Nursing Assignment: Evaluation Of Professional Care To Clinical Deterioration Patient Scenario
Question
Task:
Description:
This nursing assignment task allows students to demonstrate theoretical clinical knowledge around nursing assessment, pathophysiology of factors impacting on clinical deterioration, planning of nursing care, nursing and medical management, and evaluation of care. Students are required to answer the case scenario questions provided.
Students should attempt all questions in the case study:
Sharon is a 66-year-old, admitted to the medical ward with a diagnosis of Right Pulmonary Embolism (PE).
She has been commenced on Apixaban 10mg PO BD for 7 days to treat her PE.
- History of presenting complaint: increased right sided chest pain and increased shortness of breath for 1 week.
- Past Medical History: Previous Deep Vein Thrombosis (DVT) & hypertension
- Regular Medications: Micardis,
- Nil Known Allergies.
Question 1: Provide a description of the pathophysiology of a pulmonary embolism AND in your answer make links to the patient history to highlight relevant risk factors and clinical features (300 words).
Question 2: Explain the use of Apixaban in the management of a PE. In your answer include – mechanism of action, indications, side effects and contraindications (300 words).
Sharon is resting in bed. You attend to her routine vital signs, which reveal the following:
- Conscious state - Alert
- Temperature: 36.3
- Pulse: 98 bpm and regular
- Blood Pressure: 110/62mmHg
- Respiration: 22 bpm
- SpO2: 91% on room air (Fi02 21%)
- Pain: 3/10
Question 3: Review Sharon’s vital signs above. Using your knowledge of reversible causes of patient deterioration (one of the 4H’s & 4T’s), discuss the following:
- Describe ONE reversible cause Sharon is experiencing and describe the pathophysiology that occurs which results in patient deterioration. (200 words)
- Describe the impact of a pulmonary embolism on the Ventilation/Perfusion (VQ) Ratio and link to the above vital signs. (200 words)
Question 4: Discuss TWO PRIORITISED nursing assessments that would be prioritised for Sharon’s present deterioration (excluding vital signs). For EACH nursing assessment, ensure your discussion includes a description of the assessments in the context of Sharon condition AND clear rationale as to why these assessments would be priority. (200 words)
Question 5: Discuss TWO PRIORITISED nursing interventions that YOU as a Registered Nurse could initiate to manage Sharon’s deterioration. For EACH intervention, ensure your discussion includes link to evidence-based practice AND provides rationale as to how it would improve the physiological outcomes of Sharon’s condition. (200 words)
*Nursing interventions would include nursing activities or actions that the nurse could initiate in response to nursing assessment findings. Note: please be aware of the difference between an assessment and an intervention.
Question 6: Describe TWO relevant nursing evaluations that you would complete in response to the interventions you have just described. For EACH evaluation, provide a brief rationale as to how these evaluations will assist in preventing the further clinical deterioration of Sharon. (100 words).
Answer
Answer 1
The distinctive pathophysiology of PE may be divided into causes, risk factors and pathogenesis. It is viewed herein nursing assignment that causes primarily in terms of Pulmonary Embolism (PE) are subdivided into two categories of common causes and less common causes. An embolized clot due to “deep vein thrombosis (DVT)” involving the lower leg is a very common cause as to why PE occurs. Additional reasons which may be stated are that of“tissue fragments, lipids, foreign body reactions, air bubbles and amniotic fluid”. Factors promoting venous thrombosis are known as the “Triad of Virchow” (Mehla et al. 2020). “Venous stasis” refers to the element of “immobilization, heart failure, obesity, prolonged leg dependency and age. Hypercoagulability”occurs from “inherited coagulation disorders, malignancy, hormone replacement, oral contraceptives, pregnancy and smoking”. “Endothelial injury” may occur due to “trauma, infection, caustic intravenous infusion and so on”. Additionally, “genetic risk factors” are inclusive of “Factor V Leiden mutation, antithrombin III deficiency protein S deficiency, activated protein C deficiency and prothrombin 20210”(u.osu.edu, 2020).
Pulmonary emboli development is associated with the resulting impact being death which is caused to a portion of lung tissue (Embolism with Infarction). Alternatively, permanent lung injury may not be caused either. Other possible impacts are that of blockage of major portions of pulmonary circulation or numerous embolisms which may be chronic or recurrent in nature. In circumstances where the conditions are developed from a thrombus, it is viewed that it may dislodge and this may then obstruct pulmonary circulation. The body responds by releasing neurohormonal substances and inflammatory mediators which cause vasecstriction and pulmonary hypertension. Atelectasis is derived and this worsens the hypoxia (u.osu.edu, 2020).
In Sharon’s case, history indicates that she has risk factors associated with DVT and also has had hypertension. She currently indicates increasing right chest pain. This may be cause for concern and intervention required is immediate.
Answer 2
Apixaban was recently approved for administration in cases of PE. This segment will look into the actions of this drug, indications, side effects and contraindications.
Actions
The actions of Apixaban selective factor Xa (FXa) is determined from its nature being an inhibitor which does not require antithrombin for its antithrombotic activity which is undertaken. During the process of action it inhibits free and clot-bound FXa and prothrombinase activity. Platelet aggravation is a result of thrombin and this is decreased as thrombin generation is bottlenecked. As a result of this fibrin clot development is also inhibited. This drug essentially prolongs the time for Prothrombin (PT) and activated partial thromboplastin time (aPTT) (Mandernach et al. 2015).
Indications
The indication of Apixaban in the treatment of PE and DVT is followed by a strict administration period with small amounts of the same. It can be viewed that for the first 7 days 10 mg doses need to be administered twice a day, following which the dose is to be reduced to 5 mg with the same frequency for 3 months. In cases where the patients have completed a total of 6 months of PE treatment the dose needs to be administered at the same frequency but the size is to be reduced to 2.5 mg (Nice, 2015).
Side Effects
The side-effects of Apixaban are nose bleeding which is the most common side effect. Additionally, a person may experience heavier periods, gum bleeding and bruising (Groetzonger et al. 2018). It is normally seen in the first few weeks of the treatment if a person is unwell. These side effects generally occur as the drug is an inhibitor to clotting and thus these are very common (NHS, 2021).
Contraindications
Contraindications include the element of pathological bleeding and severe elements of hypersensitivity as a reaction to the drug, for example, an anaphylactic reaction (Ncbi, 2015).
Answer 3
Pathophysiology of reversible condition
One of the reversible conditions are RV functional distortion and failure. The pathophysiology indicates that the right ventricle provides sustained low-pressure perfusion of the pulmonary vasculature. This is sensitive to changes which relate to intrinsic contractility and loading conditions. Factors such as that of ventricular preload, afterload and LV function have a potential adverse impact on the case of the RV functionality. RVF increase is sharply associated with the element of pronounced tricuspid regurgitation which worsens organ conditions due to the impact of decreased cardiac output (Bryce et al. 2019).
There are several different causes of Right ventricular Failure which can be seen. It can be understood that “Pulmonary Arterial Hypertension (PAH)”, “Pulmonary Hypertension Secondary to left heart disease”, “Pulmonary Hypertension associated with diseases in the lung or hypoxaemia”, “chronic thromboembolic pulmonary hypertension” and other causes such as that of haematological conditions, Systemic disorders, Metabolic disorders contribute to causes which may cause RVF (escardio, 2016).
Essentially concisely it can be summed up that the RV failureis attributed very closely with a volume overload which is present. Additionally, it may also occur due to myocardial disease such as RV infarction and cardiomyopathy.
Impact of PE on V/Q Ratio
The ventilation rate of an individual refers to the amount of gas which is inhaled by a person and exhaled from the lungs within a fixed duration. It is calculated by measuring the tidal volume and then multiplying it with the respiratory rate. Perfusion on the other hand refers to the blood volume levelwhich reaches the pulmonary capillaries within a specific given time period. The ideal ratio for V/Q would be 1 for the most efficient pulmonary function within an individual.
Pulmonary Embolism leads to the clotting of blood and generally decreases the perfusion in the lugs. In major areas of pulmonary circulation obstructions cause decrease in the blood flow which reaches the alveoli. Thus, as a consequence of this the blood is required to be redirected towards other areas in the lungs. Increase in other areas will lead to a decreased V/Q ratio which is less than 1. It is probable that hypoxia may occur in such a case as the lung functions with a V/Q of less than one (Kline et al. 2020). In relevance to Sharon’s conditions, it can be viewed that her respiration is unusually high and mild pain. This may indicate that there is a chance of risk thus interventions should be taken early.
Answer 4
One of the primary assessment methods for the case of Sharon would be that of pain assessment. Kotfis et al. (2017), indicates that the assessment of pain is essential because it clearly creates a significant impact on a patient. Thus, pain assessment is the first method which is associated with the case of Sharon. This is done because Sharon is experiencing a mild level of pain even though all of her vitals are more or less stable and congruent to normal standards.
In the case of Sharon additionally, in case of deterioration, it is advised that nursing assessments need to be physical in nature as well. As it can be viewed that the respiration of Sharon is adherent to undo levels of respiration, there is an importance of noting that ongoing assessments are very important (Copley et al.2021). Taking a pulse oximetry reading at 30 minute intervals and checking the oxygen saturation levels are important to ensure that the condition can be monitored. This assessment needs to be continuous in nature.
Answer 5
In terms of pain, as the deterioration of the condition in Sharon, it can be understood that the goal is to manage the pain so that the patient is more at ease and at ease. Pain management is the recommended intervention in such a scenario. Primarily In this method, the determination of the nature of pain is important. Then the nurses need to identify Sharon’s perception and expression of pain. Determination of administration of analgesics is also imperative only if it is prescribed by the doctors. Evaluation of the impact of the same and management of side effects are also imperative (Hcpro, 2021).
For the case of the other problem that Sharon faces it can be understood that she needs an intervention in terms of the element of respiration. Her SpO2 level is 91 % however the aimed level is always at 94 %. Additionally, her respiration is at 22 which is higher than the normal of 10-12. At this point the intervention of oxygen therapy is recommended. However, if Sharon is unresponsive to the same then other interventions for chest pain might require a 12-lead ECG (healthtimes, 2020). These interventions are designed to help manage the deterioration.
Answer 6
In the case of the evaluation of the pain management intervention which is placed the most commonly used scales or tools are that of the verbal rating scale, numeric rating scales and visual analogue scales. Either one of these scales can be used to effectively assess the pain (Serra et al. 2019).
In terms of evaluation of the respiration pulse oximetry is the prescribed technique which can be brought around and generated. This helps in order for the generation of a larger understanding of the SpO2 levels and also observation of the wreaths being taken by Sharon is a good indicator of the deterioration in Sharon’s case.
Reference List
Bryce, Y.C., Perez-Johnston, R., Bryce, E.B., Homayoon, B. & Santos-Martin, E.G., (2019). Pathophysiology of right ventricular failure in acute pulmonary embolism and chronic thromboembolic pulmonary hypertension: a pictorial essay for the interventional radiologist. Insights into imaging, 10(1), pp.1-13.https://link.springer.com/article/10.1186/s13244-019-0695-9;
escardio.org, (2016). Right ventricular failure. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-14/Right-ventricular-failure
hcpro.com, (2021).Nursing responsibilities for managing pain. https://www.hcpro.com/LTC-221162-1983/Nursing-responsibilities-for-managing-pain.html
healthtimes.com.au, (2020). Respiratory Assessment for Nurses.https://healthtimes.com.au/hub/respiratory/53/practice/nm/respiratory-assessment-for-nurses/1539/#:~:text=Breathing%20%E2%80%93%20if%20the%20patient%20has,aim%20for% 20SpO2%20%3E94%25.&text=Circulation%20%E2%80%93%20insert%202%20large% 20IV,the%20patient%20has%20chest%20pain.
Kline, J. A., Garrett, J. S., Sarmiento, E. J., Strachan, C. C., & Courtney, D. M. (2020). Over-testing for suspected pulmonary embolism in American emergency departments: the continuing epidemic. Circulation: Cardiovascular Quality and Outcomes, 13(1), e005753.https://www.ahajournals.org/doi/pdf/10.1161/CIRCOUTCOMES.119.005753
Kotfis, K., Zegan-Bara?ska, M., Szyd?owski, ?., ?ukowski, M., & Ely, E. W. (2017). Methods of pain assessment in adult intensive care unit patients—Polish version of the CPOT (Critical Care Pain Observation Tool) and BPS (Behavioral Pain Scale). Anaesthesiology intensive therapy, 49(1), 66-72.https://pdfs.semanticscholar.org/9bd6/b1ac1eae132398f7c8ac8fdfeb72e329828d.pdf
Mandernach, M.W., Beyth, R.J. &Rajasekhar, A., (2015). Apixaban for the prophylaxis and treatment of deep vein thrombosis and pulmonary embolism: an evidence-based review. Nursing assignment Therapeutics and clinical risk management, 11, p.1273.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556259/
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ncbi.nlm.nih.gov, (2015). Apixaban. https://www.ncbi.nlm.nih.gov/books/NBK507910/#:~:text=Active%20pathological%20 bleeding%20and%20severe,to%20the%20use%20of%20apixaban.
nhs.uk, (2021). Apixaban. https://www.nhs.uk/medicines/apixaban/#:~:text=The%20most%20common% 20side%20effect,or%20if%20you're%20unwell.
nice.org.uk, (2015). Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism.https://www.nice.org.uk/guidance/ta341/documents/deep-vein-thrombosis-pulmonary-embolism-treatment-secondary-prevention-apixaban-id726-final-appraisal-determination-document2#:~:text=To%20treat%20deep%20vein%20thrombosis,2.5%20mg%20twice%20a%20day.
u.osu.edu, (2020). Pathophysiology.https://u.osu.edu/smoot.43/pathophysiology-of-pulmonary-embolism/
Groetzinger, L. M., Miller, T. J., Rivosecchi, R. M., Smith, R. E., Gladwin, M. T., & Rivera-Lebron, B. N.(2018). Apixaban or rivaroxaban versus warfarin for treatment of submassive pulmonary embolism after catheter-directed thrombolysis. Clinical and Applied Thrombosis/Hemostasis, 24(6), 908-913.https://scholar.google.com/scholar?output=instlink&q=info:3TFZCyggBZIJ:scholar.google.com/&hl=en&as_sdt=0,5&as_ylo=2017 &scillfp=17403063099653201173&oi=lle
Copley, A., Gardner, S., Joy, E., Oliver, J., English, K., Cullington, D., &Gopaul, K. (2021). 25 Advance care planning in patients with systemic right ventricular failure.https://heart.bmj.com/content/107/Suppl_1/A23.abstract
Serra, C., Soler-Font, M., García, A. M., Peña, P., Vargas-Prada, S., & Ramada, J. M. (2019). Prevention and management of musculoskeletal pain in nursing staff by a multifaceted intervention in the workplace: design of a cluster randomized controlled trial with effectiveness, process and economic evaluation (INTEVAL_Spain). BMC Public Health, 19(1), 1-9.
