An evaluation of the planning and delivery of nursing care. Acute management of patient with NSTEMI - Essay Example

?Case study-An evaluation of the planning and delivery of nursing care I. Acute management of patient with NSTEMI Heart disease remains the leading cause of death in the United States with an estimated cost of approximate­ly $142.5 billion just in 2006, but certainly not all people who arrive in every ED with the complaint of chest pain are experiencing heart disease (Miranda & Crown 2009). Chest pain is a very wide complaint that can be pointing to several diseases other than cardiac in origin. The reason why there is a need to evaluate patients presenting with chest pain in any situation is that for health care providers to assess at once the possibility of the patient having a heart attack that is a life threatening condition and to save as much as heart muscle as possible from damage. It is always better to diagnose early than to misdiagnose. In the United States, every year, approximately 5.3 million patients present to the ED with chest discomfort and related symptoms and nearly about 1.4 individuals are hospitalized for unstable angina and Non ST Elevation Myocardial Infarction (NSTEMI) (Cannon & O’Gara 2006). On the same context, in 2000 it was estimated that 1.4 million people in England suffer from angina. 300,000 of which have heart attacks, and it is estimated that more than 110,000 die every year. Although much has improved in terms of treatment and modalities when it comes to cardiac problems and the mortality from cardiovascular causes has declined still the numbers that hit the scale will always remain as a basis for improving programs against coronary artery disease and myocardial infarctions (The National Clinical Guideline Centre 2010). However, the number of people admitted with NSTEMI ACS has shown less of a decline and the management of these conditions remains a high priority (The National Clinical Guideline Centre 2010). The healthcare delivery system is designed to address the growing health problems of the population is a systematic procedure and nurses play an important role on the lead in the promotion, prevention and rehabilitation of health of people. In the concept of this paper the role of the nurse will be given much focus as an evaluative tool in the planning and the delivery of nursing care to NSTEMI patients from the perceived onset, the course of the disease and the rehabilitative phase. With this Nurses’ play an important role as health guide that improve the totality of patient outcome for better prognosis and continuous recovery. NSTEMI: Overview and Understanding the disease According to Anderson et al. (2007), NSTEMI constitute a clinical syndrome subset of Acute Coronary Syndrome that is usually caused by Cardiovascular Atherosclerotic Disease and is associated with increased risk of cardiac death and subsequent myocardial infarction. It is defined by the electrocardiographic ST segment depression or prominent T wave inversion and positive biomarkers of necrosis in the absence of ST-segment elevation and in an appropriate clinical setting such as chest discomfort (Anderson et al. 2007; Kalra et al. 2008). Acute coronary syndrome starts when platelet aggregates clump together and forms a thrombi from a ruptured arteriosclerotic plaque. Once the clot occludes the vessels for more than 20 minutes, the myocardial tissue becomes necrotic due to the occlusion (Smeltzer et al. 2009; White et al. 2012). Due to this the heart will not be able to pump enough blood to vital organs and tissues leading to shock and eventually death. Chest pain in NSTEMI lasts longer and is more severe than the pain of unstable angina and can lasts for 15 minutes if not treated with rest or nitro-glycerine. The pain may or may not radiate to the arm, neck, back or epigastric area and may also experience dyspnoea, diaphoresis, nausea, and dizziness (Jevon et al. 2008). Women experiencing ACS may experience misleading symptoms of indigestion, palpitations, nausea, numbness in the hands, and fatigue rather than chest pain (Overbaugh 2009) The US Department of Health & Human Services (2010) have cited and summarized the guidelines for management and treatment for ACS in the early management of NSTEMI. The provision of information under the said guideline is to offer patients clear information about the risks and benefits of treatment. Moreover, assessment of a patient’s risk of future adverse cardiovascular events should include: full clinical history to note on the familial risks that can aggravate the chances or risks of having the disease or recurrence; complete and detailed physical examination; 12-lead ECG and blood tests for cardiac markers to confirm the diagnosis for further management (US Department of Health & Human Services 2010). Risk assessment should be used to guide clinical management (US Department of Health & Human Services 2010). Low- and intermediate-risk patients are frequently managed in a chest pain centre or in the emergency department while high-risk patients are often managed with an early invasive strategy. Nowadays, with the increased availability of cardiac catheterization facilities worldwide, patients with STEMI are now being managed early with a primary percutaneous coronary intervention. But thrombolytic therapy is still used if such facilities are not immediately available especially in countries where finances are not stable because such procedure is costly (Kalra et al. 2008). Pharmacologic treatment for NSTEMI includes antiplatelet therapy such as aspirin and Clopidogrel and Antithrombin therapy to prevent the formation of thrombus that can clog coronary arteries (US Department of Health & Human Services 2010). And of course rehabilitation and discharge planning will have an impact in patient survival in decreasing the chances of reinfarction and the possibility of return to normal activities the soonest possible time after discharge (US Department of Health & Human Services 2010). Key goals in the management of NSTEMI The major goals for patient include relief of pain or ischemic signs and symptoms, prevention of further myocardial damage, absence of respiratory dysfunction, maintenance of adequate tissue perfusion, reduced anxiety, and adherence to the self-care program and absence of complications (Smeltzer et al. 2009). Important early goals are long term plaque stabilization and secondary prevention of recurrent vascular events which is achieved through aggressive and evidence-based use of lipid lowering agents, anti-hypertensive and hyperglycaemic therapy (Gelfand & Cannon 2009). The pneumonic MONA is used for the acute management of NSTEMI that stands for Oxygen therapy to supply oxygen deficit, Nitroglycerin used for the reduction of pain, Aspirin to inhibit platelet aggregation and Morphine to reduce the cardiac work load as well as addressing the pain (Porter 2008). The role of the nurse is to initially able to diagnose and prioritize NSTEMI patients together with the rest of the health care team to be able to give proper care the soonest possible time to decrease the chances of progression and myocardial damage (Monahan et al. 2010). Balancing myocardial oxygen supply with demand is, evidenced by relief of chest pain, is the top priority in patient care with ACS. Although giving pharmacologic treatments is required to accomplish this still nursing interventions are also important. It is critical that there is collaboration among the patient, nurse and physician in assessing the client’s response to the therapy and in altering interventions accordingly (Smeltzer 2009) As a nurse the primary initial focus of care in an acute attack is the management of the severe chest pain or discomfort the patient is experiencing. In addition to the pharmacologic treatment nursing management can include the use of relaxation technique such as deep breathing exercises, guided imagery, and minimizing pain by the use of therapeutic touch and communication technique to alleviate the client’s anxiety (Humphreys 2011). Patients should be placed on bed rest during the initial phase of medical management to reduce cardiac workload by activity and patients should remain NPO until clinical stability is demonstrated and the necessity/timing of cardiac catheterization is determined (Fonarow 2005). On the invasive management of NSTEMI, angioplasty and angiography is a common tem heard. Before, there was considerable controversy over invasive versus early conservative strategy for the treatment of unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI). Critics of routine early intervention argued that patients should only be subjected to the risks of invasive procedures when the potential benefit outweighed the potential for adverse outcomes. On the other hand, proponents of an early invasive approach countered with the argument that the benefits of diagnostic catheterization and early revascularization were clear and should be available to all patients (Hod et al., 2001). According to a study regarding the issues in cardiac intervention, coronary angiography should be performed during the initial hospitalization in all high-risk patients, and as soon as possible in patients with ‘major arrhythmias, hemodynamic instability, post-myocardial infarction unstable angina, or a history of prior bypass surgery (Hod et al., 2001). Invasive Therapy for NSTEMI Primary PCI is now the reperfusion treatment of choice for STEMI; the majority of patients coming for revascularisation in the UK have stable coronary disease or NSTE-ACS. In the treatment of NSTE-ACS, first principles involve the selection of patients for diagnostic angiography followed by either PCI or coronary artery bypass grafting (CABG). Rates of PCI are increasing annually in the UK. Data from the British Cardiovascular Intervention Society show the current state of PCI in the UK that it is becoming an increasingly common procedure. Latest data from 2008 show that 105 centre in the UK performed percutaneous coronary intervention. The total number of PCIs for the UK for 2008 was 80,331: the vast majority (78,077) in NHS hospitals and 2,254 in the private sector (British Journal of Cardiology, 2010). During an angioplasty, a tiny tube known as a catheter is put into a large artery in your groin or arm. The catheter is passed through blood vessels and to the heart, over a fine guidewire, using X-rays to guide it, before being moved into the narrowed section of your coronary artery. Once in position, the balloon is inflated inside the narrowed part of the artery to open it wide. A stent is usually inserted into the artery to help keep it open afterwards (NHS Choices, 2012). Recent research suggests that intervention by angioplasty or coronary surgery soon after presentation with UA, especially in those patients with markers of muscle damage, reduces recurrent chest pain and MI. However, there is no evidence that mortality is reduced thus, although PCI for patients with NSTEMI is helpful, it should not be considered in all patients; only in those considered to be high risk (Sheppard & Channer, 2004) as researchers have cited improvements due to combination of better care and new drugs making heart attack cases reaching the hospital to drop by 50 percent. The use of angioplasty among the key factors, along with anti-clotting drugs, statins and beta-blockers to stop further heart problems were considered in the study and death rates could drop even further as treatments improve and all hospitals adopt standard treatment for patients with heart attack and angina (Royal College of Nursing, 2007). II. Health Promotion and Disease Prevention Coronary heart disease remains the single biggest killer in the western world, accounting for over 135 000 deaths in the UK alone (British Heart Foundation, 2000). A number of strategies have been introduced in an attempt to reduce the mortality of this disease and the latest figures suggest that these strategies have started to have an effect (Jones 2003) but the key concept in actually decreasing the numbers may lie in the health promotion aspects. The focus of health promotion is targeted on the modifiable risks factors present such as encouraging the provision of exercise regimen for sedentary individuals, cessation of smoking, blood pressure and sugar control, compliance with medications and patients at risk and relaxation and stress management (Tidy 2012). Risk factors for acute coronary syndrome- NSTEMI NSTEMI are not likely to happen to all individuals but the chances of acquiring the disease is increased in certain conditions that puts a person at a higher risk. Risk factors is defined as an aspect of personal behaviour or lifestyle, an environmental exposure, or an inborn or inherited characteristic which on the basis of epidemiological evidence is known to be associated with health-related condition considered important to prevent (Burt 2001). Non modifiable factors are the ones that can no longer be changed such as age, sex, family history, and ethnicity or race. According to American Heart Association about 80% of people who die from cardiovascular disease are over 65 years and men have a higher (Overbaugh 2009; American Heart Association 2012). Family medical history is also a risk. Development of the disease is increased with a family member who has developed a heart disease before the age of 55. It is important to elicit familial history during interview to note (The Regents of The University of California 2012). Race is considered a factor according to studies. It has been found out that African-Americans are at a great risk of developing cardiovascular diseases among other races. That is why health promotion should be given special priority on prevention for people of African-American decent (The Regents of The University of California 2012). In a similar context of race as a factor, in the UK, the highest recorded rates of CAD mortality are in people from India, Pakistan and Bangladesh (Tidy 2012). Modifiable risk factors are factors that can be changed (The Regents of The University of California 2012) that includes elevated levels of serum cholesterol, lower levels of high-density lipoprotein cholesterol; diabetes, cigarette smoking, obesity, a sedentary lifestyle, hypertension, and stress (Overbaugh 2009). Moreover, hypertension if left untreated can lead to coronary artery disease. High cholesterol profile levels also increases the risk of having heart diseases. Low density Lipoprotien contributes to artery blockages or plaques while High density lipoprotein removes cholesterol from the arteries and takes it to the liver for synthesis. Having high levels of HDL decreases a person’s risk of acquiring heart disease. Increased Triglyceride and total cholesterol levels like HDL contributes to increased risk (The Regents of The University of California 2012). Diabetes Mellitus is also one of the leading risk factors for cardiovascular diseases and it can lead to serious health issues such as high cholesterol level, high blood pressure and obesity and eventually coronary artery diseases (The Regents of The University of California 2012). All these factors add up to the possibility of acquiring coronary artery diseases that predisposes a person to having a NSTEMI. But these factors can be changed through modifications such as compliance to pharmacologic treatment and changes in lifestyle and others which will be discussed as part of the long term management plan to elicit redundancy. III. Managing the long term phase The likelihood of developing of infarction recurrence is very high in patients who have had an initial NSTEMI that is why management of long term phase is intended for these patients. It is important to discuss with patients and their care givers these long term goals in order to have high compliance rates and thus the incidence of recurrence can also be decreased significantly. The following texts are the nurses’ focus of long term goals prior to or after a client has been discharged from the health care facility: a. Compliance to pharmacological treatment. It is highly recommended that those patients who have had NSTEMI to follow strict compliance with medical treatment to prevent the likelihood of recurrence of infarction. Individualization of therapy depending on other medical issues may be appropriate. The benefits of medical therapy with regards to the reduction in the risk of MI, stroke, rehospitalisation, need for revascularization should be continued long term because patients with clinically evident atherosclerosis remain at life-long risk thus life-long treatment is recommended (Fonarow 2005). It is now recommended that a fibrate or niacin be administered if the HDL cholesterol level is 100 mg/dL (Banas 2004). As a nurse it is a goal that patients for discharge should be taught well on the Discharge Antithrombotic Therapy as recommended on the 2007 AHA guidelines. The benefits and risks of triple antithrombotic therapy with aspirin, clopidogrel, and warfarin therapy should be selected only when clear indications are present and should be administered for the shortest possible time and at the lowest effective doses as follows: aspirin, 81 mg; warfarin, titrated to the dosage necessary to sustain an international normalized ratio (Kumar & Cannon 2009). b. Encourage Physical Activity and Exercise It is important for patients to receive specific instructions to a minimum of 5 times per week exercise program. Exercise plays an important role in the reduction of predisposing to CAD because it increases HDL, reduces the risk of MI, and improves survival in patients with CAD. Nurses should encourage a minimum of 30-60 minutes of moderate activity 3- 4 times per week such as walking, cycling, swimming or other equivalent aerobic activities (Quek Kwang Leng 2002). A supervised cardiac rehabilitation program is recommended after AMI. Exercise is highly effective in preventing subsequent cardiac events. Patients should be offered referral to a cardiac rehabilitation program for even faster and monitored recovery. In addition to a specific exercise prescription, patients require instructions on activities that are permissible and those that should be avoided such heavy lifting and other strenuous activities (Fonarow 2005). c. Smoking Cessation Particular attention should be paid to smoking cessation counselling. Patients who continue to smoke after presenting with Unstable Angina have 5.4 times the risk of death. Patients should be offered intensive smoking cessation intervention during hospitalization. This should include both physician and nurse counselling focusing on relapse prevention be given written information about the outpatient behavioural modification programs available and the option of nicotine replacement therapy should be documented well in the medical record (Fonarow 2005). Women who smoke and use oral contraception have an even greater risk of heart attacks. Cessation of smoking is relevant at once because 1 year after quitting smoking, the risk of a heart attack drops to about half that of current smokers, and continues to decline over time (American College of Cardiology 2011). d. Diet and Weight Management Patients and family members, if available, should receive counselling on the National Cholesterol Education Program TLC diet or Mediterranean diet and recommended body weight (BMI) during the hospitalization. Information on the outpatient dietary modification programs available should be provided. Supplementation with omega-3 fatty acids has lowered the risk of recurrent MI but use very low-fat diets should be discouraged (Fonarow 2005). Patients should achieve and maintain a body mass index between 18.5 and 24.9 and should be assessed regularly. Weight maintenance/reduction should be attained through an appropriate balance of physical activity, reduced caloric intake, and formal behavioural programs (American College of Cardiology 2011). e. Patient Education The patient and family members should be instructed regarding medications and monitoring of symptoms. The purpose, dose, and major side effects of each medication prescribed should be explained. Written medication sheets and a medication schedule should be provided. The warning signs should be discussed and the immediate plan of action. Patients should be instructed to contact their primary care physician or cardiologist if they have a non-acute change in symptom pattern (Fonarow 2005). Treatment and care should take into account patients' needs and preferences. Patients with NSTEMI should have informed decisions about own care and treatment, in partnership with healthcare professionals. Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities (National Institute for Health and Clinical Excellence 2010). f. Follow-Up Follow up should strongly be advised to the client to note on the prognosis or progression. The continued use of the beneficial therapies prescribed should be strongly reinforced during patient follow-up and the medications should be reviewed on each visit. (Fonarow 2005). The Nurses role Nurses play an important role in the management of acute coronary syndrome in collaboration with the medical team and the client. The success of management of NSTEMI and its recovery can be attributed to the hands of a nurse in caring for such patients. People with non-ST-segment acute coronary syndrome need to receive appropriate evidence-based therapies to optimise outcomes and nurses play an integral part in ensuring appropriate care. In a study by Tierney et al. (2012) on the “Nurses' role in the acute management of patients with non-ST-segment elevation acute coronary syndromes: an integrative review,” An integrative literature review was made to evaluate the role nurses undertake during the acute phase in identifying, risk stratifying and managing patients with Non ST-Elevation Myocardial Infarction Acute Coronary Syndrome. The reviewed literature revealed that nurses in the acute setting perform five different roles in the care of people with NSTEMI-ACS: as an educator, a comforter, risk taker, data conduit and decision maker. And it was concluded that nurse-initiated thrombolysis improved care for such patients (Tierney 2012) In another study, it was cited that it is critical to accurately and rapidly diagnose NSTEMI and to provide appropriate pharmacologic and non-pharmacologic treatment to prevent further heart tissue damage and have greater chances of returning to optimum cardiac function. According to Housholder-Hughes (2011), nurses play a vital role in ensuring that patients are given appropriate intervention based on recommended guidelines. Today it can be evaluated that the delivery of nursing care for NSTEMI patients are still on the recommended guidelines as shown by the significant decrease in the mortality and morbidity rates of patients having NSTEMI over the years. Therefore it should continually be studied, analysed and improved to maintain greater better patient outcome (Mcmanus et al. 2011) Bibliography: Agostini-Miranda A. & Crown L. 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