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  • 1. FACULTY HEALTH & SOCIAL WORK UNIVERSITY OF PLYMOUTH ASSESSMENT OF THEORY NUR 258 Nursing 0ne ACADEMIC YEAR 2007 – 2008 Assessment of priories, rationale of care of individual experiencing cardiac chest pain within the general ward environment, focusing on pain as the key priority. Student Name: ALAN P JACK University Registration number: 001255 Faculty of Health and Social Work Partnership Site: CORNWALL (KNOWLEDGE SPA) Hand in deadline: 18th January 2008 Word count: 2688 Words Module Leader Carole Coleman C417Portland Square Plymouth, PL4 8AA Tel: 01752-233862 clcoleman@plymouth.ac.uk Modular Teacher/Personal Tutor: KIM YOUNG (kim.young@plymouth.ac.uk) List of Contents 1
  • 2. Front sheet Page 1 List of Contents Page 2 Confidentiality statement Page 3 NUR258 Assessment of Theory: Assignment Guidelines Page 4 Assignment Page 6 References Page 16 Appendix 1 : Example of a Modified Early Warning System Chart after Stenhouse, C. Coates, S. Tivey, M. Allsop, P. and Parker, T. (2000) Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. British Journal of Anaesthesia, Vol. 84, (5) 663. Page 19 2
  • 3. Confidentiality statement “An NMC Guide for Students of Nursing and Midwifery” (NMC 2002) states: “If you want to refer in a written assignment to some real life situation in which you have been involved, do not provide any information that could identify a particular patient” (page 5). This has been complied with in this assignment as all individuals mentioned have been given pseudonyms NMC (2002) An NMC Guide for Students of Nursing and Midwifery. London, NMC 3
  • 4. NUR258 Assessment of Theory: Assignment Guidelines September 06 Intake Module Assessment NUR 258 Adult Nursing 1 – 20 level 2 credits. Aims of Assessment In common with other modules that you will study, NUR 258 contains elements of theory and practice and seeks to integrate these into the modular assessment processes Summative Assessment The summative assessment for module NUR 258 is in two parts. Theoretical Assessment: A 2500 word essay This assignment requires you use a problem solving approach to demonstrate ability to assess and prioritise care needs for your patient. It must go beyond the purely descriptive (Please refer to the programme handbook re level two assignment guidelines.)  Choose a patient you have looked after in your current practice area.  Discuss your assessment of the patient & identify the priorities of care, giving a rationale for your decision.  Identify one key priority and discuss the care needed. Essay on competent assessment and care planning Section Content Suggested word limit Introduction Offer introductory definitions to set 250 the scene. Identify key aspects you will include in the main body, with short rationale for choice. Main body of the Discuss your assessment of the 1000 essay patient and identify & rationalise thepriorities. Discuss nursing interventionsfor the key priority for this patient, with 1000 reference to appropriate literature. Safe and appropriate care and your accountability must be evident. Conclusion Summarise the key points of250 learning in this assignment. 2500 word count. + /- 10% Marking Criteria 4
  • 5. Please refer to your programme handbook for information on the University of Plymouth’s marking criteria, referencing and correct presentation. 5
  • 6. This assignment will discuss nursing assessment, the ramifications of accountability within the scope of pain and chest pain. It will explore the use of ALERT (Acute Life- threatening Events Recognition and Treatment) and MEWS (Modified Early Warning System), pain assessment and tools and nurse biases. Andrew was a 53-year-old gentleman who was admitted with chest pain and had been found to have an Anterior Myocardial Infarction (MI) with a past medical history of Coronary Heart Disease and Unstable Angina Pectoris. He had been admitted to the acute medical ward on which I was working from the Medical Admissions Unit where this had been diagnosed. He had been on the ward for three hours when he reported that he had pain in the centre of his chest. As a result, Oxygen was administered, observations were taken and recorded and a MEWS score calculated. A doctor not that an electrocardiogram (ECG) showed no changes compared to older examples. McCaffrery (1968: 95) states ‘Pain is whatever the experiencing person says it is, existing whenever the existing whenever the experiencing persons as it does’. More specifically, Mackway-Jones (2002: 57) defines cardiac pain as ‘Classically, a severe dull ‘gripping’ or ‘heavy’ pain in the centre of the chest, radiating to the left-arm or to the neck. May be associated with sweating and nausea’. Upon assessment, Andrews care priority was reducing his cardiac chest pain. Recently, having had an MI, thus he needed to rehabilitate safely. His chest pain took precedence as it was a symptom that, if attended, could have resulted in life threatening complications, namely a further MI. Dougherty and Lister (2004e: p25) explain ‘nursing assessment includes gathering, validating and organising data, identifying patterns, and reporting and recording relevant data’. They add that it is a continuous dynamic, used collaboratively by the 6
  • 7. nurse to establish clients’ needs so care plans can be. Assessment is the first step of the nursing process, popularised by Logan, Tierney and Roper (1980), which comprises assessment, planning, implementation and evaluation of care. With the communication skill such as active listening and appropriate use of questioning, the nurse can determine what needs the patient has at present and will have in the future. If assessment is not at an optimum or a robust enough level, then all other aspects of the nursing process will not be met, moreover, resultant care could be both unsafe and inappropriate to the care needs of the client. There are many reasons for reducing/eliminating pain, these incorporate deontology and ethics. The Code of Professional Conduct: Standards for Conduct, Performance and Ethics (Nursing and Midwifery Council (NMC), 2004) explain how due to contracts of employment, the nurse has a Duty of Care for patients. This involves having to act continuously beneficently and in a non-maleficent manner. Therefore as a registered nurse, it is important to acknowledge that you have duty to reduce pain and prevent deterioration of Andrew’s condition. The code of conduct notes that registrants on the NMC Register of Nurses, Midwives and Community Public Health Nurses (NMC, 2008) are accountable for their actions or omissions in a Court of Law. The implications of this accountability extend to any delegated task given to other workers whom the nurse must know are competent to do the task. As a result of a Department of Health (DH) report, “Comprehensive critical care: a review of adult critical care services” (DH), the ALERT (Acute Life-threatening Events Recognition and Treatment) course was created (Smith 2003). This course, based around a manual, was designed to assist acute healthcare professionals to recognise early signs that patients may be deteriorating. It encourages workers to predict and prevent and treat deterioration whilst communicating their actions to 7
  • 8. both patients and others in the multidisciplinary team. There is an acknowledgement that workers on non-critical care can find dealing with acute deterioration extremely stressful. Furthermore, the DH document called for an early warning scoring system to be introduced for detecting such deterioration. One of the major tenets of the ALERT course is the use of the ABCDE mnemonic, which stands for airway, breathing, circulation, disability and exposure. ABCDE is used to prioritise the assessment of an individual patient. Each of these areas needs to be attended to and any problems noted dealt with prior to proceeding on to the next letter. The professional would use a look, listen and feel approach, for example if an individual has an occluded airway it is imperative it is dealt with prior to dealing with the patient not breathing. Airway is the first area to be addressed. Andrews’s airway was patent, which was evident by the fact that he was able to talk in sentences without any impedance as well as corresponding appropriately to questioning. Had his airway been compromised, this would not have been possible and the emergency team would need summoning. Smith (2003) identifies how opening the airway or use of a jaw thrust would be needed in an emergency to attempt to gain a patent airway. Once a patent airway has been established, breathing should be assessed. This should include how the individual appears such as evidence of cyanosis, evidence of sweating, depth and rate. Listening to breathing will assist in establishing if there are any problems such as excessive secretions or wheezing/stidor which may be indicative of partial airway obstruction (Smith 2003). Moore and Woodrow (2004) note that respiratory failure is the most common cause of admission to High Dependency Units. 8
  • 9. The assessment of circulation is primarily concerned with the effectiveness of the cardiovascular system to perform gaseous/nutrient transfer throughout the body. This is assessed by assessing capillary refill time (Ahern et al, 2002). Cyanosis is also indicative of cardiovascular impairment as it can mean that Oxygenation of the tissues is not occurring adequately (Smith 2003). Blood pressure, pulse and Oxygen saturations are also measures of cardiovascular function. Andrew had had a MI which meant that some of his cardiac muscle had died. These necrosic areas could no longer contract/relax in synergy with the rest of his cardiac muscle thus reducing the effectiveness of his heart’s pumping action. ECGs can also show the rhythm and rate of the heart as well as indicating any areas of cardiac insufficiency (Kumar 2006). Within the ABCDE rubric, the presence of disability pertains to the individual’s neurological state. Smith (2000) advocates the use of AVPU scoring (American College of Surgeons, 1997). This system is used to assess the alertness of an individual by classifying her/him as alert, responding to voice or pain or if the individual is unconscious. It forms part of the MEWS score. It is provides a rapid assessment of the consciousness of an individual but does not take into account if an individual is confused which can be indicative of neurological deficit. It is also not as rigorous as the Glasgow Coma Scale which is widely used for more in depth neurological assessment (Dougherty and Lister, 2004). Once all the above steps have been assessed and dealt with, then a fuller assessment of the patient is undertaken under the exposure label. This is a head to toe assessment and is where such areas as temperature blood glucose and pain are considered. 9
  • 10. All aspects of the ABCDE are considered within the modified early warning system score. Subbe et al (2001) devised a score which encompassed systolic blood pressure, pulse, respiration and temperature. Stenhouse et al (2000) then included urine output and normal blood pressure so that deviations in temperature would be less sensitive. This is the scoring system which is used in the ALERT course (Smith, 2003). In a well argued paper, Johnston et al (2007) suggests that although early warning scoring can be sensitive to deterioration, their potential is not maximised and the developmental rigour of both critical care outreach teams and MEWS are both poor. They call for more research into the physiological trigger factor variables which elicit the calling of outreach teams. The MEWS score is calculated by allocating the results of clinical observation a score from 0 to 3. If the total score exceeds 4, the protocol in Appendix 1 is followed. Chest pain is one of the leading cause of acute hospital admission in the United Kingdom, accounting for approximately 20-40% of acute medical admissions (Capewell and McMurray, 2000). These figures appear to be the only ones available thus more recent research would provide some valuable information. Its origin can be as diverse as from resulting from a myocardial infarction (MI), angina pectoris, 10nfracted10l/gastic origin, to anxiety (Kessenich, 1999). Melzack and Wall (1996) argue that it pain, generally, is a multi-factoral concept encompassing both physiological and psychological factors. Epstein (2003) reports that MI is the major cause of chest pain on admission to hospital and can present itself with severe, central crushing (sometimes described as band-like or severe indigestion) which can persist 15 to 20 minutes, despite rest or the use of Nitrate preparations. The patient may appear pail and be sweating perfusely. Hypotension may be present with reduced pulse pressure (difference 10
  • 11. between systolic and diastolic readings). This may be due to compromised pumping potential caused by 11nfracted areas of muscle. The pulse may be irregular with ectopic beats. He also acknowledges that with elderly patients and individuals with Diabetes Mellitus symptoms may be present with reduced levels of pain being reported due to neuropathy. The cause of chest pain in MI is due to insufficient perfusion to the heart due to an embolus, travelling blood clot, lodges in one of the coronary arteries. This is the mechanism by which the administration of high flow (as near as 100%) Oxygen works. Insufficient oxygen is being perfused to the cardiac muscle thus the heart is less efficient. This leads to insufficient oxygen perfusion to the rest of the body, which is detected by chemoreceptors responding to acidosis caused by build up of Carbon Didoxide in tissue. This, in turn, stimulates tachycardia, thus increasing strain on the heart. Increasing inhaled Oxygen percentage results in increased perfusion and strain thus pain reduction. Respiration rate will increase by this mechanism also which will be stimulated to reduce in the same way (Clancy and McVicar, 2002). The British National Formulary 54 (BNF) (2007) suggests that Oxygen, Diamorphine and Nitrates are the used in initial support and for pain relief. High flow (up to 60%) oxygen can be given (Section 3.6) does not cause extreme risk in Pneumonia or fibrosing alveoli as lower arterial Oxygen levels are associated with normal or lower levels of arterial Carbon Dioxide. This is not the case in Asthma where positive airway pressure may be required to remove excess build up of Carbon Dioxide and Chronic Obstructive Pulmonary Disease. Other methods of reducing chest plain include the administration of Glyceryl Trinitrate (section 2.6.1) which acts as a vasodilator. The stenosed coronary vessels 11
  • 12. dilate thus facilitating blood flow thus increasing oxygenation. This medication can cause hypotension as the lumen of the vessels increases whilst the volume of blood remains constant thus pressure exerted by the vessels is less. For this reason, its use is contra-indicated in Aortic Stenosis as the reduced lumen of the aorta, the primary artery of the body, cannot provide adequate blood flow to not only the heart but the rest of the body. Glyceryl Dinitrate can be given in intravenous form to induce vasodilation but regular assessment of blood pressure must be made as hypotension is a complication. Diamorphine is another pain killer which is used widely and effectively with individuals with chest pain. The BNF (section 4.7.2) states that is does not cause neither as severe hypotension or nausea as morphine. Intravenous administration provides the fasted route. If it is only used in emergency situations; the risks of dependency on the part of the individual are low. However, if an individual has a propensity for addiction/dependency upon morphine then this may be a problem. As an opioid, it can suppress the respiratory centre in the brain. Once morphine has been administered, it is very important that respiratory rate is monitored at regularly. Assessment of pain can be complicated due to its subjective nature with many tools used attempting to measure it. Several visual scales are analysed by Duke (2006).the visual analogue scale consists of a line with no pain at all at one end and the worst pain possible at the other. The numerical rating scale is similar that has figures 0 to 10 marked on it. The verbal rating scale is similar to the visual analogue scale that has increasing description of pain degrees from no pain at all to worst possible pain. These provide some idea of the patient’s own perception of her/his pain. She cites Turk (1989) as being one of the first writers to argue that pain may not be linear and maybe more complex and that the unidirectional approach may 12
  • 13. cause distortion to the individual’s pain experience. Also, the individual needs to be able to understand the concepts involved as well as being able to express her/his self and be understood for these tools to be effective. Some pain assessment tools use acronyms an aide-memoir to consider the different dimensions of pain assessment. “OLD CART” (Onset, Location, Duration, Characteristics, Accompanying symptoms, Radiation and Treatment) (MacAvoy, 2001) and PQRST (provocation and palliation, quality of pain, region and radiation, severity on a 0-to-10 scale and timing) (Wentz, 2003) are mnemonic pain assessment tool. The former is specifically designed for cardiac pain. However, both tools origin is unknown and little is written about them, moreover its rigour, uses and limitations. More research in this area could provide some light in these areas. Much research has been carried out into how Nurse’s biases can influence their assessment of pain in individuals. This is exemplified by Macfrey et al (2007) who compare how respondents to 2 vignettes created by Marks and Sachar (1973). These vignettes, one describing 2 similar 25 year olds who report eight out of ten pain scores, one smiling and one grimacing, were presented to individuals attending pain conferences. They were asked what pain score they would record on the patients pain and if they would give more intravenous morphine. Results showed that, over time, more nurses reported that they would actually recorded 8/10 pain scores for both clients and would also give higher levels of morphine. Although this may give an insight into the attitude of Nurses, there are several flaws. The respondents are dealing with vignettes, not actual patients so ethnographic validity is an issue. Also, both patients mentioned are male thus the question of different responses may have been different if they had been female. Furthermore, on some 13
  • 14. occasions, the vignettes were not in their original form so methodology can be criticized. Cardiac chest pain can have serious implications if action is not taken quickly after it inception. For this reason timely and effective assessment is essential. Nurses are accountable for their actions/inaction and have a duty to respond if individuals reporting pain, not only for physiological reasons but for humanitarian ones also. Pain assessment can be complex. Not only are there issues of measuring the intangible but also issues of nurse bias. Several tools can be helpful but these require the client to be able to show understanding as well as appropriate expression. There are several chemical pain relievers but these all require skilled nursing assessment. A Nurse making an assessment of pain must be weary of not allowing her/his own biases to enter proceedings as this may cloud her/his judgement when making clinical decisions, thus delivering suboptimal care. Much has been learned during the writing of this piece. This includes much about the ALERT course and some of the processes involved. The value of incorporating ALERT into pre-registration Nursing could be considered. This could have ramifications for Nursing as a whole as individuals would be more aware of signs that could be indicative of patient deterioration and the steps to take to summon help where required. Pain, especial when of cardiac in origin, is a very complex concept requiring specialist assessment part of which can be facilitated by understanding the nature of pain and being aware of the psychological aspects of it. (2688 Words) 14
  • 15. References American College of Surgeons (ACS) (1997) Advanced Trauma Life Support Manual. Sixth edition. Chicago, American College of Surgeons. In: Ahern, J. and Philpot, P (2002) Assessing Critically Ill Patients on General Wards. Nursing Standard 16(47), pp 47-56 British National Formulary 54 (2007) London. BMJ Publishing Capewell S, McMurray J (2000) Chest pain-please admit: is there an alternative?. A rapid cardiological assessment service may prevent unnecessary admissions. British medical Journal. 8;320(7240):951-2. Clancy, J. and McVicar, J. (2002) Physiology and Anatomy. London: Arnold Department of Health (2000). Comprehensive critical care: a review of adult critical care services. London. Stationery Office Dougherty, L. and Lister, S. (Eds)(2004) The Royal Marsden Hospital manual of clinical nursing procedures (6th ed) Oxford: Blackwell publishing Duke, S. (2006) Pain Management in: Alexander,-M.., Fawcett, J. and Rucciman P. J. (2006) Nursing practice: Hospital and Home – The Adult. Churchill Livinstone: London Epstein, O. (2003) Clinical Examination. 3e London: Mosby. Johnstone, CC. Rattray, J. and Myers, L. (2007) Physiological risk factors, early warning scoring systems and organizational changes. Nursing in Critical Care. 12 (5) pp 219-224, 15
  • 16. Kessenich, C R. (1999) Differential Diagnosis of Chest Pain: A Case Report. Gastroenterology Nursing. 22(1):10-12. Kumar, D. (2006) Cardiac Monitoring: New Trends and capabilities. Nursing. (34) pp 7-10 MacAvoy, J (2001) Cardiac pain: Discover the unexpected: Staff Development Special. Nursing Management. 32(2), pp 27-34 Mackway-Jones, K. (2002 ed) Emergency Triage, 9e, Publishing Group, London Marks, RM. and Sachar EJ. (1973) Undertreatment of medical inpatients with narcotic analgesics. Annals of International Medicine ;78(2):173–81 McCaffery, M. Pasero, C. Ferrell B R (2007) Nurses' Decisions About Opioid Dose. American Journal of Nursing. 107(12), December 2007, p 35–39 McCaffery, M. (1968) Nursing Practice Theory Related to Cognition, Bodily Pain, and Man-Environment Interactions. University of California, Los Angeles in: Dougherty, L. and Lister, S. (2004 Eds) The Royal Marsden Hospital manual of clinical nursing procedures (6th ed) Oxford: Blackwell publishing Melzack R, Wall P D (1996) The Challenge of pain. Marmondsworth, Penguin Moore, T. and Woodrow, P. (2004) High Dependency Nursing Care: Observation, Intervention and Support. London: Routledge, Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for conduct, performance and Ethics. London: Stationery Office: 16
  • 17. Nursing and Midwifery Council [online] (2008) Nursing and Midwifery Register http://www.nmc-uk.org/aSection.aspx?SectionID=20 (visited 17 January 2008) Roper N., Logan W.W. & Tierney A.J. (1980). The Elements of Nursing. London, Churchill Livingstone Smith, G. (2003) ALERT - a Multi-professional Course in Care of Acutely Ill Patients. Portsmouth, University of Portsmouth. Stenhouse, C. Coates, S. Tivey, M. Allsop, P. and Parker, T. (2000) Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. British Journal of Anaesthesia, 84, (5) 663. Subbe C.P., Kruger M., Gemmel L. (2001) Validation of a modified Early Warning Score in medical admissions. Quarterly Journal of Medicine; 94; 521-6. Turk, D. C. (1989) Assessment of Pain: the Elusiveness of Latent Constructs. In Chapman, C. R. and Loeser, J. D. (eds) Issues in pain measurement. Advances in pain research and therapy. 12. New York: Raven. Wentz, J. D (2003) Assessing pain at the end of life. Nursing. 33(8), p 22 17
  • 18. Appendix 1: Example of a Modified Early Warning System Chart after Stenhouse, C. Coates, S. Tivey, M. Allsop, P. and Parker, T. (2000) Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. British Journal of Anaesthesia, 84, (5) 663. 18
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