Decision Making in Acute Coronary Syndrome - Essay Example

Advanced nursing consultation and decision making in Acute Coronary Syndrome: A case study Advanced nursing consultation and decision making in Acute Coronary Syndrome: A case study Introduction This case study is a critical analysis of the differential diagnosis and initial treatment of 42 year old Mr Ali Bahmani. Mr. Ali Bahmani was brought to the hospital by his wife. Patient health care is composed of accurate and secure health information where all personal health information is held under firm terms of confidentiality. Hence, any information that would identify Mr Ali Bahmani has been withheld (NHS, 2003). In advanced nursing consultation and decision making, reflection is an integral part of training. It is an active procedure of viewing your own experience so as to review it later. Professionals like nurses learn through doing. As a result they develop and grow in their professional career. In this case study, I used Driscoll’s reflection model due to its easy format of 3 questions, what?, so what?, now what? Its advantage is the use of sudden questions which initiate a thoughtful and meaningful reflection process by motivating deeper analysis that leads to formation of a future action plan. The term Acute Coronary Syndrome describes a range of cardiovascular disorder that encompasses both unstable angina and myocardial infarction. Through this reflective case study, differential diagnosis shall be used to look at the decision making process while examining Mr Ali Bahmani. The main focus of the condition at hand is the central chest area. Background An Advanced Practice Nurse (APN) is a highly qualified nurse with post graduate education and experience that prepares them for highly specialised roles (White, 2010). Nurses who were initially registered to perform certain roles are diversifying their areas of practice and working at advanced levels. This has been a boost for the health service as it has enhanced positive health outcomes and promoted service delivery. When nurses work at an advanced level, they are able to make autonomous decisions. This makes them accountable for each decision they make. In fact, APN have the mandate of receiving patients with problems that have not been diagnosed and evaluate what form of treatment and health care patients require. This is on the basis of their advanced knowledge and skills in nursing which normally are not undertaken by nurses like physical examinations. APN screen patients for risk factors and symptoms associated with diseases. They then make differential diagnosis by utilization of acquired and learnt decision making skills. APN involve the patient in developing a nursing care plan on the basis of diagnosis. All in all, the main role of ANP’s is to complement the care that is provided by doctors and other health care personnel. The Royal College of Nursing notes that the ANP is initial contact with the patient. He or she deals with the issues brought by the patient. Currently, ANPs who are already in practice have not yet gone through the education process needed to partake in their advanced roles. However, as for me, my advanced level in education is a guide on how to undertake my role as an ANP. This is shown in this case study, which details the care of a patient by an APN, decision making and consultation role of the APN. Justification Shared Decision Making is a process in which patients are encouraged to participate in selecting appropriate treatments or management options (Aqua, NHS, 2012). Aim The aim is to polish my ADP roles by studying a patient case study. In this case study, the heart physiology, pathophysiology is described. Consultation is based on a chosen consultation model. As noted earlier, Driscoll’s model of reflection has been used. Literature Search Strategy This case study involved research into the condition ACS through a comprehensive literature search of academic and medical books, studies, data bases and clinical experiences as well as some journals and search engines on the internet. By using research and clinical information on ACS the diagnosis and treatments included in this study are objective. Normal Heart Physiology The heart is a specialised fist shaped organ located in the thorax, between the lungs and above the diaphragm, lying behind the sternum and being surrounded by the pericardium and weighing normally about 250-300 grams. The aorta, the superior and inferior vena cava; the pulmonary artery and vein serve the heart(Preston and Wilson, 2012) and the heart receives deoxygenated blood from the body via the veins, pumping it first to the lungs for oxygenation, and then on to the body via the arteries. The heart has four compartments, the left and right atria and the left and right ventricles which lie beneath them. It also has four valves: the tricuspid, the mitral, the pulmonary and the aortic. These control the flow of blood to and from the heart. Just like any other muscle the heart requires a good blood supply. This comes via the coronary arteries (Patient.co.uk, 2014). The coronary arteries branch off from the aorta to the heart muscle. From these main coronary arteries small arteries divide into smaller braches to take blood to all parts of the heart muscle. It is clear that these vessels must be functioning properly if the heart is to do its work properly. Heart Pathophysiology: ACS Occurrence ACS occurs in different forms which depend upon the effect of the blockage of the coronary artery on the affected part of the heart muscle and the cause. The condition varies in severity from unstable angina to myocardial infarction (M.I.). In the case of an M.I. one of the smaller branches of the affected coronary artery suddenly becomes blocked. There are several types of M.I. which are designated according to the tracing obtained from an electrocardiogram (E.C.G.). The two main types are where there is non-ST elevation (NSTEM) and it’s opposite where ST elevation is present (STEMI). In the case of unstable angina the blockage to the artery is only partial, although blood flow is reduced (White 2010). The result is a loss of oxygen and blood to the heart muscle served by the blocked vessel. The word ‘infarction’ refers to the death of the tissue because of the absence of blood flow beyond the blockage. This is also referred to as a coronary thrombosis or heart attack (Porth, chapter 20, 2010). The degree of infarction is determined by the position of the occlusion which establishes the area at risk. It also is determined by the acuteness and period of myocardial ischaemia (Hamm, Heeschen, Falk and Fox, n.d.). At the time of occlusion, the collateral flow that is present can control or even prevent myocardial infarction development. In unstable angina where the patients experiences pain at rest around 10% of them have an occluded culprit artery at the moment of presentation (Hamm, Heeschen, Falk and Fox, n.d.). Also in STEMI, almost all patients have a occluded culprit artery. As well as infarction, the majority of cases of heart dysfunction are due to narrowing of the blood vessels supplying the heart. This may be because of artheroma, which is when fatty plaques or patches develop within the artery lining. Figure 1: Overbaugh, 2009 What? I was alerted by the medical consultant about Mr Ali Bahmani’s case. He had been admitted to the hospital at the moment of my notification. On approaching him, he was sweating; breathing deeply and I could observe chest movement. I also observed nausea. I calmly introduced myself after which I noted that he immediately held his chest and shut his eyes tightly, an indication of pain. According to Eldarir & Abd el Hamid (2013), the right method of evaluation is significant in achieving correct result and making the right judgement. Traditional nursing examination which gives summative scores was undertaken. As I questioned him, he opened his eyes and grumbled of pain in his central chest that was spreading out towards his left arm. He indicated that it was his first time in hospital and he had no important medical history which was largely due to his wife who is a nutritionist. However, he is fond of eating junk food. In between a short silence, he states that he spends most of his time at work on his office chair and that his office is situated near his home although he drives to work. The observations on physical examination recorded at the time of admission are indicated in table 1. Table 2: Respiratory Rate (Breaths/minute) 16 breaths/minute Blood Pressure (mmHg) 135/78 mmHg Temperature (0C) 370C Pulse Rate (Beats/minute) 68 beats/minute So What? Consultation Consultation is the time when ANP utilizes the various models of consultation that are available. The diagnosis and treatment along with the problem areas are verified during consultation. It is also during consultation that I was able to assess my performance as this was my first time undertaking it. It was important that I expressed professionalism during the consultation so that the patient would feel at ease with me, comfortable and confident that he was under the care of an able health care practitioner. My attitude towards Mr Ali was a friendly attitude. As it is known, the attitude determines the atmosphere. It is necessary to have a relaxed and friendly atmosphere so that the patient is able to express himself and open up about how exactly he is feeling. I ensured that physical proximity between me and the patient was enough for me to hear the patient and observe him keenly. My orientation was in such a manner to enable an all round view of the patient as he sat on the bed. Virtually all consultation models involve the recording of medical history. However, they are different when it comes to certain aspects as patient diagnosis and knowing what the patient wants. The consultation model I based my consultation on was the Calgary – Cambridge model. The unique thing about this model is that it avails the need to have an organization to the consultation and form a relationship with my patient. The model I used is patient centred. It creates two scenarios, that of the nurse and that of the patient with the intention being to unite both in an acceptable way. Basing my approach on this model, I began with an introduction where I greeted the patient and introduced myself hence creating rapport. As this was my first time, respect was paramount. It is through respect that interest is created. The opening question I asked the patient was how he was feeling, to which he replied by holding his chest and moving his hand to the direction of his left arm while he murmured as I listened keenly without interruption. I encouraged the patient to speak and facilitated it through repetitively asking him details that were not clear. This enabled the gathering of enough information to assist in patient’s diagnosis. Mr. Ali could communicate in English effectively which was advantageous as I had encountered cases before APN where the doctor had issues recording the patient’s history due to communication barrier. The Calgary – Cambridge model was the best in this case scenario as it enabled the understanding of the view of the patient. The provision of correct information and aiding recall and understanding is achieved by a shared understanding which incorporates the patient’s perspective (Tate, 2007). As the end of the consultation session neared, I realised that the patient was at ease and there was a level of understanding that had been attained. It was clear that the aim of the Calgary – Cambridge model which is giving more power to the patient had been achieved. After the consultation, I had time to reflect and discuss the consultation with the medical consultant. Diagnosis According to Hamm, Heeschen, Falk and Fox (n.d.), the leading complaint in ACS is chest pain which triggers the diagnostic cascade. Chest pain was depicted in Mr Bahman’s case. Clinical Manifestation It is important that a precise history is obtained in differentiating the start of ACS from alternative diagnoses. The characteristics of the prodrome are shown by angina type discomfort which usually occurs at rest or on exertion. The clinical presentation of ACS consists of a wide range of signs. The main symptom is ischaemic chest pain which Mr. Bahman had indicated of. He also expressed nausea and fatigue which is associated with the chest pain. The grading of chest pain can be done according to the Canadian Cardiovascular Society Classification. According to CCS, the grading includes prolonged angina pain which occurs for more than 20 minutes at rest, new onset severe angina, or recent destabilization of previously stable angina with at least CCS III angina features (Hamm, Heeschen, Falk and Fox, n.d.). The Braunwald classification is normally used to identify subgroups of patients with unstable angina and who are at dissimilar stages of cardiac risk. Mr Bahman’s case indicated that his was a new onset severe angina. This class type is observed in only 20% of the patients (Hamm, Heeschen, Falk and Fox, n.d.). The basis of the Braunwald classification is the symptoms which are in regard to the duration and severity of the pain along with the pathogenesis of myocardial ischaemia. According to this classification, patients who have the highest risk of an adverse cardiac event are those with unstable angina at rest that has occurred within the last 48 hours (Hamm, Heeschen, Falk and Fox, n.d.). Hamm, Heeschen and Fox (n.d.) note that patients with STEMI normally have severe chest pain while in non – ST elevation ACS, pain is dependent on the amount of exertion and usually lasts around 20 minutes. In the case study, Mr. Bahman’s case is that of non – ST elevation ACS. As he had indicated, the pain he was feeling pain was located at the centre of his chest and radiating towards the left shoulder and arm. It should be noted that if pain is felt on the right side of the chest, it does not rule out myocardial ischaemia. Also, if the pain is connected to inspiration or radiates to the back, then it should be important to consider other differential diagnoses. However, in Mr. Bahmani’s case, none of these was reported. If the pain had gone on for many days, that would have nullified myocardial ischaemia and may have been as a result of mechanical injury (Hamm, Heeschen, Falk and Fox, n.d.). Physical Examination The physical examination of Mr. Bahman was done at the time of admission. It included heart rate and blood pressure measurement, respiratory rate and temperature. The reason why I undertook these examinations was so that I could exclude non – ischaemic cardiac conditions, non – cardiac causes of the chest pain, pneumothorax and likely precipitating etracardiac causes. I also wanted to check for symptoms of likely hemodynamic instability and left ventricular dysfunction. For patients with myocardial infarctions, specific attention has to be paid to systolic murmurs which indicate ventricular septal defect or mitral regurgitation (Hamm, Heeschen, Falk and Fox, n.d.). The Electrocardiogram The early evaluation of ACS is vital. A vital instrument that is used in its assessment is the ECD. For all patients who report to a hospital with severe chest pain, it is important that a 12 – lead ECG is recorded. Mr Baharain had a 12 – lead ECG recorded within the first 10 minutes of admission. According to O’Connor et al. (2010), ECG is vital in screening as it also used in screening of patients with atypical presentations. It can avail evidence for alternative diagnoses such as pulmonary embolism. The ST – segment shifts along with the T – wave provides the most dependable electrocardiographic signals of unstable coronary disease and increased risks. The changes occurring as chest pain occurs are of a high diagnostic value. ACS is suggested when the ST – segment depression is greater than 1 mm in two or more contiguous leads (Hamm, Heeschen, Falk and Fox, n.d.). Decision Making and Diagnostic Reasoning From these descriptions I deduced that Mr Bahmani was showing certain signs of ACS. Nurses mostly think of ACS in the first instance when a patient complains of chest pain (Woo & Schneider, 2009). Patients such as this need to be evaluated for ACS based upon the presence of possible signs and symptoms of ACS. Mr Bahmani had his vital signs checked and a 12 lead ECG was conducted in order to check him for infarct or ischaemia (Woo & Schneider, 2009). When he arrived in the hospital he had chest pain but no acute ischaemic change was indicated by his ECG and vital signs were stable. Possible other causes of chest pain are many and include muscoskeletal origins, perforating peptic ulcer and pulmonary embolism (Meisel & Cottrell, 2014). Mr Bahmani was questioned further in relation to the episodes of chest pain. He reported that he had just been experiencing sporadic pain which he took to be “normal”, especially after he had worked too long, or had involved himself in a tedious job. He reported however that in the past week the attacks of chest pain had been lasting longer and was more severe. This had to be relieved by taking more sublingual Nitroglycerin tablets (he had a previous history of angina). The previous night he had a prolonged episode of chest pain which made him decide to seek medical help. Rationale When chest pains like these occur in a predictable pattern, the situation may be triggered by exertion. In Mr Bahmani’s case, these episodes are readily relieved by rest. The tablets of Nitroglycerin taken are used in cases of stable angina. This stable form of angina is a characteristic symptom of coronary artery disease, but can be a rare indictor of acute myocardial ischaemia. On the other hand attacks of chest pain that increase in severity and frequency require more Nitoglycerin tablets. In the previous week the pain was severe and had not been relieved by rest. This indicates that the previously stable angina had now become unstable and required immediate medical intervention. Therefore Mr. Bahmani was informed of possible treatment and was asked to contribute to making decision about his case. Treatment From the indication, we decided to have him on oxygen so as to maintain the oxygen saturation level. Three doses of Nitroglycerin tablets were also administered for pain control at a dosage of 0.3 – 0.4 mg sublingual tablets every 5 minutes (Overbaugh, 2009). Patient’s Past and Admission It was established that five years earlier Mr Bahmani had undergone Coronary Artery Bypass Graft surgery (CABG) before the present episodes of pain. He also required a drug-eluting stent replacement two years ago in order to open a blockage found in one of the saphenous vein grafts put in place during his previous CABG surgery. He had also been prescribed Simvastatin 20mg/daily to treat abnormal amount of lipids in the blood or dyslipidemia. This was done after laboratory tests indicated a high level of low density lipoprotein (LDL) at 135mg/dl. He had stopped smoking two years ago, but was 30 pounds overweight, which he admitted he could not manage. Rationale A careful evaluation of a patient’s history provides information which is necessary in order to triage his present medical condition, in this case chest pains (Bickley, 2009). It also stratifies the possibility of having serious consequences such as acute M.I. The main risk factors for ACS include the patient’s CAD history. In addition the evaluation must also include a history of any occlusions that needed the restoration of blood flow and as well as oxygen supply as an intervention. Moreover the symptoms of ACS also include the experience of risk factors such as smoking, obesity, dyslipidaemia and hypertension (Mayo Clinic, 2014). After the establishment of Mr Bahmani’s CAD, previous CABG surgery and Percutaneous Coronary Intervention (PCI) with stents, as well as the presence of risk factors already described, he was taken to the emergency department of the hospital. Mr Bahmani resisted this at first and wanted to drive himself, but eventually, with persuasion, he was transferred by the emergency medical services. Rationale It is strongly recommended that patients with the possibility of having ACS be taken to hospital by the emergency medical services (O’Conner et al., 2010). This allows emergency medical staff the opportunity to assess the patient, to establish their immediate ECG and to give therapies as recommended (Hastings & Redsell, n. p., 2006). This transport will also enable the emergency medical staff to notify the hospital emergency department to prepare for the receipt and admission of the patient by facilitating triage and evaluation (O’Conner et al., 2010). I informed Mr Bahmani of all these advantages and in he cooperated in return. This fits in with the idea that patients who are involved in decision making are more likely to be compliant, because they understand the reasons behind care decisions (Kurtz & Silverman, 1996). He will also be aware of new roles nurses are taking on in recent times such as giving information to patients, assessing health risks and screening for the early signs of disease so that they can be treated at an early stage (Kurtz & Silverman, 1996). This is all part of a framework of care which makes staff accountable for providing high standards of care (Department of Health, U.K. 2006). Clinical Implications In ACS cases, it is common to have atherothrombosis which has ruptured and eroded coronoray plaques. This can be clinically silent for long durations. Nevertheless, it is the instantaneous obstruction of blood flow that results to ACS. The lesion which causes it is normally ‘dynamic.’ As a result, it causes intermittent obstruction of blood flow. Thus, its outcome is determined by obstruction location, duration and severity of myocardial ischaemia (Hamm, Heeschen, Falk and Fox, n.d.). It is worth noting that a non – occlusive is the most basis of ACS without ST – segment elevation, while an occlusive and more stable thrombus dominates in STEMI. When treating ACS, it is vital to know that they are the consequences of an interaction between 2 unique processes which are atherosclerosis and thrombosis. Defining the two, atherosclerosis is chronic. It is also fixed and sets the extent for what is attainable by antithrombotic and thrombolytic therapies (Hamm, Heeschen, Falk and Fox, n.d.). Thrombosis is a dynamic and delicate procedure that is very vulnerable to drug treatment. This means that on drug treatment, it may vanish quickly or the drugs may accelerate it. Thrombosis and vasospasm normally exist together (Hamm, Heeschen, Falk and Fox, n.d.). All in all, drug treatment along with mechanical interventions usually work in tandem in ACS treatment to attain quick, sustained and total reperfusion. Invasive approaches may be required to attain quick, sustained and total reperfusion of infarct – associated arteries. This approach may also be used to make several intricate lesions which pose certain great short term risk in ACS passive (Hamm, Heeschen, Falk and Fox, n.d.). Use of only a target based lesion approach usually does not eradicate the danger posed by all coronary plaques that are present. Their total risk establishes the long term diagnosis (Hamm, Heeschen, Falk and Fox, n.d.). Altered Physiology The altered physiology of chest pain will be looked at as it is the main symptom of ACS. According to Green and Hill (n.d.), two pain syndromes result from stimulation of visceral or somatic afferent pain fibres. Somatic pain fibres innervate the skin layer, dermis and parietal pleura. These pain fibres are organized in dermatomal patterns and they enter the spinal cord at certain levels. Internal body organs contain the visceral pain fibres. They enter the spinal cord at multiple levels. Pain associated with somatic nerve fibres is unique in that it can be easily traced. It is normally felt as a sharp sensation. Pain associated with visceral nerve fibres is hard to trace and is not exactly localized. As a result, it’s common for patients to describe it as aching or heaviness. It is common for patients to mistake its origin. This is because it normally is referred to another area in the body which corresponds to a bordering somatic nerve. In our case, Mr Bahman expressed pain on left arm. This is an example of a misinterpretation of its origin. Pain on the arm usually on diagnosis may be established to represent myocardial ischemia. The perception and communication of pain by a patient depends on their gender, age, medication and drugs (Green & Hill, n.d.). What Now? Conclusion As I reflect on the consultation itself, I realise that it has been a whole new experience for me. Most importantly was interacting with the patient from the onset. It was not an easy experience for me as I had to conceal various fears during my whole time with the patient. I realised that one vital point during the initial contact is creating a rapport. This was because it enabled me to relax and it loosened up the atmosphere. This allowed for communication to take shape. The good thing about it was that once communication ensued, then everything fell right in place. The consultation also allowed me to put into practice the theoretical models that I had been learning in my readings. I realise that they are vital in getting as much information from the patient as possible. In my evaluation, I questioned the patient regarding his medical background and followed all the principles of the Calgary – Cambridge model. The consultation allowed me to learn more about the disease been evaluated to detail. ACS as O’Connor (2010) notes, chest pain identification protocols are vital in identifying patients who have suspected ACS. With the right observation, diagnosis and treatment as the one I used, then the condition can be put in control. My conclusion was that this new part of nurse practice, APN, that I was venturing into will not only be beneficial to the health care system, it shall also improve the delivery of health services. Based on my observation skills, assessment skills and diagnosis, I realised that the traditional roles of the nurse have virtually been restrictive on the ability of nurses to deliver. As I consulted with the medical consultant, am the one who made all the major calls on the steps to take during diagnosis. With the rise in needs of the healthcare system, then Advanced Practice Nurses like me will get even more recognition for the roles they will play. As time proceeds, so do the advancements in health increase, this rises the expectations of the people regarding the type of healthcare they receive. Hence, the decision making and diagnostic skills of APNs will be of much value. Mr Bahman was later transferred to the cath lab. A stent was installed in his right anterior descending coronary artery. Consequently, Mr Bahman made a full recovery without complications. He was discharged after a week. References Aqua, NHS, 2012. About Shared Decision Making.  Available at: http://www.advancingqualitynw.nhs.uk/sandbox/SDM3/AQuA-Shared-Decision-Making-introduction.html 19th March 2014 [Accessed 15 April 2014]. Bickley L. S., 2009 Bates’ Guide to Physical Examination and History Taking 10th ed. Philadelphia: Lippincott Williams and Wilkins. Department of Health, 2006. Modernising Nursing Careers – Setting the direction. DH London. Eldarir, S. A. & Abd el Hamid, N. A., 2013. Objective Structured Clinical Evaluation (OSCE) versus Traditional Clinical Students Achievement at Maternity Nursing: A Comparative Approach. IOSR Journal of Dental and Medical Sciences, 4 (3), pp. 63 – 68. Available at: http://www.iosrjournals.org/iosr-jdms/papers/Vol4-issue3/L0436368.pdf [Accessed 15 April 2014]. Green, G. B. & Hill, P. M., n.d. Cardiovascular Disease, Chest pain: Cardiac or Not. Hamm, C. W., Heeschen, C., Falk, E. & Fox, K. A. A., n.d. Acute Coronary Syndromes: Pathophysiology, Diagnosis and Risk Stratification. [pdf]. Available at: https://www.mst.nl/opleidingcardiologie/boeken/esc/1405126957_chapter_12.pdf [Accessed 15 April 2014]. Hastings, A. & Redsell, S., 2006. The Good Consultation Guide for Nurses. Oxford, Radcliffe. Kurtz, S. M. & Silverman, J.D., 1996. The Calgary – Cambridge Referenced Observation Guides: An aid to defining the curriculum and organising the teaching in communication training programmes. Med. Education, 30, 83 – 9. Available at: http://www.floppybunny.org/robin/web/virtualclassroom/comms/models/consultation_models.pdf [Accessed 15 April 2014]. Mayo Clinic, 2014. Acute Coronary Syndrome: Risk Factors. Available at: http://www.mayoclinic.org/diseases-conditions/acute-coronary-syndrome/basics/risk-factors/con-20033942 [Accessed 15 April 2014]. Meisel,J. and Cottrell, D., 2014. Differential diagnosis of chest pain in adults UpToDate, Available at: http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-adults [Accessed 15 April 2014]. NHS, 2003. NHS Code of Practice on Protecting Patient Confidentiality. [pdf] Scottish executive. Available at: http://www.ehealth.scot.nhs.uk/wp-content/documents/nhs-code-of-practice-on-protecting-patient-confidentiality.pdf [Accessed 15 April 2014]. O’Conner, P., Brady,W., Brooks .S., Diercks, D., Egan, J., Ghaemmaghami, C, Menon, V., ; ONeil, B., Travers,A., Yannopoulos,D., 2010. Part 10: Acute Coronary Syndromes , American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation 122 (18) Suppl 3, S pp. 737- 817. O’Connor, R. E., Bossaert, L., Arntz, H, et al., 2010. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, Part 9: Acute Coronary Syndromes. Circulation, 122, S422 – S465. doi: 10.1161/​CIRCULATIONAHA.110.985549 Overbaugh, K. J., 2009. ACUTE CORONARY SYNDROME: Even nurses outside ED should recognize its signs and symptoms. AJN, 109 (5), pp. 42 -52. Available at: http://www.ucdenver.edu/academics/colleges/nursing/Documents/PDF/coronary-syndrome.pdf [Accessed 15 April 2014]. Patient.co.uk, 2014. Acute Coronary Syndrome, Available at: http://www.patient.co.uk/health/acute-coronary-syndrome [Accessed 15 April 2014]. Porth, C., 2010. Pathophysiology. Philadelphia: Lippincott Williams & Wilkins. Preston, R. R. & Wilson, T. E., 2012. Physiology. Lippincott Williams & Wilikins. Tate, P., 2007. The Doctor’s Communication Handbook, Milton Keynes. Radcliffe Medical Press White, J., 2010. Framework for Advanced Nursing, Midwifery and Allied Health Professional Practices in Wales. Available at www.wales.nhs.uk/sitesplus/829/opendoc/162753 [Accessed 15 April 2014]. Woo,K. and Schneider,J., 2009. High risk chief complaints, 1. Chest pain –the Big Three, Emergency Medicine Clinics of North America, 27(4,) pp. 685-712. Read More