Furthermore, one of the pillars of collaborative care that will need to be firmly established is the fostering of clear dialogue and a means for strong communication within the care management planning. For instance, there needs to be a clear decision and communication of all tests ordered and when the test results will be available. One of the most important aspects of this collaborative care will be the nursing interventions which can have significant impact on the patient's health and stabilization (Allen, 2010). In fact, strategic nursing care can even minimize readmission rates of Margaret and other patients with comparable conditions (Chen et al., 2012).

Prioritize the Nursing Care Needs of Margaret

The prioritization of nursing interventions is essential, and the way in which a nurse determines this priority is going to be something unique and distinct. "Trials reviewed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure. However, the optimal combination of intervention components, including strategy, mode of delivery, frequency, and duration, remains unknown. Establishing consensus regarding outcome measures, inclusion of adequate, representative samples, along with cost-effectiveness analyses will promote translation and adoption of cost-effective nursing interventions" (Allen, 2010, p. 207).

The first priority is of course an ABCD assessment: this refers to airways, breathing, circulation, disability and (exposure). "First, life-threatening airway problems are assessed and treated; second, life-threatening breathing problems are assessed and treated; and so on. Using this structured approach, the aim is to quickly identify life-threatening problems and institute treatment to correct them" (Thim et al., 2012).

The next nursing priority would be determining any medication errors. In this particular case, one of the primary nursing priorities stems from the establishment that a conflict exists with the amioderone maintenance dose. So one of the top priorities remains as correcting this drug error immediately. One of the ways that this can occur is by turning off the medication until the order is correct and then reestablishing it once it has been revised. The preferred infusion site for amiodaron is via CVC but Margaret has no CVC at this point; the infusion has been commenced via IVC. As such, stopping for incorrect dose and restarting when dose corrected and CVC insitu would be ideal option. Placing monitor would be a subsequent nursing priority.

The next nursing priority would be the insertion of the indwelling catheter. This patient is in critical care and would thus require an indwelling catheter. For a patient with the conditions that Margaret has, accurate urine monitoring is absolutely essential (Foxley, 2011). The CVC would have to be inserted in order to measure the CVP; this can be done by connecting the CVC to a particular infusion set.

Establishing the arterial line placement is a frequent procedure for the management of patients in as serious a condition as Margaret. This type of measurement is so necessary because it's more accurate than blood pressure and can more readily pinpoint changes in blood pressure and can allow for the removal of frequent blood gas samples (Peterson, 2012).

Another major consideration would be doing everything possible to relieve the patient's pain. For instance, the patient would be instructed to speak to the nurse immediately as soon as chest pain occurs. The duty of the nurse would be to keep a strict eye on how the client reacts to the response and impact of medication, as well as the frequency, length, intensity and area where the client's pain occurs. Another aspect of the nurse's duty to observe is to look for and keep track of associated symptoms such as dyspnea, nausea and vomiting, heart palpitations, dizziness/vertigo along with a need to urinate. There would also be a priority of checking with the patient to evaluate any sensations of pain in the jaw, chin, neck, shoulder, back, arm or hand, particularly on the left side of her body. The nurse's duty would be to keep the patient at rest during these episodes. Elevating the head of the bed is a necessity if Margaret continues to exhibit a shortness of breath. Monitoring Margaret for shortness of breath, along with her heart rate and rhythm is an immediate necessity. Implementing a pain rating scale to assess the patient's perception of the level of pain that she is in could be useful in seeing if the medication for pain relief is at all effective (Moreau, 2003).

Furthermore, since heart failure is one of the afflicting conditions, it's absolutely possible that the doctor might prescribe Continuous Positive Airway Pressure (CPAP). "Standard medical treatment of CHF includes oxygen, diuretics, nitrates...

Most patients respond to standard medical treatment; however some patients require NIV as a more aggressive intervention particularly for cardiac pulmonary edema" (Stoltzfus, 2006). This is where CPAP might be prescribed to Margaret. It is of course the physician's duty to determine whether or not this measure is necessary for this particular patient in order to increase cardiac output (Stoltzfus, 2006). CPAP is another measure to keep the alveoli from collapsing; if used its yet another intervention that the nurse will need to monitor.
Meanwhile, the nurse needs to be constantly evaluating the effectiveness of the oxygen therapy to see if it is in fact increasing the oxygenation of the myocardial tissue so the consequential ischemia is prevented (coursewareobjects.com). All prescribed and revised medications need to be administered consistently to stop all pain, prevent new pain from occurring and to decrease the anxiety of the patient. Decreasing the anxiety of the patient is essential for the patient's overall homeostasis as it will also decrease the fundamental workload of the cardiac system (coursewareobjects.com). Aside from monitoring the vital signs of the patient, consistently observing the patient's cardiac rhythm and rate and all patterns in blood pressure are essential, along with keeping track of the patient's hemodynamic parameters. Factors like the patient's central venous pressure and pulmonary artery edge pressure can provide clear clues as to the state of hypotension and bradycardia, which may lead to hypoperfusion (coursewareobjects.com).

As already stated, aside from monitoring the patient's vital signs to assess and establish baseline and ongoing changes, a nursing priority needs to be established which looks for cardiac dysrhythmias, such as disruptions of rhythm and conduction and to pinpoint and give treatment to substantial dysrhytmias. As alluded to earlier, the patient's respiratory status needs to constantly be checked, not just to ascertain that the patient has adequate levels of oxygenation, but to see if there are indications of pulmonary edema (coursewareobjects.com).

Another consideration would involve how in critical care, the RN is responsible for documenting observations and fluid balance hourly. Any change in the client's condition needs to be documented as it happens- this can occur by recording your observations either in the progress notes or on the observation charts at the bed site. Excess fluid volume, one must recall, is directly connected to the ineffective pumping mechanism of the heart as well as an increased preload, increased sodium and water retention, diminished organ perfusion, compromised regulatory mechanisms, diminished cardiac output, as well as bolstered ADH production (Comer, 2005). Thus, the nurse needs to be well acquainted with and check all signs of fluid retention. As already established, looking for signs of edema is important, as is the patient taking in more fluids than putting out, increased pulmonary artery pressures, increased blood pressures, increased heart rate, shortness of breath, dyspnea, wheezing, frothy white or pink sputum, hypoxia, cool/moist skin, altered electrolyte levels (Comer, 2005). These are all factors that the nurse needs to be prepared to deal with immediately as a hazardous sign of fluid retention. For instance one of the definitive ways to determine fluid intake vs. output, is to measure and document it. Margaret should still be kept hydrated with fluids and given a total of 2 liters per day, unless her attending physician has a problem with that.

Oxygen therapy is an effective means of dealing with such fluid retention, particularly when administered as prescribed. "Supplemental oxygen may be required to prevent hypoxia caused by increased cardiac pressures, fluid increases, and hypoventiliation. Depending on the severity of the condition, the patient may require varying amounts of oxygen supplementation to maintain adequate blood saturations, and mechanical ventilation may be required to ensure proper oxygenation" (Comer, 2005, p. 42). Thus, this excerpt clearly demonstrates why it was so necessary to engage in aggressive oxygenation of Margaret.

Another nursing priority which needs to occur is the auscultation of the lungs for the presence of crackles (rales) and other noises made by the breath (Comer, 2005). Watching the patient for signs like dyspnea or nocturnal dyspnea is important because these symptoms could indicate pulmonary edema as a result of cardiac decompensation and pulmonary congestion (Comer, 2005). Symptoms of pulmonary edema generally reflect left-sided heart failure; right-sided heart failure may have a more gradual onset and manifestation, but many of these symptoms (dyspnea and the debilitating cough) can be very difficult to abolish. Another factor of checking the patient carefully for edema…