr. Bahmani involved asking him to give information about his health status. The model was further adopted because of its emphasis on a patient-centered consultation. This is because the consultation process was based on retrieving useful information from the patient based on his health history.
The process involved the step of initiating the Session by the nurse from which the initial rapport was established. Then the nurse identified the reasons for the consultation process before gathering information from Mr Bahmani, the patient. In gathering the needed information, the nurse explored problems and took an understanding based on the patient`s perspective with the model providing structure to the process. This leads to a relationship building and develops a report by involving the patient, which then makes explanation and planning stage possible (Tate, 2007). Provision of correct information and aiding recall and understanding is achieved by a shared understanding that incorporates the patient`s perspective (Tate, 2007). This way the nurse can use the model to establish all the needed facts about the patient and finish with the last stage of closing the Session.
Initiating the Session
After a very warm greeting and chat on general issues as well as the hot environment, the nurse offered Mr. Bahmani a glass of water, which he took in a very friendly way. This greatly made the room friendly and the nurse was able to comfortably ask Mr. Bahmani how she could assist him. He was free to answer and started narrating how is past one week was. At some point, the nurse requested the wife to excuse the two of them, which she respectfully did to give them privacy.
On learning that the problem was related to chest pains, the nurse focused on the general questions such as home and work information. This was important to get his background information on his risk factors. In particular, she was asking for information such as family information, meals taken, type of work done and details related to the tasks performed at the family. From the time the nurse was left with Mr. Bahmani in the room, she started asking both general and specific questions that led to the identification of the problem and further diagnosis. Bickley (2009) argues that it is recommended for patients to answer questions relating to their medical history in privacy. That is the reason why the nurse requested to interview Mr. Bahmani in privacy.
Explanation and Planning
The first day that the patient complained, he had presented to the primary care team with complaints of chest pain. After performing a 12-lead ECG the patient illustrated no changes from the ECGs that had been performed previously. The vital signs of the patient were also found to be within his normal range and were stable. More specifically: he had 135/78 mm Hg in blood pressure, 68 beats per minute in heart rate, which was regular, and 16 breaths per minute in respiration which was unlabeled.
Rationale: the descriptions of Mr. Bahmani`s conditions showed signs that could allow for hypothesis that could lead to deduction of the presence of Acute Coronary Syndrome. This is because people with complaints of chest pain require further tests based on a hypothesis (Woo & Schneider, 2009). Therefore, patients like him need to be evaluated for ACS based on the present signs and symptoms. As it was done to Mr. Bahmani, the most appropriate assessment measures comprised of vital signs as well as a 12-lead ECG in order to assess him for infarct or ischemia (Woo & Schneider, 2009). The Patient was free of chest pains when he arrived at the nurse`s office and also had no case of acute ischemic change as they were indicated by his ECG in addition, his vital signs were also stable as indicated by further assessment.
Further questioning of Mr. Bahmani was done by the nurse in relation to the episodes of his chest pain. On further responses, he reported that he just had been experiencing sporadic chest pain, especially which he took to be “normal” especially after he had worked too long or he involved himself in a tedious job. However, he reported that in the last week, the attacks of the chest pains have lasted longer. The previous night, as he narrated, he had a prolonged chest pain which made him arrive at the conclusion of seeking medical attention.
Rationale: When chest pains like those of this patient are experienced in a predictable pattern, the situation may be triggered by an exertion of the same level. However, the episodes are readily relieved by rest just like it was established in Mr. Bahmani`s case. This level of stable angina is a characteristic symptom of CAD despite being a rare indicator of acute myocardial ischemia. On the other hand, the attacks of chest pain increased in terms of severity and frequency this way, they required more Nitroglycerin tablets for relief (White, 2010). Furthermore, the indicative chest pain just like Mr. Bahmani had in the previous one week had been severe and occurred even at rest. This indicates that angina like the one of Mr. Bahmani had become “unstable,” which require immediate medical intervention as he had sought.
Patient`s Past History and Admission
After further reviewing Mr. Bahmani`s medical records, it was established that he had a Coronary Artery Bypass Grafting (CABG) surgery 5 years before the episodes. It was noted that he had required a drug-eluting stent replacement two years ago in order to open a blockage existing in one of the saphenous vein grafts as indicated by his Coronary Artery Bypass Grafting surgery. It was further noted that he had also been prescribed Dyslipidemia medication. This medication was for recently done laboratory tests that indicated his high LDL borderline at 135 mg/dl (Bickley, 2009). He had stopped smoking due to the placement, two years, but he was overweight by approximately 30 pounds which he admits he cannot manage.
Rationale: A careful evaluation of a patient`s history provides information that is necessary to triage his medical condition, and in this case chest pains (Bickley, 2009). It also stratifies their possibility of having serious consequences like acute MI. The main risk factors for Acute Coronary Syndromes (ACS) include the patient`s CAD history. In addition, it also includes occlusions history that needs the restoration of blood flow as well as oxygen supply to intervene the condition. Moreover, the symptoms of Acute Coronary Syndromes (ACS) also include experience of risk factors like smoking, obesity and dyslipidemia (Bickley, 2009).
After the establishment of Mr. Bahmani`s CAD, previous CABG history in addition to the risk factors, the nurse took him to the emergency department at the hospital. However, he went on to resist at the beginning and insisted to drive himself to the hospital, but finally with nursing intervention he was transferred by emergency medical services.
Rationale: It is strongly recommended that patients with possible condition of ACS be taken to the hospital through the provided emergency medical services (O`Connor et al, 2010). This provides emergency medical staff with the opportunity to assess the patient further establish their immediate ECG and give therapies as recommended (Hastings & Redsell, 2006). In addition, this transport will enable the emergency medical staff to notify the hospital emergency department to prepare for the receipt and admission of the patient by facilitating triage and evaluation (O`Connor et al, 2010). Mr. Bahmani was provided with all these information by his nurse therefore he turned to be cooperative.
After arrival at the emergency department, Mr. Bahmani was attacked with the chest pains that were rated at 10 out of 10. This scale is applied to provide a rating of the severity of the chest pains. The chest pains were located in the substernal region, the left side of his chest. He was diaphoretic slightly he had a 170/90 mm Hg blood pressure and 110 beats per minute in heart rate. It is worth noting that severe and intense chest pain in the left substernal chest area, in addition to diaphoresis presented critical sign changes and indicators of Acute Coronary Syndromes (ACS). The physician in the emergency department made a joint decision with the APN to start chest pain protocol on Mr. Bahmani and gave him 325 mg of aspirin to chew and swallow.
In addition, he was given supplemental oxygen, which was admitted at 2 liters per nasal cannula and sublingual Nitroglycerin. The nurse performed a 12-lead ECG and blood tests, which included troponin T level and a CK-MB. In Acute Coronary Syndromes (ACS), aspirin was given to the patient immediately on admission for its antiplatelet action.
Rationale: This treatment was given to decrease the risk of forming a thrombus (Wolff & Miller, 2009). In addition, Sublingual Nitroglycerin was given as a vasodilator thereby reducing the workload of myocardial while raising the supply of myocardial oxygen in addition to lowering the blood pressure.
The 12-lead ECG that was performed on Mr. Bahmani indicated a non-specific ST-segment and changes in the T-wave. After five minutes after being given the sublingual nitroglycerin tablet, the blood pressure of the patient was 140/88 mm Hg and that his chest pain was 10/10. The five minutes after the admission of the second sublingual Nitroglycerin tablet it was noted that his blood pressure was constant at 140/88 mm Hg but his pain was 8/10. A further three minutes after admission of the third sublingual Nitroglycerin tablet it was reported that his pain was 5/10 and his blood pressure was 132/80 mm Hg. It is at this point that the physician consulted the APN to give him morphine IV 2 mg.
Rationale: The explanation to this is that patients with proven ACS symptoms, T-wave changes and nonspecific ST-segment are worrisome. This is because the Serial ECGs can be established to illustrate the presence of a developing MI. If the patient does not turn to be hypotensive, Sublingual Nitroglycerin dose can be administered after every 5 minutes for 3 times. The goal of this therapy in managing ACS is to free the patient from the chest pain (Coven & Yang, 2014). In addition, Morphine may be administered to treat chest pain if the condition is not resolved after the administration of the 3 sublingual Nitroglycerin tablets. This is because Morphine tends to decrease myocardial oxygen needs and increases myocardial oxygen supply by acting as a vasodilator (White & Stancombe, 2003).
Giving of Morphine
After Mr. Bahmani received morphine, the APN reported to the physician that he was free from chest pain. He had returned to normal blood pressure levels and his heart rate was now at the “usual” level. However, the APN suggested transferring the patient to the telemetry or the step-down floor to carry out further observation and to monitor him further.
Rationale: The combination of Mr. Bahmani`s severe and regular episodes of chest pain in addition to the presence of unclear changes on 12-lead ECG showed evidence of Acute Coronary Syndromes (ACS). In addition, his previous CAD history, the CABG instances and stent placements all indicated that he was at increased MI risk (Coven & Yang, 2014). In addition, Serial biomarkers were involved to provide significant diagnostic information that will be useful in the assessment whether to confirm or not to confirm NSTEMI diagnosis. The consistent monitoring of ECG provides information regarding changes in ST-segment that indicate ischemia and infarct (Coven & Yang, 2014). Finally, a record of 12-lead ECG during the chest pain episodes provides information on the possibility of ischemia and the part of the heart that is exposed to risk.
The second set of cardiac biomarkers for this patient was reported to indicate an elevated level of Creatine Kinase MB, CK-MB. A repeat ECG indicated no evidence of ischemia or infarct. The third cardiac biomarkers set that were done approximately 8 hours later indicated that the CK-MB level had elevated and increased and that there was a positive Troponin T for myocardial damage. A diagnosis for NSTEMI was therefore confirmed by both the physician and the nurse. After returning the laboratory work, another ECG was taken immediately, but did not show any ischemia evidence. However, Mr. Bahmani developed chest pain episodes a few minutes later. Therefore, depression of ST-segment in the lower leads was established on the consistent ECG monitoring.
Rationale: the changes in ECG and the indication of the cardiac biomarker elevation of myocardial ischemia can build up over a phase time of minutes and even hours. For people with persistent chest pain like Mr. Bahmani and with initial negative findings of ECG and levels of cardiac biomarker, serial measurements are indicated (Coven & Yang, 2014). What Mr. Bahmani indicated was an indication of infarct of biomarker changes that can develop over several hours of the initial chest pain episode (Standing, 2010). There is also diagnostic for NSTEMI by the presence of high levels of cardiac troponin levels and the absence of ST-segment.
Later, the physician agreed with the APN that Mr. Bahmani needs to undergo a continuous infusion of heparin along with an Eptifibatide (Integrilin) bolus dose. The physician and the APN consulted with the patient before coming to the conclusion. In the emergency department, the patient had been administered aspirin. Additionally, he received 600 mg of Clopidogrel while on the floor and also a low dose of a beta blocker. However, Mr. Bahmani developed another chest pain episode that was not relieved by either sublingual Nitroglycerin or IV Morphine. Because of these developments, the physician accepted the nurse`s recommendation that the patient to be put on a continuous Nitroglycerin drip.
Rationale: The instantaneous goal of treatment is to prevent on-going infarction and relieve ischemia. The key elements of managing the situation included aspirin that was chewed and Clopidogrel. This treatment was meant to reduce the formation of platelets and aggregation (Wolff & Miller, 2009). In addition, the Morphine for the unrelieved chest pain beyond sublingual Nitroglycerin can be treated by the consistent Nitroglycerin infusion that is titrated to maintain a normal range of blood pressure and to relieve chest pain (Coven & Yang, 2014). The third key element in acute NSTEMI management is anticoagulation. An infusion of heparin continuously is an option for anticoagulation through the use of heparin that can be combined with Glycoprotein IIb/IIIa inhibitor. The acute NSTEMI stages can be treated by using Glycoprotein IIb/IIIa inhibitor (Coven & Yang, 2014).
The physician agreed with the nurse that Mr. Bahmani needed diagnostic coronary angiography in the cardiac catheterization laboratory and also a possible PCI. It was discovered that he had a blockage area in his right coronary artery. His previous stent, however remained open while other grafts of vein from his earlier surgery were patent.
Rationale: it is during the process of the PCI that the intracoronary stents are deployed to help ensure that the affected vessel`s lumen remains open (Coven & Yang, 2014). The choice of the type of stent used, whether drug-eluting or bare-metal is up to the Interventional cardiologist to decide as he will be performing the procedure (a condition that shared decision has no place).
The case of interviewing Mr. Bahmani involved a number of tests and procedures that had to be taken in the process of getting information and analyzing. Through the information and the analysis, the hypothesis that way formed by the physician and the APN helped them make decisions on the diagnosis of Mr. Bahmani`s problem. However, all the decisions regarding test procedures had involved the understanding and the consent of Mr. Bahmani. Hastings and Redsell (2006) argue that it is important and necessary that all the decisions made in relation to a patient to involve his or her consent. According to Hastings and Redsell (2006), this consent should be made after the patient has fully been briefed on his or her condition and the expected hypothesis.
In this regard, the two health officers consulted with Mr. Bahmani to get an agreement to this procedure. During the consultation, the APN and the physician extensively explained to Mr. Bahmani of the reasons why they recommended the procedure. As recommended by White and Stancombe (2003), the medics further discussed with Mr. Bahmani on the way the procedure will be done to the point that he understood the need and the process of infusion of heparin. This is the decision that led to a cardiac catheterization procedure on Mr. Bahmani which he fully recovered from. The post-catheterization instruction by the APN was for him to rest in bed for 4 hours and then the Eptifibatide drip to continue for 18 hours after the PCI procedure had been concluded. This was after clear understanding of the patient`s history and current conditions as well as the test results.
Clear understanding of Mr. Bahmani`s history required a review of his past history, especially in regard to his heart conditions and chest pains. Through the consultation process, the physician and the APN at the hospital were able to extract information from Mr. Bahmani in relation to his medical history. White and Stancombe (2003) recommends that the use of such historical information will shape the steps that a medic takes during and after consultation. This information helped the APN and the physician to engage Mr. Bahmani with a view of discussing his condition and the results of the tests and medical procedures that were done on him.
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