Chest Pain Case Study
The presenting patient in the present case scenario is Mr. Hay, an 82-year-old male with an existing diagnosis of Cardiac Obstructive Pulmonary Disease (COPD). This existing diagnosis will prove relevant in a care plan for Mr. Hay, who has been admitted following a loss of consciousness. Having been discovered by a neighbor after some sustained period of unconsciousness, Mr. Hay would be admitted with an array of treatment issues. The three most pressing would prove to be the patient’s Activity Intolerance, his Ineffective Airway Clearance and his Pain management. The discussion here below considers these treatment challenges.
Patient Problem 1: Activity intolerance
In any case where an elderly patient is admitted to the hospital, sedentary conditions can lead to an exacerbation of existing illness or to the formulation of new and problematic health concerns. This is especially true for the patient for whom excessive activity may produce negative health consequences as well. This is the case for the Mr. Hay, whose vital signs demonstrate the need for light but regular activity engagement.
For Mr. Hay, several factors are responsible for his activity intolerance and must therefore be accounted for even in the stimulation of activity. First, the fall caused by the patient’s loss of consciousness has produced injuries to hip, ankle and shoulder. These injuries are likely to be an obstruction in the patient’s attendance of daily physical engagement.
Additionally, the symptoms of Mr. Hay’s COPD present a distinct challenge to ambulatory behavior. Shortness of breath, to be addressed in greater detail in the section below, may lead to dizziness, fatigue or disorientation and must therefore be monitored closely during the engagement of physical activity. Likewise, all evidence points to a mounting cardiac issue — in all probability related to the existing COPD diagnosis — that must itself be managed with care. Any physical activity must be offset by recognition of the patient’s immediate cardiac state. The patient’s heart-rate is recorded at 106 beats per minute (BPM). This is high relative to the normal rate of 60 to 100 BPM. This is consistent with MRIs showing the patient’s moderately enlarged heart and a blood pressure reading placing the patient in the hyptertension risk index with a reading of 160 over 95.
These conditions collectively produce an intolerance to physical activity that must be managed and overcome in order to protect the patient from the danger of physical decline that may accompany hospitalization. The condition calls for assisted, light physical ambulation several times a day with constant monitoring of vital signs for indications of over-stimulation.
Patient Problem 2: Airway clearance, ineffective
The second problem of pressing importance is the patient’s airway clearance difficulties. Here, a range of presenting symptoms suggest a worsening of Mr. Hay’s COPD. The patient has experienced and, at the time of admission, continued to experience, respiratory difficulty. The patient’s pursed lips and shallow breath suggest that he is struggling to breathe without assistance. Having performed medication reconciliation, caregivers have determined that the subject is already taking antibiotics for treatment of this condition. However, the progressive nature of COPD denotes that the subject’s breathing difficulties are accelerating even with the administration of medication.
This is likely the leading cause of the patient’s loss of consciousness and denotes a pressing health problem. At the point of presenting, it is incumbent upon caregivers to provide the patient with breathing assistance. According to the text by Sanders (2011), the Venturi Mask is likely to be the most appropriate assistive device in this process. Sanders indicates that this particular apparatus is “advised for patients who rely on hypoxic respiratory drive. This includes, for example, patients with COPD. The main benefit of the Venturi Mask is that it allows precise regulation of the FiO2. It also permits the paramedic to titrate oxygen for the patient with COPD so as not to exceed the patient’s hypoxic drive while allowing enrichment of supplemental oxygen.” (Sanders, p. 422)
In addition the Venturi Mask which can help to normalize pulmonary activity, the patient is also experiencing a productive cough with thick yellow sputum. The presence of excessive mucus is also likely contributing to Mr. Hay’s airway blockages. This would be an appropriate place to use the Yankeur sucker in order to help remove fluids that might be making it more difficult for the patient to breathe independently.
Patient Problem 3: Pain
Also of critical importance once the patient’s vital signs and breathing have been stabilized is the management of pain. This is especially pressing in an older patient with indicators of high blood pressure and other abnormal cardiac abnormalities. Excessive pain may stress the subject’s body and lead to an intensification of other more troubling symptoms.
Two particular sources of pain require management and attention. First and foremost, the subject’s chest pain must be reduced so as to improve the patient’s comfort and lower the risk that this could mount into a more pressing issue of patient distress and its attendant possibility of true cardiac arrest. In this case, the recommended course of treatment is a Vasodilator. Provided that no conflict can be determined between existing prescriptions such as the COPD antibiotic, and provided that no patient allergies exist, Sanders provides a rationale for this approach as a way of diminishing chest pain symptoms. As a valuable side-effect, the properly selected Vasodilator may also reduce the patient’s demonstrated proclivity for high blood pressure. According to the text by Sanders, “in addition to their use as antihypertensives, some vasodilator drugs work to treat angina pectoris (ischemic chest pain). For example, nitrates dilate veins and arteriesâ€¦.the subsequent decrease in wall tension helps to reduce myocardial oxygen demand and also relieves the chest pain of myocardial ischemia.” (Sanders, p. 314)
Also necessary for pain management is treatment of pressure injuries produced by the subject’s fall and unconsciousness. This should include x-rays of the sited points of the hip, ankle and shoulder, proper stabilization of impacted points and the prescription of an anti-inflammatory presuming, once again, that no drug conflicts or allergies can be determined.
The three patient problems and treatment strategies outlined above should also be used to issue the patient a comprehensive plan for follow-up treatment and self-care following discharge.
Australian Nursing and Midwifery Council. (2006). National competency standards for the midwife. Retrieved from: http://www.nursingmidwiferyboard.gov.au/Codes-and-Guidelines.aspx#competencystandards
Ambulance Victoria. (2012). Ambulance Victoria clinical practice guidelines for ambulance and MICA paramedics. Retrieved from: http://www.ambulance.vic.gov.au/Paramedics/Qualified-Paramedic-Training/Clinical-Practice-Guidelines.html.
Courtney, M. (2005). Evidence for nursing practice. Marrickville NSW: Livingstone Churchill Elsevier. Page 19 of 24.
Johnson, R. & Taylor, W. (2010). Skills for midwifery practice (3rd ed.). Edinburgh: Elsevier.
Sanders, M.J. (ed.) (2011). Mosby’s paramedic practice (4th ed.).St. Louis, MO: Elsevier.
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