NURBN3030 - Clinical Reasoning Cycle In Nursing Care Plan Deteriorating Patient

Assignment Task

Scenario Details

Mr Antonio has been readmitted to the ward following an episode of chest pain last evening. He

was assessed in the ED and pathology review indicated elevated Troponin levels. He has been diagnosed with a non-ST-elevation Myocardial Infarction (NSTEMI). He has been accepted for transfer to a tertiary facility and an Angiogram has been scheduled within 24 hours. He will stay in the ED while awaiting ambulance transfer. He requires serial Troponin levels and ECGs. Any chest pain must be reported.

His past history includes asthma and COPD, and his medications include:

• Fluticasone Accuhaler 500mcg twice daily,
• Salbutamol MDI 2 puffs twice daily and up to 8 – 10 puffs PRN during acute exacerbations of his COPD
• Ipratroprium Bromide MDI 2 puffs 4 times daily and up to 4 puffs during acute exacerbations of his COPD.

Antonio has a documented allergy to Penicillin .

It is the morning shift, and you are just entering the room post-handover to introduce yourself. You notice that Mr Antonio appears uncomfortable. You ask how he is, and he reports he has developed some chest pain following a walk to the toilet.

In your allocated group initiate assessment and implement the plan of care that you formulated for AT1A, applying the final three steps of the clinical reasoning cycle. Your management for this patient must include the following:

• Systematic assessment of the Antonio
• Provide appropriate and prioritised nursing care: including administration of medication.
• Problem solving abilities incorporating clinical reasoning skills.
• Effective teamwork: each person allocated a designated role/s.
• Display effective communication between team members.
• Display therapeutic communication with Antonio.
•  Accurate documentation

His vital signs now are as follows. 

• HR = 46
• BP = 86/45
• RR = 18
• T   = 36.0
• SaO2 = 93%

1. Consider the Patient’s Situation – Komalpreet

2. Collect Cues/Information - Jessica

3. Process the Information - Belinda

4. Identify Problems/Issues - Bakhshinder Singh

Past History - Antinio has been readmitted to the ward following episode of chest pain last evening. He has been assessed based on high troponin levels in the emergency department and has been diagnosed with a non-ST-elevation Myocardial Infarction (NSTEMI). Now he has been transferred to the cardiology ward from ED and been scheduled an Angiogram within 24 hrs. He needs serial troponin level and ECG

Post handover- Nurse went to Antonio to introduce himself and noticed that Antonio is uncomfortable and after asking him he responds that he developed chest pain following a walk to the toilet. A met call should be initiated as the nurse needs more help in case the situation worsens. One nurse does the vital while other can perform ECG on Antonio. After performing a 12 lead ECG and vital has been taken. On examining Antonio’s ECG, it has been found that ST elevation in leads II, III and aVF. Also, after performing vital it has been noticed that Antonio has signs of low oxygen saturation of 93%, Bradycardia as the BP is 86/45, low heart rate at 46 beats per minute. But the respiration and temperature seemed to be normal. Antonio seemed to have stable Angina as he stated that he had developed chest pain after he had a walk to the toilet. He should be monitored closely by staying along his bedside and checking vitals every 5 min. Even though Antonio was previously diagnosed with non-ST elevated MI, but as per his ECG he clearly has developed inferior (Diaphragmatic) left ventricular Myocardial infarction (STEMI) with sinus node dysfunction as his ECG clearly shows ST elevation in leads II, III, and aVF which demonstrates inferior left ventricular myocardial infarction. Antonio blood test must be taken to check for troponins levels. Antonio must be assessed for his medication compliance and if taking how often he is taking. He also needs to be assessed that has he taken any inhaler/puffs following his breathlessness as his oxygen saturation is falling which may be caused due to his exacerbation of COPD.

5. Establish Goals - Komalpreet

Prompt identification and delivery of reperfusion therapy is essential in managing ST-elevation myocardial infarction (STEMI). Treatment should also aim to prevent additional blood clots, reduce heart muscle damage and alleviate heart attack symptoms.

Standard medical treatment

• Aspirin with nitrates.
• Beta blockers
• Administration of anticoagulant medications along with supplementary antiplatelet medicines.
• Cholesterol-lowering drugs called statins
• Morphine and oxygen (Granger et al., 2019)

Treatment for distinct symptoms and syndromes - In individuals with ST-elevation myocardial infarction (STEMI), prevalent symptoms and syndromes necessitating immediate intervention encompass the following:

• Sensation of discomfort or pain in the chest region
• Cardiac insufficiency
• Cardiac dysrhythmias
• Infarction of the right ventricle
• Cardiogenic shock refers to a condition when the heart is unable to pump enough blood to meet the body's needs

Therapies with uncertain efficacy - The following treatments in patients with STEMI have no established clinical benefit or may be harmful.

1. Regular administration of morphine

In ST-elevation myocardial infarction (STEMI), the main objective For people who have had an ST-elevation myocardial infarction (STEMI), the main goal of reperfusion therapy, like percutaneous coronary intervention (PCI) or fibrinolysis, is to get blood flowing again to the coronary artery that is blocked.Theomptly and activating the necessary personnel and resources is crucial.

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