Nursing Interventions to Prevent PostCoronary Angioplasty Stroke and Neurovascular Outcomes - Essay Example

Nursing Interventions to Prevent Post–Coronary Angioplasty Stroke and Adverse Neurovascular Outcomes: The Case of Elizabeth Rose Green This paper is discussing nursing interventions that will minimize neurovascular deterioration and stroke outcomes which are normally associated with the post-surgery period in cases where coronary angioplasty has been applied. Born in 1936, Mrs. Elizabeth Green, a mother of two has just undergone a coronary angiogram plus stenting procedure. Mrs. Green is a former smoker and she is currently suffering from osteoarthritis and type 2 diabetes which is diet controlled. Mrs. Green was rushed to hospital by an ambulance team after experiencing continued chest pains while she was doing her dishes in the morning.In Mrs Elizabeth Green’s case, most of the risk factors are presented in her history, including genetic outcomes. In the case study, the family history reveals that Mrs Green’s mother suffered from cardiac disease, and artery blockages run in the family. However, despite knowledge of potential risk factors, the role of genetics cannot be confirmed with certainty, as genetic testing on this front is not yet available. It is more likely that Mrs Green will develop notable adverse outcomes after the coronary angioplasty, including neurovascular complications and stroke. According to the clinical guidelines of the Royal Children’s Hospital Melbourne, monitoring the neurovascular status of a patient is mandatory in order to ensure that neurovascular compromise or deterioration is recognized early. The clinical guidelines define neurovascular as the overall functioning and structural formation of the combined nervous and vascular systems. Delays in recognizing a loss of neurovascular function post–coronary angioplasty could result in a loss of limbs, permanent deficits or even death. For an RN or clinical facility, such outcomes could constitute clinical negligence, which could lead to law suits against the facility for professional negligence or even ethical disciplinary proceedings by the Nursing and Midwifery Board of Australia for failing to provide nursing care according to documented treatment or care plans. Indeed, the board’s national competency standards for RNs require them to use all available evidence, including reports, records and personal experience or knowledge, for the provision and coordination of care. The standard nursing practice is to provide neurovascular assessment and observation for patients who have some form of musculoskeletal trauma or are in the post-operative stages of health care. According to the case, Mrs Green had just undergone cardiac catheterization. According to standard nursing practice, she was a suitable candidate for neurovascular assessment. Furthermore, she was also experiencing a musculoskeletal trauma, as she was suffering from osteoarthritis, which increases the risk of neurovascular compromise. The care plan for Mrs Green should focus on regular neurovascular assessments, particularly of the limbs, as Mrs Green’s left foot was pale and cool and there were pedal and dorsal pulses present. The frequency of neurovascular observation varies according to individual care facilities. The clinical guidelines of the Royal Children’s Hospital Melbourne recommend a post-surgery frequency of one observation hourly for the initial 24 hours, with observations every four hours for a further 48 hours. The observations should be more frequent if any deviation from the baseline observations is noted. In Mrs Green’s case, the cardiologist conducted a neurovascular observation at 1400, exactly one hour after she had undergone her scheduled angioplasty. The cardiologist requested the RN to continue with the neurovascular observations on a half-hourly frequency for the following two hours in order to check for any change in outcomes. When conducting a peripheral vascular assessment, a pale colour and a cool temperature are indicative of inadequate arterial supply. According to Judge (2007), neurovascular assessment must consider the neurological and vascular integrity of the limb, including the warmth of the limb and the existence of pain or swelling. Mrs Green would have faced an increased risk of neurovascular compromise if there was excessive swelling. Doppler Ultrasound or Duplex Ultrasound (DUS) is the best diagnostic non-invasive imaging solution for easily isolating the sites of occlusion. However, this diagnostic imaging technique is operator dependent, so it should be conducted by a well-trained sonographer. In Elizabeth’s case, it is the cardiologist who instead performs the Doppler ultrasound instead of a sonographer or a radiographer. A radiographer or a sonographer is the healthcare professional with specialty in such imaging techniques for purposes of producing diagnostic images and data. One wonders why the cardiologist concludes that the blood flow is adequate yet the coloring and the temperature of the limb are indicative of inadequate blood flow – the diagnostic images could have easily misleading due to lapses in professional responsibilities. The normal indicators of adequate blood supply would be pink and warm. This underscores the key role of a multidisciplinary team in the delivery of adequate health care. In the case of an incorrect diagnosis, the care facility could be exposed to a variety of legal hurdles due to the potential of professional negligence. Such could be the adverse legal implications of the nursing practice and interventions (Nursing and Midwifery Board of Australia 2006, p 2). Mental assessment is also crucial in this case, including assessment of Mrs Green’s cognition and conception. In addition, mental assessment is important in detecting early signs of neurovascular changes. These observations must be documented regularly and compared in order to ensure the patients safety and that the implemented care plan is suitable for the patient. In implementing the nursing care plan for Mrs Green, it is essential to apply the Nursing and Midwifery Board of Australia competency standards, explaining the procedure to the patient and gaining her consent, maintaining her privacy and applying hygienic standards during assessment (Judge 2007, pp. 39-43). According to Guptill et al. (2012, pp. 176-178), stroke is a potential complication for both acute myocardial infarction and the primary percutaneous coronary intervention (PCI) procedure. During Mrs Green’s procedure, the inserted sheath could have moved some of the clots from the artery wall, creating an embolism in the blood stream. This embolism could block one of the arterioles in the brain, as this is the nearest organ, resulting in a stroke, which is a devastating complication that could lead to patient morbidity (Summers et al. 2009, p. 1). Almost 4% of patients who have similar procedures will experience a stroke as a complication (Summers et al. 2009, p. 177). According to Guptill et al. (2012), the timing of the stroke after the PCI procedure varies from 1–14 days. Other risk factors associated with post-PCI stroke include gender (female), advanced age, diabetes and peripheral vascular disease, all of which apply to Mrs Green. It is for this reason that Mrs Green should consider using the cardiac rehab services for continued observation after she has been discharged from the hospital. Clinical Handover and the Importance of a Multidisciplinary Team The nature of the nursing profession is such that its daily application is limited based on pre-agreed working hours. This is meant to counter the effects of work fatigue, which could lead to health risks not only for the patient but also for the nursing practitioner. This scenario has led to professional development in nursing environments to accommodate work shifts. Work shifts ensure that the nursing professional can enjoy the benefits of rest without compromising care for the patient. This is the case in healthcare facilities that offer the best patient care. In the cardiac care ward in the case study, the late-shift RN, Mary, completes an assessment of Mrs Green to ascertain the cause of her lightheadedness. This type of scenario, along with many others, including hospital transfers or the need for different types of assessment by a multidisciplinary team, can occasion the need for a handover (New South Wales Department of Health, 2009). According to the New South Wales Department of Health (2009), clinical handover refers to the effective transfer of the accountability and professional responsibility, for all or some aspects of patient care, to another practitioner or group of practitioners on a permanent or temporary basis. In the case study, the clinical handovers that take place within the facility as Mrs Green is referred from one ward to another—including when she is seen by the physiotherapist, Eloise—point to the key role that a structured handover in a multidisciplinary team plays in ensuring that the best care is offered to a patient. Incident Information Management System data and Root Cause Analysis data have been reviewed by Australia’s Clinical Excellence Commission, and adverse events that occur due to deficiencies in clinical handover have been identified. Root Cause Analysis data identified multidisciplinary-team handover as one of the areas that should be prioritized for review (NSW Department of Health, 2009). It is for this reason that the National Clinical Handover Initiative proposed the Identification Situation/Status Background Assessment Recommendation (ISBAR) standards to govern inter-facility transfers. The ISBAR guidelines prioritise patient identification, situation and status, patient background, assessment and recommendation. The use of ISBAR for inter-hospital transfers was trialled by the Hunter New England Area Health Service, and the clinicians who were involved in the trial reported that the standard was simple, memorable and portable. The nursing staff showed increased confidence during clinical handovers, and the ensuing audit of the medical charts showed that the information quality had improved (NSW Department Of Health, 2009). On the day of discharge, Mrs Green was referred to, among other professionals, her GP for a mediation review and ongoing management of her condition. This is multidisciplinary-team handover across different facilities, where the ISBAR standards are most applicable. In the introductory phase, Mrs Green can be accompanied by any of the RNs who played a key role in her treatment and recovery. If Mrs Green opts to use the cardiac rehab services, Kate would be the best placed to handle the clinical handover, as her current role is the most complimentary to the role that will be undertaken by Elizabeth’s GP. In line with the ISBAR provisions, the information phase would entail that Kate introduces herself to Elizabeth’s GP and explains her current role in Elizabeth’s life. The next step would be to explain the current situation to the GP. One example of an explanation of the situation could be as follows: “My patient Elizabeth is familiar to you. She has successfully undergone a coronary angioplasty. Although she is stable and already undergoing cardiac rehab, she still faces imminent risks, including the possibility of a stroke or developing neurovascular complications”. The background component can be handled by providing information on such issues as the date of admission and the date of the procedure. The status changes, test results, medications and symptoms should also be included in the background section. A thorough assessment of the situation should then follow, including why Mrs Green is at risk of experiencing a stroke or other adverse cardiovascular outcomes. Her needs at the current moment will also be explained to her GP, including a proposal to review the current dose of prescribed medication. A side-effects review is mandatory for determining the prescription needs during the recommendation phase. The GP has a longer history with the patient. The prescriptions drugs which Mrs Green is currently taking were prescribed by the GP hence knowledge on probable side effects and impact on new prescriptions including cases of compatibility and possible discordance. This outcome, the collaboration between a GP and combined cardiac specialists, underpins the relevance of a multidisciplinary team in ensuring the full recovery of the patient (Australian Commission on Safety and Quality in Health Care, 2012, p29). A Reflection on the Australian Nursing and Midwifery Council’s Competency Elements Analysing this case has brought forth some of the key competency elements specified by the Australian Nursing and Midwifery Council (ANMC).Key competency elements are with regards to the professional practice of nursing, particularly as it relates to ethical and professional responsibilities. Analysing the case has made it possible for me to assess my abilities and how I would fulfil the duty of care if such a case was entrusted to me or if I to ensure that Mrs Green received the best treatment and post-treatment care. In fulfilling the duty of care, the required ANMC competencies include the performance of nursing duties in line with the best-practice standards, the separation of responsibilities for the various aspects of care, the prevention of harm and the performance of duties and responsibilities in accordance with accurate and comprehensive assessments (Nursing and Midwifery Board of Australia 2006, p2).. Deliberating on the case study and the health issue under consideration has tested my knowledge of best-nursing standards, which has been demonstrated in the information provided on Australian nursing standards and evidenced by my deliberation on the ISBAR provisions and the role of a multidisciplinary team in delivering an appropriate healthcare intervention that is adequately responsive to the matter at hand. The multidisciplinary approach also includes a separation of the various unique roles played by the team. Comprehensive and accurate assessment competencies were evidenced from the onset, where I associated the PCI procedure that Mrs Green had undergone with a stroke as a possible adverse event, and hence the need for close monitoring by both Mrs Green’s GP and the RN responsible for cardiac rehab – as an emphasis that all proper patient care is multidisciplinary (Australian Commission on Safety and Quality in Health Care, 2012, p 18). 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