Exploring Real Nursing Practice - Case Study Example

Exploring Nursing Practice For the present study for greater insight in nursing practice a 58-year-old man with an 8-month history of progressive dyspnoea and hypertension was kept under the scientific study focus. The history of the patient included his inability to climb a flight of stairs or walk across a room without stopping. The patient denied presence of any chest pain or palpitations but reported of having episodes of light-headedness for the past six months. The patient under scientific study consideration is white and non-diabetic. The past medical history of the patient includes a mention of being a sufferer of peptic ulcer since 20s. In addition, the patient had suffered from a fracture of his right tibia and fibula at the age of 35 because of road traffic accident. The patient has also been reported of being suffering from systolic hypertension and raised cholesterol levels. On examination the patient was reported of being apyrexial, having irregular pulse of 88 bpm, blood pressure of 180/90 mmHG, jugular venous pressure elevated by 4cm. On examination it was discovered that the apex beat is not palpable and on auscultation there is a grade 2/6 pan systolic murmur at the apex and an audible third heart sound. The patient has mild peripheral oedema and auscultation of the lungs reveal mild inspiratory crackling. Neuro-examinations revealed sensory neuropathy affecting his feet. The patient was diagnosed of dilated cardiomyopathy secondary to alcohol. The patient has been reported of being presenting with signs of congestive heart failure and an irregular pulse. The ECG revealed left bundle branch block and atrial fibrillation. An echocardiogram showed dilated cardiomyopathy, functional atrial regurgitation and evidence of atrial valve prolapse. The left atrium was dilated at 4.7cm. This patient has been suffering from heart failure. He was initially given Frusemide intravenously and Perindopril 4mg once daily with improvements in symptoms. He was then prescribed Atenolol 100mg once daily and Amiloride 5mg twice daily. As we have studied in the brief reference of the patient that he is being suffering of mild peripheral oedema, it is essential to focus our attention on oedema as an essential nursing problem for addressal for the patient. The scientific study of the patient has also brought to the medical knowledge that the patient was suffering with atrial fibrillation and the resultant consequences of which have been reported as being shortness of breath due to pulmonary oedema and oedema of the lower limbs. In addition study has also presented an essential finding of the patient being oedematous right up to his waist, which severely restricted her mobility. The prescription of Furesemide can therefore be presented for the removal of excess fluid. The administration of Frusemide shall be seen as a general reduction of oedema. The improvement in mobility can thus result because of a reduction in leg swelling. An improvement in the mobility shall result in the venous return from his legs due to the action of his leg muscles. A reduction in the effects of pulmonary oedema resulted in an improvement in breathing. The improvement in breathing shall then benefit the process of healing by causing an increase in the level of oxygen in his blood (Phillips, J., 1997). It is also essential to note here that immobility can be considered as an extrinsic factor in the development of pressure sores. (Austin, 1999). The patient may be nursed in the hospital and during his stay be provided with two pressure relieving aids, a Roho cushion and an alternating-pressure mattress. The use of pressure relieving aids has been considered essential because of the high risk of developing pressure sore. This can be presented to the platform of scientific knowledge by the use of the Waterlow scale. The health benefit of pressure relieving aids can positively be guided by the Waterlow scale, however the beneficial effect can respire with even greater prominence by encouraging the patient to change position regularly. This object of health attention benefit can sometimes be overlooked on the assumption that the cushion or mattress shall prevent causation of further deterioration (Phillips, L., 1999). It is essential to note that a deficiency in the required level of nutrients, micronutrients and oxygen supply to the wound are essential at every stage of healing. However, the necessity of the optimum level of nutrients, micronutrients and oxygen supply is substantiated to a greatest level in the inflammation state, which can therefore significantly affect the process of healing. It is essential to note that all nutrient groups hold an essential place in the maintenance of a healthy body. This specific need shows an increase in the case when damage takes place to the body. This can be reflected also in the need of protein for the production of collagen at the site of wound. The necessity for protein also shows an increase since quite a significant amount gets lost from pressure sore wounds. In addition, the necessity of the patient of energy from carbohydrates and fats shall also exhibit an increase due to the difficulty with breathing and an increase in the effort of muscle. The body also exhibits the need of micronutrients. Micronutrients include in its area of inclusion those elements of a proper diet such as minerals and vitamins, which are required in very small but essential quantities (Kershaw, 1997). Vitamin C is an example of micronutrients, which holds its important place in the formation of collagen as it helps in the formation of strands between the amino acids. In the healing process the enzymes involved shall include the need of zinc. Therefore a deficiency of zinc can result in less of the enzymes needing zinc and thus causing delay in healing. Another important micronutrient is iron whose deficiency can cause anemia and therefore result in the reduction of the oxygen carrying capacity of the blood. A decrease in the level of oxygen can cause in slowing down of the healing process. In the case of the present patient his appetite was greatly reduced in the diseased condition and this resulted in a severe impairment in the progress. In addition, it is important to consider that there is a dominant need of making a choice of a right dressing for the proper treatment of the pressure sore should not be underestimated. Therefore the development of many of the modern dressings, which hold their availability to nurses, shall be developed after research into the essential factors that shall be the promotion of wound healing. This can also be realized by the fact that Winter (1962, cited in Russell, 2000) concluded that moist wound granulated at a significantly faster rate than the dry one. Other scientifically important research work of important factors affecting wound healing has indicated that the optimum dressing should include provision of a moist environment and provision of exchange of gases. It should also hold the efficiency to provide a barrier to bacteria and thus allow the maintenance of wound at 37 degree Celsius so as to have leukocyte activity. The removal of excess exudates and allowance of dressing change without wound trauma and maintenance of wound pH are other essential points that need the rays of scientific consideration in the platform of optimum dressing. Also, it should be free of particulates, which may be shed into the wound (Mallett & Bailey, 1996, and Russell, 2000). Based on the knowledge gained by virtue of previous experience as a nurse we may recommend the use of Lyofoam as a dressing which is a choice holding its essential preference in pressure sore. Lyoform holds the essential benefit of meeting several criteria as were set important. It is also greatly suitable for resulting in the absorption of large amounts of wound exudates. Congestive heart failure is a gradually developing inability of the cardiac system to pump the required blood with an aim to meet the needs of the body. Thus, in congestive cardiac failure the heart fails to function as an efficient pump. Congestive heart failure results in an inadequate cardiac output that becomes the cause of breathlessness on exertion and may also be seen at rest. This causes a decrease in the level of exercise tolerance. For the purpose of treatment it is important to consider the beneficial effects of cardiac glycosides on the heart. Cardiac glycosides are naturally occurring drugs whose mode of action includes both positive effects and negative side effects on the heart. It is important to note that in the intervention of the present patient the desirable cardio tonic action is of great benefit in the treatment of congestive heart failure and associated edema. The introduction of foxglove and some of its medicinal uses has resulted in the standardization of cardiac glucose therapy (Rietbrock, and Woodcock, 1985; Smith, 1984). The purification and therapeutic benefit realization of purified cardiac glycoside preparations has gained insight in recent times. Cardiac glycosides exhibit positive affect on the heart in a dual fashion. It acts directly on the cardiac muscle and the specialized conduction system of sinoatrial (SA) node, atrioventricular (AV) node, and His-Purkinje system. It acts indirectly through the autonomic nerve reflexes, which are mediated by the cardiovascular system. These direct and indirect effects of the cardiac glycosides results in the causation of changes in the electrophysiological properties of the heart. These positive effects include alteration of the contractility, and other important functions of the heart. The chief therapeutic benefit of digitalis glycoside, a cardiac glycoside is for the treatment of congestive heart failure. However, it is essential to note that these agents can also be used in the cases of atrial flutter or fibrillation. In addressing the problem of congestive cardiac failure by means of digitalis glycosides or other cardiac glycosides it is also essential to holds an attentive focus for the treatment of cardiac glycosides toxicity. For the purpose of this it is important to administer potassium slats with an objective to increase intracellular potassium level, which causes the stimulation of sodium-potassium pump that results in, decreased intracellular sodium levels and thus decreased intracellular calcium. It is also important to keep in the area of medical focus the need of discontinuation of cardiac glycosides and addition of potassium salt in order to treat toxicity. Other important drugs that might prove themselves of being beneficial in the treatment of tachyarrhythmias holding presence in the treatment of toxicity include lidocaine, phenytoin, and propranol. In addition, the beneficial effect of specific antibodies directed towards digoxin has been proved on experimental grounds. In the administration of digitalis glycosides it is also essential to keep an attentive eye at the probable drug interactions. This is because the gastrointestinal absorption of digoxin and digitoxin after oral administration can experience a significant alteration because of the presence of other drugs. For example, the absorption of digoxin can be interfered by laxative. This effect of laxatives can act at physiological level because of increased intestinal motility. Also, antacids especially magnesium trisilicate may cause inhibition in the absorption of the glycosides. Different degrees of arrhythmias may be caused by the concurrent use of the cardiac glycosides with antiarrhythmics, symapthomimetics, calcium salts, and calcium channel blockers. The absorption of cardiac glycosides can also be affected by the antidiarrheal adsorbent suspensions. It is also essential to note that potassium-depleting diuretics like thiazides may cause an increase in the level of digitalis toxicity that results from the additive hypokalemia. For the purpose of treatment of patients with atrial fibrillation the combined US/European guidelines are available (Fuster V, Ryden LE, Asinger RW, 2001; Peters NS, Schilling RJ, Kanagaratnam P, Markides V, 2002). Figure 1. Current clinical issues in atrial fibrillation have been shown in the graph above Chung, M. K. (2003). Summary The patient under consideration of scientific study was presented atrial fibrillation. In the present paper the two nursing problems hat were considered for scientific addressal are congestive cardiac failure and oedema. The evidence base for atrial fibrillation has been briefly presented in the present essay. References Austin, G. (1999) Eating into resources. Nursing Times. 95(11). pp65-67. Chung, M. K. (2003) Current clinical issues in atrial fibrillation Cleveland Clinic Journal of Medicine Volume 70 - Supplement S6 - S11. Kershaw, B. (ed). (1997) Bailliere's Nurses' Dictionary (22nd edition). Bailliere Tindall, London. Mallett, J., Bailey, C. (eds) (1996) The Royal Marsden NHS Trust: Manual of Clinical Nursing Procedures (4th ed.). Blackwell Science Ltd, Oxford. Phillips, J. (1997) Pressure Sores. Churchill Livingstone, Edinburgh. Phillips, L. (1999) Pressure ulcers - prevention and treatment guidelines. Nursing Standard. 14(12). pp56-62. Russell, L (2000) understanding physiology of wound healing and how dressings help. British Journal of Nursing. Pp10-21 Rietbrock, N. and Woodcock, B. G. (1985). Trends Pharmacol. Sci., 6, 267. Smith, T.W. et al., (1984). Prog. Cardiovasc. Dis., 26, 413; 27, 21. Fuster V, Ryden LE, Asinger RW et al. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation). European Heart Journal 2001; 22(20):1852-1923. Also published in: Circulation 2001; 104(17):2118-2150, Journal of the American College of Cardiology 2001; 38(4):1266 Executive summary available: http://www.acc.org/clinical/guidelines/atrial_fib/ exec_summ/exec_afindex.htm [accessed 22.12.03] Peters NS, Schilling RJ, Kanagaratnam P, Markides V. Atrial fibrillation: strategies to control, combat, and cure. Lancet 2002; 359: 593-603 Read More