Daisy

the scenario is

Background information

Daisy is a 70 year old widow who lives alone. She has a fairly active life doing part-time volunteer work for the CWA and local heritage museum. Her daughter lives nearby and works full time. She relies on Daisy to look after her 3 year old son on Fridays. Daisy is a non-smoker, occasional social ETOH drinker (1 €“ 2 standard drinks) though was a moderate risk consumer of ETOH in her miIDle-age.

Health history:

€¢ Hypertension

€¢ Hyperlipidemia

€¢ Mild obesity

Surgical: hysterectomy at 42 years of age

Diet: Does some cooking but prefers instant microwave meals. Enjoys a daily pastry or cake from the local bakery.

Exercise: Recently started walking every 2nd morning following GP advice to lose weight. Minimal exercise for last 30 years.

Medications

€¢ Perindopril 5mg daily

€¢ Atorvastatin 20mg daily

€¢ Aspirin 150 mg daily

€¢ Progynova 2mg daily

Daisy was recently diagnosed with colorectal cancer following complaints of lethargy, abdominal discomfort and episodes of frequent diarrhoea. She was admitted to hospital for elective surgery to remove the tumour and required the formation of a temporary colostomy. On day two post-operatively, Daisy complained of suIDen dizziness and palpitations. Her nurse found that she was tachycardic and hypotensive and called a Rapid Response.

Vital signs:

€¢ Pulse 130-150 irregular

€¢ BP 100/65

€¢ RR 24

€¢ SpO2 98% on 2L NP

€¢ Temp 37.2

PCA €“ moderate wound pain

Following the Rapid Response, Daisy was transferred to the High Dependency Unit for treatment and monitoring.

question 1 is
You are the RN working in the HDU and accept Daisy into your care. Discuss your nursing management for Daisy on her admission to the unit. Your response should be evidence-based demonstrated by an engagement with the literature and any relevant guidelines. In your discussion, include:

€¢
€¢ The interventions that you would anticipate to investigate and treat atrial fibrillation with a focus on your role and responsibilities as an RN.

my response is
As soon as Daisy has been admitted to the HDU, it is important to follow the nursing process to assess, diagnose, plan, implement and evaluate treatment, in order to provide outcome based care to the patient. This discussion will examine the assessments used to diagnose Daisy’s deteriorating cardiovascular status, following with interventions that the RN would anticipate to investigate and use to treat atrial fibrillation.

To begin the assessment process, it is important to ensure Daisy has a patent airway and is breathing without compromise. Once we have established airway patency, and normal breathing, a set of vital signs will be undertaken as a fundamental starting point to obtain a baseline set of observations. This will give the treatment team some direction as to what may be happening to cause the patients deterioration.

Following the vital signs, Daisy is tachycardic, with an irregular pulse. The next vital step in the assessment process will be to conduct an electrocardiogram (ECG) to detect the electrical activity of Daisy’s heart. From this, the ECG has revealed that Daisy in Atrial Fibrillation (AF).

After diagnosing AF via the ECG, it is important for the Registered Nurse (RN) to obtain consent from Daisy, to investigate her condition further. A critical step in the investigation process will be a blood test. This will help to check for certain underlying causes of Daisy’s AF, and to rule out heart damage, as from a heart attack. An important level to check in this situation is a troponin level. This test will need to be repeated over the next 6-24 hours, to detect any rise in troponin that may indicate a myocardial infarction as the main contributing factor to Daisy’s deteriorating cardiovascular status.

question 2 is
On your next shift you have been allocated two HDU patients to care for, one of them is Daisy. Over the preceding 24 hours, Daisy has required several IV fluid boluses to maintain her mean arterial pressure above 65 mmHg. She has had an arterial line inserted to allow continuous blood pressure monitoring and blood samples to be taken. On your initial assessment of Daisy you notice that her respiratory rate is 28 bpm and her SpO2 is reading 92% despite being on a Hudson mask at 6L/min. Discuss your immediate interventions, including:

€¢ Further assessments that could gather data regarding her respiratory status.
€¢ Interventions that you would anticipate to manage and treat pulmonary oedema.

question 3 is
Two weeks later Daisy has recovered from her surgery and has had no further complications. She has spent ten days on the surgical ward and is coping with caring for her colostomy. During her recovery, Daisy was informed that she may have had a small myocardial infarction post-operatively and that she should have a coronary angiogram in a few weeks.
You are the nurse caring for Daisy over her last couple of days in hospital. Discuss her discharge plan including a focus on:
€¢ Education on what a percutaneous cardiac intervention (PCI) involves
€¢ Daisy’s cardiovascular disease risk factors
€¢ A chest pain action plan.