Care, rationale and outcome in Coronary Care Unit

Care, rationale and outcome in Coronary Care Unit Nurses are required to continue education and upgrading of skills to ensure their patients receive the best possible nursing care. Cardiac nursing is a dedicated nursing practice that gives focused and precise nursing interventions, that are governed by the best practice nursing standards using latest research based facts. Nurses need to have good technique and skill when performing health history and physical assessments to enable them to look after the person as a whole. When nursing patients, nurses need to understand the care they give and reasoning of why they deliver the cares in a certain way. A sound knowledge of assessment and observations help nurses plan, initiate and deliver health care. Without knowledge and rationales the nurse may not deliver cares in the correct manner or have the ability to know when to initiate them. Myocardial infarction is a common cause for admission into the Coronary Care Unit and this case study follows cares, rationales and outcomes in this se tting. Mr Smith (synonym for confidentiality) is a retired 58 year old man that was admitted to a Coronary Care Unit (CCU) via the Emergency Department (ED) of the Atherton Hospital. His admission diagnosis was an Anterior ST Elevated Myocardial Infarction (STEMI), which had already been treated with thrombolytic therapy. On the morning of his admission, he drove himself to the ED with chest pain. He presented with left sided chest pain that radiated to his left jaw and left arm which he scored 10/10 and described as crushing. He was diaphoretic and hypertensive with nausea and vomiting. An ECG showed sinus bradycardia, rate of 60 bpm with hyperacute T waves in V2-V4, that progressed to ST Elevation. Thrombolytic therapy was administered 1 hour of his presenting to ED and within 2 hours of the initial chest pain that commenced at home. His ST segment was elevated approximately 8mm and continued to increase until 70 minutes post thrombolytic when he had 50% resolution of the ST elevation. When he presented to the ED he was given oxygen, morphine, anginine, aspirin, clopidigrel and enoxaparin as first line pharmaceutical treatments. He was transferred that afternoon to Townsville. Mr Smith was not managed in Atherton due to the lack of cardiac catheter services and was transferred for a Percutaneous Coronary Intervention (PCI) the next day where he had a stent placed in his proximal area of his Left Anterior Descending Coronary Artery (LAD). Anterior MIs affect a large surface of the heart, thrombolytic therapy and PCI are the most effective way to treat them (Evans-Murray, 2008 ). His medical history includes a previous STEMI and PCI in 1997, hypercholesterolemia, depression, a ruptured bowel and neck injury from a Motor Vehicle Accident in 1977. Upon further questioning Mr Smith admitted to recently becoming very short of breath whilst mowing the lawn. His risk factors include ex-smoker ceasing in 1993, hypercholesteremia, and stress of brother dying 3 weeks previous. His current medications were aspirin 100mg daily, atorvastatin 20 mg daily and zoloft 200mg daily. Upon arrival to a Townsville Coronary Care Unit (CCU), Mr Smith was pain free. He was connected to continuous cardiac monitoring and admission workup was attended, this includes admission paperwork, ECG, vital signs, mobile Chest x-ray and pathology tests. He was ordered and given stat doses of aspirin, clopidigrel and IV lasix. Mr Smith had an IVT running in his Left hand and an IVC in his Right hand. During the next few days Mr Smith remained febrile 37.6 ° with only a small elevation in white cell count (Huszar, 2007). Four days post infarction, Mr Smith became short of breath (SOB) in the shower and felt light headed; he was monitored in Sinus Rhythm with SaO2 of 95% on 3lpm via nasal cannula. On auscultation, crackles were heard in his lower bases. He was commenced on lasix 20mg daily. This was an indication that his Left Ventricle may not have been functioning adequately. An Echocardiogram was performed to see if the heart wall motion and valves were performing to their best ability (Kern, 2003). The report showed extensive akinesis of the septal, anterior and apex left ventricle wall. His Left Ventricle Ejection Fraction (LEVF) was 35%. Normal values for (LVEF) are 60-65% (Moser Riegel, 2008). He was commenced on a Beta Blocker Cavedilol 6.25mg and Ramipril, which was commenced post PCI and decreased from 2.5mg to 1.25 mg. Use of these medications follow the criteria of the Reducing Risk in Heart Disease (Heart Foundation, 2007). He was sent to the cardiothoracic unit on day 5 with telemetry, to monitor for any changes in his cardiac condition (Jayasekara, 2009) and discharged two days later. A systematic approach should be taken when attending to health history and physical assessment. Throughout the assessment, skin temperature, body odour, mood and appearance are observed. Patients need to feel comfortable with nurses so Mr Smith had the physical assessment explained to him and the reasons for performing it. (Brown, 2007) Mr Smiths physical assessment was completed in the morning prior to his PCI. He seemed relaxed with a jovial manner but at times did appear nervous. He was of a clean well kept appearance and looked younger than his 58 years. Neuro intact. Orientated to time, person and place, GCS 15 and PEARLA. He had a good memory of the event. Cardiovascular monitored in sinus rhythm with frequent PVCs and runs of bigeminy. ECG attached. Febrile- low grade 37.4  °, Pulse 70 bpm, blood pressure 102/69, no peripheral oedema. Jugular venous pressure was approximately 4 cms. Initially I could not palpate the apical pulse but when patient positioned onto his left side it was felt 5th ICS MCL. The reason it is felt is due to the apex of the heart comes into contact with the chest wall (Marieb Hoehn, 2010) No thrills or heaves heard. Mr Smith was warm to touch but not diaphoretic. Upon auscultation of the carotid arteries no bruits were heard. Normal S1 and S2 heart sounds were heard upon auscultation. Good radial, carotid and femoral pulses, Normal 2+ according to pulse volume scale (Lewis, 2007). Mr Smith did look pale and his haemoglobin was 121g/L. Respiratory rate of 18 per minute. Sao2 94% on 2lpm via Nasal cannula. Inspection of the thorax area revealed equal shape, size and symmetry of chest with nil use of accessory muscles. Trachea was midline. Lips and nail beds showed no signs of cyanosis. Diaphragmatic excursion was equal at 4 cms. Anterior, lateral and posterior areas revealed equal air entry, bilaterally in high and mid thoracic zones. Basal zones of thorax areas were bilaterally dull. No adventious sounds heard. Chest X-ray noted that some consolidation in bilateral bases which corresponds to the decreased air entry heard in the bases (Wang, Baumann, Slutsky, Gruber, Jean, 2010). Gastrointestinal revealed an old scar midline under the umbilicus from previous MVA. Bowel sounds heard in all 4 quadrants. Abdomen was soft with no distension. Mr Smiths upper and lower limbs and nail beds showed no signs of cyanosis or clubbing, ulceration or varicose veins. Capillary refill was normal less than 3 seconds in all limbs. Range of motions and strength were bilaterally equal and normal in all 4 limbs. Dorsalis pedis and posterior tibial veins were felt on palpation and scored 2+ bilaterally (Lewis, 2007). Acute coronary syndrome is a common cause of death. Myocardial infarction can have a good mortality rate if treated early. Treatment can be as basic as oxygen, ECG, observations, nitroglycerine through to thrombolytic therapy or a rescue angiogram/angioplasty (Overbaugh, 2009). One is not more important than the other and the patients prognosis is the main concern. Patients complain of chest pain due to myocardial oxygen demand and supply mismatching. The coronary arteries supply the myocardium with blood supply, if the supply is interrupted by a clot, spasm or atherosclerotic plaque the myocardial oxygen requirement (demand) is not met which causes myocardial cells to starve for oxygen supply. This causes the depolarization of the cells to be interrupted and changes will occur on the ECG. (Woods, 1995) Ischemia is shown on the ECG by ST segment elevation. This is primarily an emergency situation as the first 6 hours post infarction is when myocardial damage becomes irreversible (Thelan, 1994). In this time many interventions can be attended to resupply the myocardium with oxygen enriched blood supply. Oxygen is administered for at least the first 48 hours post MI so that tissue hypoxia does not become evident. At times chest pain can be relieved by applying oxygen.(Swearingen Keen, 2001) Vital signs are attended to frequently in CCU, usually hourly, which enables nurses to see any changes in hemodynamic monitoring. Complications of infarctions are heart failure and arrhythmias, due to the large area of heart wall damaged. When Mr Smith suddenly became SOB and adventious breath sounds were heard on auscultation, it alerted medical staff that his left side of the heart was congested and not efficiently pumping. Early indications of Left ventricular failure are shortness of breath (SOB) and intolerance of beta blockers, nitrates, or ACE inhibitors. Mr Smith showed signs of SOB and lightheadedness, which may be due to Ramipril ( ACE inhibitor) that was then decreased in dose (Schell Puntillo, 2006). Continuous cardiac monitoring enables nurses to keep constant checks on heart rates and rhythms, it gives nurses the ability to act on any life threatening rhythms immediately or enables them with the knowledge of impending problems that could arise (Drew, 2004). Premature Ventricular Contractions (PVC), Ventricular Tachycardia (VT) or Ventricular Fibrillation(VF) are the most likely rythyms to be noted due to the scarring or necrotic myocardial tissue (Aehlert eInstruction Corp., 2011). Mr Smith was noted to have occasional PVCs that became more frequent until he was monitored in bigeminy, which can lead to runs of VT (Huszar, 2007). Monitored patients can be observed in pulseless VT/ VF via the central monitor at the nurses station and can be immediately defibrillated, whereas if a ward patient collapses a monitor needs to be attached before the heart rhythm can be established and treatment given (McDonough, 2009). ST Segment monitoring shows significant changes in monitoring that can indicate ischemia or infarction. Central monitors should have regular nurse surveillance, will alarm if there is a significant change to the ST segment. Changes occur with or without complaints of chest pain or shortness of breath, indicating myocardial oxygen mismatch (Smith, 2008). Patients need to advised to tell staff of chest pain whilst being monitored. Some patients assume nursing staff know from the monitor when they are experiencing chest pain. (Swearingen Keen, 2001) An ECG can be performed to show any significant changes of the heart. Mr Smith showed ST segment changes in his anterior /septal (V3 V4 position) aspect of his left ventricle. This area is supplied by the Left Anterior Descending Coronary Artery. Treatment does not differ depending on which area of the heart is affected. All areas require oxygen supply. While in hospital Mr Smith was ordered serial ECGs, these are taken daily to show any changes. Expected changes expected post MI are the development of a pathological Q wave. Q waves indicate the necrosis of myocardial tissue and specifically in V1 to V4 indicates anteroseptal infarction (Dubin, 2000) Mr Smith was initially given morphine, an opioid that relieves pain by decreasing myocardial oxygen demand by decreasing the Autonomic Nervous System and decreasing anxiety (Lewis, 2007). Nitro-glycerine, was ordered as a smooth muscle relaxant that vasodilates the vessels to restore blood supply if the mismatch is due to a coronary spasm(Yassin, 2007). Aspirin is given daily indefinitely as it is a antiplatelet aggregation inhibitor that Hung, 2008 states is proven for secondary prevention of myocardial infarction, stroke and cardiovascular death in both men and women. He also discusses the combined use of clopidigrel and aspirin to reduce subacute stent thrombosis after PCIs (Hung, 2008). Thrombolytic therapy is given within the first 6 hours of chest pain.(Levin, 2008) Tenecteplase 90mg was given. Thrombolytic Therapy is given to dispel the clot and allow blood flow to the affected area. It can take up to 90 minutes for full resolution to occur (Goldberger,2010). There are certain considerations that medical staff must ensure prior to administration of this therapy, these include an absence of CVA/TIAs or surgery in the last 12 weeks (Gibson, 2009). Once administered ECGs are taken in 15-30 min intervals to see changes of ST segment, showing that myocardial blood supply and depolarization being restored. Cardiac markers are Pathology tests that also give evidence of myocardial damage. When cardiac cells are damaged the membrane walls leak these substances into the blood stream (Aehlert eInstruction Corp., 2011). Myoglobin, Creatine kinase (CK), Troponin T and Troponin I are myocardial specific and along with ST elevation can be evident of a STEMI. Ëarly in ischaemia the ST segment may lose the ST-T wave slope and appear straight. Then as the T wave broadens and the ST segment rises, the segment loses its concave form and becomes upwardly convex with elevations (Moser Riegel, 2008). Non STEMI do not have a significant change on the ECG only cardiac markers alter. These markers usually peak between 15-24 hours post infarction and remain elevated for 2-3days (Huszar, 2007) Creatine Kinase has normal value of 45-250 U/L and Mr Smiths on admission was 4290 U/L decreasing to 800 U/L, 2 days post. Troponin T normal values are à ¢Ã¢â‚¬ °Ã‚ ¤0.03ug/L but Mr Smiths ranged from 14.20ug/L at 2200hours on the day of MI, to 4.39ug/L 2 days later. Serial pathology tests are taken usually every 6 hours for the first 24 hours. Mr Smith was taken for a PCI the day after his MI. He had a stent put in his proximal area of his Left anterior descending coronary artery (LAD) in the Cardiac Catheter Lab. Mr Smiths had a PCI even though his blood supply looked like it had been reinstated, the stent will prevent clot formation again and reocclussion (Cannon, 2010). He was then transferred back to CCU and remained RIB overnight. He had a femoseal deployed into his groin to occlude the opening of the femoral vessel used for this procedure. Nurses need to do regular neurovascular and pedal pulse observations to check for bleeding or vessel occlusion (Shoulders-Odom, 2008). Mr Smith needed to be educated on his procedure pre and post operative. He has previously been for this procedure but needed re-education. It must be a daunting experience to be given twilight sedation whist having the PCI. Mr Smiths last procedure was 13 years ago which would see many new techniques being practiced that he was not familiar with. His post op education included the importance of keeping his affected leg still and care of his affected groin.(Moser Riegel, 2008) Myocardial Infarction education can be given to him at the same time but this is information that needs to be reiterated continually during his hospitalization(Lewis, 2007). He and his family need to be aware of the risk of reinfarction especially in the next 2 weeks post MI as the heart muscle is still weak and irritable and increase in activity can cause another MI. This is the time that patients start to resume their normal daily activities after hospitalization and are at the most risk. (Douglas, 2010) Documentation is very important and needs to be filled out correctly as it is a legal document (Lewis, 2007). The CCUs clinical pathway for infarction indicated strict rest in bed with commode privileges for the first 48 hours, this decreases the need for myocardial oxygen. This is difficult for active patients but it needs to be strictly followed. Due to immobility other medical complications can arise, pneumonia and decreased gas exchange, deep vein thrombosis or emboli are common. To prevent these patients are encouraged to attend to hourly Deep Breathing Exercises (DBE), leg exercises and triflow. Patients can also be sat in an upright position which increases venous return (Thelan, 1994). Anticoagulants prevent clot formation therefore Mr Smith was administered daily Clexane 90mg post PCI until discharge and administered Abciximab (Reopro) for 12 hours post PCI. To test the adequacy of anticoagulants, INR and APPT are taken to check patients dose is therapeutic. Problems with ad ministering the anticoagulant after thrombolytic therapy is bleeding (Yassin, 2007). Mr Smith was noted to have large traces of blood in his urinalysis and was sent for a Pelvic Ultrasound to be sure there was no other complications, the ultrasound was NAD. Prior to discharge Mr Smith was educated on his new regime of medications and the importance of medication compliance to decrease his risks of further cardiac complications (Albert, 2008). Nurses if experienced and up to date with current research and practices can work alongside medical staff and initiate nursing cares that are in the best interest of patients. Coronary Care Units must have confident and competent nurses to run the ward as most times they make significant decisions on implementation of nursing care. When Doctors have confidence in the nurse looking after their patients they will respect and listen to nurses opinions because they know they are educated and empowered with knowledge.

Comparing the Film Black Orpheus and the Original Greek Myth Essay

Comparing the Film Black Orpheus and the Original Greek Myth The story of Orpheus and Eurydice is one that has been retold countless times over the years. It started as a Greek myth, later being made into a movie titled Black Orpheus. After reading the myth and watching the movie, it is easy to see that there are far more differences in the two works than similarities. These differences are not only in the way the story is told, but also in the organization of the events that take place and in the description of the characters. The main differences in these two versions of the myth are the role of the characters, the main plot scheme, and the journey into the underworld. The characters in the movie, Black Orpheus, are significantly altered from the Greek myth. In the myth, Orpheus and Eurydice are together from the beginning and are completely in love. Everyone is happy for their love and the only thing that stands in their way is death. In the movie, however, this is notably changed. Orpheus begins as a streetcar conductor that was engaged to Mira, giving the idea that Orpheus was in love with another woman. We quickly see that this is not the case as Orpheus is always very curt and rude with his fiancà ©e. They are slated to get married, but there is an eerie feeling in the air that something is about to go wrong. The main difference with these characters is that in the movie, Orpheus cheats on his fiancà ©e. We soon see that Eurydice is the wildcard when it comes to Orpheus. It does not matter whether or not he is with another woman, she will do what it takes to win Orpheus’s love. This is where one of the main differences occurs. Contrary to the myth, Orpheus cheats on his fiancà ©e and gives his love and affection to Eurydic... ... Orpheus thinks that a trick is being played on him and turns around, causing Eurydice to be lost forever. This leads the viewer to believe that Orpheus was not really in the underworld and that this was just a fake journey into a nonexistent underworld. It seems quite odd that anyone can walk down a spiral staircase and be placed at the gates of Hades. This is the main reason the journey into the underworld appears to be a false one. Overall, the two versions of the story convey the same message, but in very different ways. From the differences in the characters to the plot variances, we can see that the similar messages can be portrayed in a variety of ways. The story of Orpheus and Eurydice is an ancient one that will forever be retold and altered. A prime example of this was shown in the differences between the original myth and that movie of Black Orpheus.

The day the Balloon Popped

To them, this situation didn't have a remote effect on their life, but to me, this caused my whole life to change. Even to this day, every time I am punished, I recall this soul destroying incident. But fortunately I have changed. Sorry for not introducing myself, my name is Joe Levi, I am the eldest out of three children. I am fifteen years old, very tall and sturdy like my father. I am looked up to by all my siblings and in a way, l lead them through their lives. My role model is definitely my father, part of the reason being that I am known as a miniature him. I have a big sense of responsibility in the family as I am always the first child to do or try out something new. Like every other child, I have my fears but I am much too proud to admit them. Exactly seven years ago, I experienced a day that had great significance to the rest of my life. This is an account on what happened. It was coming up to the big day. This was going to be the first time I had ever slept away from my parents. I was going to be sleeping at my Grandma's flat in the West End. To me, this was much more exciting than even a holiday. My parents had finally felt that I was responsible enough to stay away from them and be in charge of myself. I was buzzing with excitement. The closer it got, the bigger I felt. I was a balloon being blown up. I felt that I was supreme. Nothing could stand in my way. Until this incidence, I had been a plant, continuously growing upwards towards the sky. My parent's were always proud of me, academically but more importantly, they loved all my character-traits. My Grandma would be taking me into Central London, and as it was around Christmas time, it would be livelier than ever. I would be going to the Theatre late at night and afterwards, I would be going to a famous Creperie. Nothing could be more exciting. I had thoughts and feelings rushing through my body. The balloon was expanding, getting bigger and bigger. It was three days before the occasion and l had one of my closest friends over at my house. Surprisingly, the Sun was shining and it was a very warm day. So, we decided to have some fun with the sun. We got a big antique magnifine-glass out from the dining room cupboard, then stealing a piece of paper from the printer, we went out into the garden. Using the magnifine-glass, we focused the sun's rays onto the corner of the piece of paper. Suddenly, the edge of the paper started glowing red. It was fascinating. It continued to glow, but soon became a stronger colour and started spreading exuberantly. Suddenly, the first flame appeared. Wow! It was amazing what the Sun could do to a piece of paper, so far away. I found my dark hazel eyes fixed into the fire and didn't notice the whole paper bursting into flames. I screamed, my friend screamed. We poured a bucket of water over the piece of paper and put it in the bin. Before we could even open our mouths to let out a sigh or relief, the whole bin set alight. My mum came rushing down the stairs and It was as if the whole situation had combusted. I was terrified. I was frightened. I didn't know what to say. I didn't know what to do. I stared at the roaring flames, taking over my life. My mum, who was only ever seen calm, went from blue to red to orange. She went into an explosive mood. After she put out the conflagration and my friend was sent home, I sat next to my inflaming mother. When I heard the punishment that I had been given, I couldn't believe my ears. The plant stopped growing, the balloon popped. I felt as if I had disintegrated into a pile of ashes. I was as hot as the sun. I still couldn't believe the cruel, deflating punishment that had been chosen. I thought to myself, what was so bad about what I did? All my friends did it. It was unfeasible to think that something I viewed as so minor, was actually so dangerous and life-threatening. My parents knew how much I was looking forward to staying at my Grandma's. Tears started pouring down my red eyes and onto my rose cheeks. I felt put down. I felt embarrassed. What would happen when my siblings found out? I thought that they may no longer look up to me. My brain was sizzling, my head was frying. I started bellowing at my evil mother but she didn't even look at me. I lay in my room, staring outside into the garden, watching all my siblings making snowmen with their friends and having fun snow fights. I started imagining what I could of be doing if I wasn't punished. I felt completely terrible. I felt as lowly as a worm. I pictured my grandma taking someone else to the theatre, having fun with another person. Anger started building up inside of me. I could feel it spreading throughout my body. It is amazing that, something which has had such a huge long-term impact on me, had been forgotten about an hour after the incident by my parents. I was as hot as hell; however they were as cool as a cucumber. To them, this situation didn't have a remote effect on their life, but to me, this caused my whole life to progress. Even to this day, every time I am punished, I recall this soul destroying incident. But fortunately I have changed. I now deflate less and less; I stay strong and carry on growing upwards towards the sky.

The Issue Of Animal Welfare - 900 Words

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