Care Needs, Concerns and Treatment

¶ … care needs, concerns and treatment strategies for Mrs. Margaret Cronin, an elderly patient admitted to HDU following assessment in DEM. This paper will first examine her necessities of care while determining the impact of all biopsychosocial and pathophysiological responses of the client. Given the melee of Margaret's symptoms, along with her medical history -- hypertension, pneumonia, and extreme anxiety -- much of her care will have to be collaborative. This paper will examine the details of her collaborative care, including all diagnostic procedures and therapeutic interventions. With a patient suffering from these conditions including the immediate treatments she's been prescribed -- drug therapy, blood transfusion, and rigorous cardiorespiratory monitoring, and a saline IV -- the nursing care priorities will have to be extremely detailed and well structured.

Preparing the bed area prior to the patient arrival was crucial, ensuring that all the proper supplies were ready for the patient's entrance. For instance the indwelling catheter had to be prepared, the CVC so that CVP could be measured, all monitoring equipment had to be established and the tools needed to create the arterial line.

Assessment of the Client/Care Needs/Analysis of the impact of Biopsychosocial and Pathophysiological responses of the client

Margaret has heart failure: her body is retaining fluid, breathing is more laborious and her heart is not pumping as it should. The first assessment that needs to be done on Margaret is an airway assessment. One needs to determine if there are any obstructions or if her labored breathing is just a byproduct of her hypertension and coronary artery disease (Elliott, 2007). The assessment of Margaret's airways are that they are patent, meaning open and unblocked.

The assessment of Margaret's breathing is what needs to occur next and it was precisely what led to the usage of the Hudson mask. What also needs to occur is an assessment of whether or not Margaret is experiencing any abnormal breath sounds that are indicative of heart failure and/or pneumonia. Her breathing is at 26 per minute and she suffers from coughing episodes which she coughs up green phlegm and has difficulty catching her breath afterwards. Margaret's circulation assessment is pink in colour and warm to the touch and with her blood pressure at 168/100 she's at a high risk for hypertension. Her disability assessment demonstrates an altered level of consciousness, demonstrated by the way that Margaret keeps asking where she is. In regards to the environmental and exposure assessment, Margaret's ECG demonstrates that an abnormality is present, based on the nonstandard reading (Guerrero, 2011). Margaret's temperature is also raised (37.8) and is another manifestation of Margaret's environment and exposure assessment. Checking Margaret's skin for swelling or bruises or bloating would also be useful.

However, the assessment becomes deeper upon the arrival of Margaret's daughter who explains both the fall and the bruises on Margaret's back, which the head to toe assessment unveiled.

There needs to be a clear understanding of the biopsychosocial responses of the client and how they relate to the intimidating and confusing complications with her health. As one professional describes, clinicians need to understand that their relationship to the patient is also a form of medical treatment (Adler, 2007). The nurse needs to recognize that they are engaged in moment to moment mutual recognition of one another's biopsychosocial states (Adler, 2007). Furthermore, "the introduction by either patient or physician of even small changes in their interactive process can lead to large changes in their biopsychosocial outcomes" (Adler, 2007). Finally allowing empathy to emerge can be viewed as a biospsychosocial relational process and is something which can also act as a guide toward ideal outcomes (Adler, 2007). Thus, in this case, it's important to bear in mind the extreme emotional pain that Margaret must be enduring. She lost her husband of fifty years four months ago. This was a man that she spent almost her entire life with. The loss of her husband had to have been a devastating experience and one which is probably waging a negative impact on her mental and emotional health and no doubt negatively influencing her physical health.

When it comes to the patient's pathophysiological responses, it's absolutely vital to understand how Margaret's altered physiology impacts her clinical presentation. it's important to keep in mind that this is a disease of cellular pathophysiology and not simply a hemodynamic disorder (Pratt, 1995). "The progression of compensated ventricular dysfunction to symptomatic heart failure is marked by the activation of vasoconstrictor hormones. Norepinephrine, renin-angiotensin-aldosterone, and arginine vasopressin are secreted in response to inadequate systemic perfusion" (Pratt, 1995). This can be so damaging because the heart is already failing and doesn't need this added stress and burden. When the heart is under such stress and is experiencing a failure in functioning, the body makes up for it in the following ways: via a maintenance of systemic pressure by vasoconstriction, which leads to a redistribution of blood flow to vital organs as well as a re-establishment of cardiac output by bolstering the myocardial contractility and the heart rate by expanding the extracellular fluid volume (Colucci, 2012). Unfortunately when the human body makes these adaptations it creates an overwhelmed state of "the vasodilatory and natriuretic effects of natriuretic peptides, nitric oxide, prostaglandins, and bradykinin. Volume expansion is often effective because the heart can respond to an increase in venous return with an elevation in end -- diastolic volume that results in a rise in stroke volume" (Colucci, 2012). Furthermore, a number of maladaptive consequences generally result because of this neurohumoral activation.

Collaborative Needs of the Patient: Diagnostic Procedures and Therapeutic Interventions

"The ICU team is a self-organizing, complex entity, that expands and contracts based on the needs of the moment" (Despins, 2009). While the degree of collaboration is going to fluctuate, the team in this case will consist of a bedside nurse, respiratory therapist and a physician (Despins, 2009). Thus, there needs to be a strong degree of communication, zero conflict between the care providers and a development of a contingency plan in case the patient in non-responsive. Nurses can be members of collaborative teams by their ability to re-socialize, being able to comprehend and articulate their roles as nurses, the knowledge and skills they can bestow on others, and their willingness to work on collaborative teams (Orchard, 2010). Fundamentally, Margaret needs a highly communicative team of clinicians who all work well together.

The diagnostic procedures and therapeutic interventions were described reasonably well in the case study. For example, blood pathology testing was ordered by the medical officer, as was a sputum sample. A CRX is also ordered as is a loading and maintenance dose of amiodarone. Based on the blood test results, the medical officer ordered dosages of resonium, frusemide, the patient's standard medications, repeat ABGs, liver and thyroid exams, blood transfusion, oxygen. With a patient like Margaret, there needs to be a greater sense of collaborative care between all clinicians who are treating her and engaging with her in therapeutic interventions. For example, there needs to be a great level of cohesion and correspondence between Margaret's general practitioner, her cardiologist, the medical officer, and the nurse practitioner. There needs to be a stronger and more cohesive identification of the management of reversible cardiac causes of heart failure (wa.gov.au, 2008). "Medication and symptom review, aiming to achieve target doses of heart failure medication such as ACE/ARB Inhibitors and Beta-Blockers in line with evidence-based guidelines and changing requirements for diuretic medication" (wa.gov.au, 2008). This needs to occur with a referral for investigation and a more comprehensive care management plan along with rehabilitation services (wa.gov.au, 2008).

Furthermore, there needs to be a stronger recognition of the comorbidities that are occurring with Margaret, such as the viral pneumonia and her issues with hypertension. "Comorbidities and baseline health status are therefore important when applying and establishing appropriate medications and dosages and choosing treatment for an older person" (Kraschnewski et al., 2006). The therapeutic interventions selected for Margaret do indicate that the collaborative care team was aware and at least trying to address her range of symptoms and the various co-existing conditions. Comorbidities are serious and can often be what lead to readmission or mortality rates for HF or CAD patients (Muzzarelli et al., 2010).

It's also important to note that many of the therapeutic interventions appear to point to the physical and emotional frailty of Margaret, something that is common in elderly adults who are experiencing coronary artery disease (Kraschnewski et al., 2006). "Because frailty is a syndrome of impaired resistance to stressors, it is well suited to predict the elderly patient's response to cardiovascular stress. One of the most promising clinical applications lies in using frailty to predict the elderly patient's risk of mortality and morbidity in the setting of invasive cardiovascular procedures" (Afilalo, 2011). Margaret's frailty is no doubt aggravated by her emotional state and is something which needs to be addressed by a strong collaboration of therapeutic strategies to reverse that development and to prevent adverse outcomes (Afilalo, 2011). There's a need for both social support and the possibility of considering eventual coronary revascularization or valve replacement, or less invasive therapeutic options.

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 and morphine. 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 is to check regularly to see if there is a distention of the jugular vein, something which can also points to congestive failure and fluid excess (Comer, 2005). The nurses also has the duty to check in on the patient regularly and address any sudden complaints which could indicate pulmonary edema or pulmonary embolus such as experiencing air hunger or complaining about a distinct feeling of suffocation or doom (Comer, 2005).

Another aspect of fluid management is that the diuretics given to Margaret need to be properly managed; for instance while the diuretics increase the urine flow, which is good, they could also have a negative impact on the patient's ability to absorb sodium and chloride in the renal tabules (Comer, 2005). While diuretics can be necessary and effective, there's also a clear risk of electrolyte imbalance, along with decreased renal function: "Electrolytes, especially sodium, potassium, and magnesium, may be decreased and cause complications and organ dysfunction" (Comer, 2005). Thus, as a nurse one needs to look for signs of potential electrolyte imbalance, such as progressive lethargy, mental confusion, muscle cramping and other typical signs of a danger electrolyte imbalance.