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CARE OF ACUTELY ILL PATIENT

This assignment will discuss the nursing care/management of an acutely ill patient in
which the nurse has participated during a stay in hospital
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It will also show how the patients
altered physiology has contributed to one of these problems
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This is called becoming
acutely ill
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People who suffer an acute illness experience a wide range of
emotions (Lindsay & Craig 2000)
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This would in turn
increase the patient's risk of needing a longer stay in hospital, not recovering fully or
even dying (NICE 2007)
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Like any muscle, the heart needs a constant supply of oxygen and nutrients that are
carried to it by the blood in the coronary arteries (Vincent 1998)
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If a coronary artery or one of its smaller branches suddenly becomes blocked, the blood
supply to the heart is cut off completely and the result is a heart attack
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If one of the main coronary arteries is blocked, a large part of the heart muscle is
affected
...
Though the loss of the muscle is permanent, for those who survive an
MI, the part of the heart muscle that infarcts (dies) is replaced by scar tissue over the next
few weeks (Tortora & Grabowski 2003)
...
A
clot-dissolving drug (thrombolysis) is able to break up the clot and undo the blockage,
therefore limiting the extent of the damage to the heart muscle (DoH 2000)
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Patients who have suffered an MI should have the
opportunity to make informed decisions about their care and treatment, in partnership
with their healthcare professionals (NICE 2007)
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To enable the nurse
to do this and to identify any interrelated problems, a holistic approach to the assessment
was required
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By
applying the holistic approach to health care, the nurse places emphasis on the whole
person, taking into account the physical, emotional, psychological, spiritual, cultural

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background and needs of the individual rather than simply treating the symptoms of their
illness (Kenworthy et al 1996)
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The client’s details have been changed to maintain client confidentiality in accordance
with the nursing and midwifery council (NMC) Code of Professional Conduct 5
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Harry is a 57 year old man who was admitted to hospital after suffering from severe
central chest pain radiating down his left arm and into his jaw
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When his symptoms worsened, he called for an ambulance
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On first examination his blood pressure was 152/89, heart rate 87 beats
per minute, and respiration rate was 22 per minute
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9°C
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A cannula was inserted to gain intra-venous access and an
electrocardiogram (ECG) was carried out and reviewed by the medical team which
confirmed a diagnosis of an MI
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The nurse’s role is to prevent recognised potential problems of the client from becoming
real ones (Alexander et al 2000)
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Having previously completed the
client’s assessment, the nurse had already built up a positive relationship with the client,
and the following issues were raised:
Initially, Harry was extremely anxious and in a considerable amount of pain which was
causing him to also feel sweaty and nauseous
...
He was fearful of
another attack and very concerned about his recovery and the effects the MI would have
on his day to day life and work and therefore his ability to pay his rent
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For the purpose of this essay, the focal point will be on three of the issues that relate most
to the client
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Pain

The word pain comes from the Greek word ‘poine’ meaning ‘penalty’, which suggests it
is some form of punishment (Clancy & McVicar 2002)
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The four basic principles that are involved
are transduction, transmission, perception and modulation (Middleton 2003)
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The receptors for pain (nocicepters) are located within body
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organs and internal cavities and respond when the stimulus is strong enough to cause
tissue damage, which is the case in an MI (Tortora & Grabowski 2003)
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Transmission takes place in C fibres and A delta fibres
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For the pain stimulus to be changed to an impulse and
move to the spinal cord, an action potential must be produced
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Neurotransmitters are needed at each synapse to continue the pain
impulse across the synaptic cleft (Clancy & McVicar 2002)
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It is a
result of neural activity and is where pain becomes a conscious experience
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Modulation involves the activation of descending pathways that exert inhibitory effects
on pain transmission
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The pain in an MI is known as visceral pain, which originates from the body's viscera, or
organs
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This is known as referred pain
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Although intense chest pain is the most common symptom of a heart attack (Julian et al
2005), heart attack victims may experience a variety of symptoms including substernal
heaviness and/ or squeezing sensation of the chest, jaw pain, neck pain, toothache,
headache, arm pain (more commonly the left arm, but may be either arm), anxiety,
nausea, vomiting, and/or general epigastric (upper middle abdomen) discomfort,
heartburn and/or indigestion, upper back pain, sweating (diaphoresis), shortness of breath
(dyspnea), hypertension or hypotension (depending in part on the extent of cardiac
damage), tachycardia and arrhythmias, fatigue, fainting (syncope), general malaise
(vague feeling of illness) and sometimes patients will have no symptoms, which is
especially common among patients with diabetes mellitus (Nolan et al 2006)
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The nurse’s role in pain management is to asses, deliver and monitor the effectiveness of
any treatment prescribed (Alexander et al 2006)
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To
control pain, it must be identified
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One of the most important nursing skills is the ability to assess the client as this is

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the first stage in the nursing process and is vital to obtain the information that will allow
the nurse to plan and implement nursing care and evaluate their effectiveness (Clancy &
McVicar 2002)
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Harry indicated to the nurse that the number 7 best represented his pain
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Nurses have to be
attuned to patient’s non-verbal cues as some patients will not be able to verbalise the
intensity of their pain, and may only gesture with a clenches fist at the chest area, for
example, to indicate a tight, constricted feeling across the chest (Albarran 2002)
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However, they are limited in that they are concerned only
with measuring intensity
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It
may make more sense to ask them to rank and describe their 'dullness/ache' (Albarran
2002)
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To assess a
patient’s pain, the nurse must establish the location, duration, intensity and characteristics
of the pain (Nicol et al 2004) by asking the patient to describe it
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One method for a more holistic pain assessment is the PQRST (Budassi-Sheehy &
Miller-Barber 1992) strategy (See Appendix 2)
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It is important that the questions used to gain information are
open-ended beginning with how and why, for example, creating a much greater chance of
the client feeling able to express their feelings rather than simply answering “yes” or “no”
(Nolan 2003)
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Unfortunately the PQRST assessment tool was not used in this practice setting, and on
reflection, the patient would have received a more holistic approach to his care as patient
care is influenced by the Nursing Model used within the particular practice setting
(Albarran 2002)
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They are found throughout the central nervous system and when
released, bind to opioid receptor sites (Clancy & McVicar 2002)
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Unfortunately endogenous opiates break
down too quickly to be considered as useful analgesics (Mann & Carr 2006)
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It has been argued
that doctors assume a more physiological role when dealing with patient’s pain, whereas
nurses assume a more psychological approach (Clancy & McVicar 2000), though this can
vary in different settings where some over lay can exist
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Therefore before
administering the analgesia, the nurses checked the patient’s name band and drug chart to
ensure the right patient, right route, right drug, right dose, right time (Aspden 2004) and
that the drug chart was signed by the doctor and that the medication was in date
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As everything was
fine, the nurse administered the medication and both signed the controlled drug book to
prove these checks were made
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The administration of analgesics
needs to be regular to be effective (Alexander et al 2006)
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Lack of time available to spend with each patient is a common complaint from nursing
staff working within the NHS
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As part of pain management, an on-going assessment of the patient’s pain is also
essential to determine whether the form of pain control is effective (Mann & Carr 2006)
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It is important to use the same rating scale every time the patient’s pain is
assessed to promote continuity of care throughout the different shifts and nursing staff
(Kenworthy et al 1996)
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Anxiety

Opioid analgesics, such as diamorphine, can have the additional advantage of acting in a
physiological way to reduce anxiety (Mann & Carr 2006)
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Sigmund Freud recognized anxiety as a ‘signal of danger’ and a cause of ‘defensive
behaviour’
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Emotionally, anxiety can cause panic disorders, nervousness, a sense of dread or panic
and feelings such as fear, tension, aprehension or worry (Wikipedia 2007)
...
E
motional reactions to an MI, such as anxiety, can be linked to Maslow’s hierarchy of
needs model, as the model identifies levels of human need
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The second level on the hierarchy is based on the need
to feel safe - during an MI this need is rarely met (Russel 2006)
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Nurses must aim to reduce the anxiety of the
patient as it also places an extra strain on the heart (Faulkner 1996)
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This anxiety generally lessens over the next couple of days
but rises again just before discharge, when many patients may again become clinically
anxious (Russel 2006)
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Bolwerk (1990) suggested that health
professionals should consider all MI patients as anxious as they may be concealing their
anxiety
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Careful assessment and the development of a trusting and effective relationship
will enable the nurse to identify the cause for the anxiety more accurately (Baillie 2001)
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Before being able to talk to the patient to determine the cause of his
anxiety, the patient needed to control his breathing, as Harry was short of breath
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Once the
patient’s breathing had stabilised more, the nurse attempted to discuss with the Harry
what was causing his anxiety
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Both verbal and non-verbal communication skills are extremely
important in interaction, as any relationship comes about through communication (Nolan
2003)
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Good
communication skills, both verbal and non-verbal are essential here
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The nurse was also careful in her
choice of words when answering Harrys questions, and chose not to go into too much
detail about the life-style changes Harry could make that would also help to reduce the
likelyhood of another attck as this can cause more alarm to the patient (Julian et al 2005)
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The nurse
thought it best to aim to promte health at a more appropriate time as Harry was already
distressed about the possible lifestyle changes he would have to make and this would
have potentially made him more anxious and therefore put him at risk
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Unfortunately, the nurse was not aware of any such leaflets available for patients
and was therefore unable to reduce Harry’s anxieties in this way and upon reflection, this
is something that should have been investigated further by the nurse, as excessive anxiety
can be prevented by providing patients with information (Julian et al 2005)
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Nurses must therefore ensure that they
keep their knowledge and skills up to date, and regularly attend training and learning
sessions (NMC 2004), though this can prove difficult on a busy ward, it remains the
nurses responsibility
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One way of
enabling clients to deal with the psychological and emotional distresses that can occur
after an MI is from groups like cardiac rehabilitation for example (Kligfield 2003)
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the sum of activities required to influence favourably the
underlying cause of the disease, as well as the best possible, physical, mental and social
conditions, so that they (people) may, by their own efforts preserve or resume when lost,
as normal a place as possible in the community
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The National Service Framework
for Coronary Heart Disease (DoH 2000) highlighted the need for such rehabilitation
whose aim is to help patients who have had heart attacks to maximise their chances of
leading a full life and resuming their place in their community (DoH 2000)
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These
include physical needs, educational needs, psychological needs, social, cultural and
vocational needs, and the needs of the family of carer of the patient
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Within a group of others
with a similar condition people restore their self esteem and reduce anxieties by engaging
with others (Alexander et al 2006)
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It may also give him confidence in talking about his experience with others,
therefore increasing the opportunity for integration through shared concerns and
reassurance of worth (Hendrickson 2006)
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The nurse explained that Harry may not feel comfortable within the group but that this
should not discourage him, as it may take time to feel relaxed and open with new people
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So it is
important to approach these groups with an open mind, knowing that there are always
other options open to him
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After being given this information, the nurse asked the client if he would like to attend
one of the groups
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The nurse felt let down by the
client and found it hard to accept Harry’s decision as she strongly believed that a support
group would help the client and wanted to try and persuade the client to attend
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Although client concordance is vital, it is important to remember that some
clients still feel that the authority of a nurse is more significant than their own rights and
therefore are at risk of becoming merely a passive recipient of care rather than an active
participator (Tempest 2006)
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The nurse
could have then given the client a little more time to contemplate the idea, and asked her
again at another time
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The nurse's role is very important in ensuring
that the patient is able to make informed choices about their treatment and care (Nolan
2003)
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It also states, however, that though all patients have a right to receive information
about their condition, nurses must be sensitive to their needs and respect the patient’s
autonomy and their right to decide whether or not to undergo any health care
intervention
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Throughout the process, the nurse recorded and documented all her findings clearly and
legibly onto the clients assessment form, promoting effective communication between
other health professionals in accordance with the NMC Code of Professional Conduct
2004
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Patients are therefore unable to draw attention to it in the way they would be able to in
the case of a broken arm, for example
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This in turn, increases anxiety and a fear of the unknown (Kligfield 2003)
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Integrating the assessment tool within the observations charts used to
record vital signs would remind nurses that these patients need psychological care and
their anxiety levels should be assessed regularly (Russel 2006)
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This can involve the loss of health, loss of status, loss of control over their life and the
threat of future problems relating to home and work life and, ultimately the threat of
death (Kligfield 2003)
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The prevalence of
depression in patients who have had an MI is 15-20% compared with a 5% incidence in
the general adult population (Hendrickson 2006)
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This illustrates the importance for nurses,
who are in an ideal position as the assessors, to listen, reassure and provide information
as required to the patient to reduce these anxieties (Nicol et al 2003)
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The NHS Plan: Personal action plans (DoH, 2003) suggests that nurses should not only
encourage patients to tell their stories but also try to put themselves in the patient's shoes
to inform and improve the quality of care they offer
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Cardiac rehabilitation is also a great opportunity for improving prognosis and function for
patients following an acute MI as it aims to address the needs of each individual patient
(DoH 2000)
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REFERENCE LIST
Albarran, J
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The Language of Chest Pain
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Alexander, M, J
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Runciman
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Nursing Practice: Hospital and Home:
The Adult
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London: Churchill Livingstone
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and O
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London: Pantheon Books
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2004
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New York:
National Academy Press
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2001
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London: Arnold
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and J
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1998
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3rd Edition
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Bolwerk, C
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Effects of relaxing music on state anxiety in myocardial infarction
patients
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and J
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1992
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3rd Edition
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Clancy, J
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McVicar
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Physiology and Anatomy: A Homeostatic Approach
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London: HMSO
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2nd
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Heatherington, A
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The Use of Counselling Skills in the Emergency Services
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Hendrickson, G
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Depression after heart attack
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discovery
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Multidisciplinary work to provide cardiac rehabilitation for patients
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Julian, D, J
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Dimensions of Critical Care Nursing 12: (2) 66-76
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London: Blackwell Publishing
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and J
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Current Trends in
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Middleton, C
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Millar, B
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Critical Care Nursing
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London: Bailliere Tindall
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[Online] London:
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Essential Nursing Skills
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et al
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The Basis of Medicine
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Journal of Clinical Nursing 6 (2): 85-92
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London: XPL Publishing’s
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and R
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Heart
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Tortora, G
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10th ed
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Needs and Action Priorities in Cardiac Rehabilitation
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...


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