Nursing Care For Shortness Of Breath And Chest Pain In Mr Anthony Khoury

Patient’s Medical History and Condition

Mr Anthony Khoury, 67(M) presented at emergency department of the UTS hospital. Complain includes shortness of breath and chest pain. The patient was reported by the eldest daughter at 1000 hrs. On collection of the medical history, the patient was found to be diagnosed with type 2 diabetes 12 years ago. The patient was administered with oral medication. The diabetes complications of the patient include symptomatic neuropathy and Peripheral vascular diseases. The patient underwent coronary angioplasty and stents for myocardial infarction. He is also under regular cardiology care. Other medical history also involves hypertension, dyslipidaemia, and Angina also managed by oral medication. Recently the hypertension has exacerbated. The person is non-drinker but previously was involved in smoking. No allergies were reported in the patient.  He was administered perindopril for hypertension and Atarvostatin for hyperlipidemia.

On admission Mr Khoury  was observed with the following-

Assessment data

Mr Khoury while arguing with his sons experienced sudden chest pain and breathlessness. His pain is exacerbating due to high level of anxiety and stress. His cardiac condition is weak with history of the Angina and Myocardial infarction. Chest pain together with shortness of breath is risk factor blockage in blood vessels and reduces supply of oxygen to the heart muscles, characteristics of the coronary artery disease. It is the condition of the inactive tissue perfusion and activity intolerance (Miller et al., 2015).  There is a risk of coronary heart failure as the patient has high fluid accumulation in ankles, tachycardia, high anxiety, state of confusion and orthopnea. Orthopnea is the symptom of the left ventricular heart failure or and pulmonary edema (Gazewood & Turner, 2017). The patient was observed with fatigue. It is caused by decreased cardiac output and impaired skeletal muscle blood supply, which is causing fatigue.  According to Sheldon et al. (2015) abnormal heart rhythms, supraventricular tachycardia increases the level of anxiety in patients with previous cardiac problems. This triggers the symptoms of the light-headedness, discomfort and shortness of breath. 

The nursing goal for the patient is to reduce the chest pain scores and other contributing factors. The intervention to achieve this goal are-

• Monitoring of the vital signs- as per clinical review mandated by NSW policy. The patient blood pressure, heart rate are below the normal range therefore, regular monitoring of vital signs will help improve the condition. Clinical review is important till the patient is out of the BTF (between the flags)(Azzolin et al., 2013).
• Provide oxygen supply to achieve 99% saturation to improve ventricular function by increasing CO2 release (Martin & Grocott, 2013).
• Perform ECG- helps determine the pain quality, and mange the chest pain. With the help of the PQRST assessment the radiation of the pain can be detected. There is also need of additional information on the ventricular function, valve function, and thickness of the chest wall. EKG may be 12 lead or 24 lead. Patient with chronic heart failure should have low voltage ECG after resolving the peripheral oedema, the ECH again gains the voltage and looks normal  (AlGhatrif & Lindsay, 2012).     
• Medication- the patient can be treated with opioid analgesics by PCA system to relief pain. The patient may also be administered with the Nonopioids (acetaminophen), which stimulate the nociceptor. As this angina pain Sublingual Glyceryl trinitrate would be effective. PRN medication can be given if the pain is unmanageable with regular medicine (Collinsbet al., 2013). The patient may be educated about the side effects and observed for signs of complications as well as respiratory distress.
• Nonpharmacological intervention- Rest- the patient may be positioned with the flower or semi-flower position for maximum chest expansion. The patient may be kept in calm environment and reduce the environmental stimuli (Authors/Task et al., 2012).

The patient must be monitored for decrease in chest pain score, oxygen saturation and other vital signs to evaluate the desired outcome.  If the observations are between the flags, immediate interventions will be taken and modify the previous nursing strategies. Monitoring can be discontinued if signs are in normal range. The patient must be evaluated for the decrease n anxiety and confusion. Effective feedback must be collected from the patent to rate the pain and satisfaction after intervention. The patient may demonstrate improved well being with the base line levels of Blood pressure, pulse, improved breathing.  Pressure care shall be determined in nose and ear.  The patient may be asked to verbalise his feelings of illness (Innovation, 2016). 

Risk Factors and Symptoms

Assessment data

Shortness of breath is the other major complain of Mr Khoury. His initial oxygen saturation level was 91% in RA. After administrating the oxygen, it elevated to the 95%. The patient could utter only few short sentences. The patient has oedema in both ankles. It is the sign of the venous congestion. Tachycardia leads to decreased cardiac output, increased sodium retention, increased osmotic pressure, increased ADH, increased water reabsopption and fluid overload oedma (Belen et al., 2015). Breathlessness is caused by the raised left ventricular filling pressure to maintain the decreased cardiac output.  It increases pulmonary diffusion, and breathlessness.   Extreme shortness of breath is the sign of the pulmonary edema also accompanied with the anxiety. The patient may be at risk of the pulmonary oedema owing to the symptoms of chest discomfort, irregular heart, headaches, non productive cough (Vital et al., 2013). Pulmonary oedema and heart failure are interlinked. Fluid accumulation in lungs impairs the gaseous exchange. The heart failure prevents the adequate removal of blood from the pulmonary circulation. In this condition the respiratory distress is to hypoxia (Platz et al., 2015).

The nursing goal for Mr Khoury is to achieve the oxygen saturation of 99% and relive of respiratory distress.

• Oxygen supply- nurse collaboration with the oxygen to improve the ventricular function. It is the life saving drug. It will help heart muscles to survive and reduce pain. It will improve the oxygen saturation to 99% as it previously got elevated to 95%. Since ages it has been the standard treatment for myocardial ischemia and chest pain. While giving oxygen the patient to be positioned in the Fowler’s position. It will expand both the accessory and primary muscle. Oxygen delivery is important for maintaing the homeostasis (Lenglet et al., 2012).
• Patient education- on effective coughing and deep breathing. He must be educated about frequent changes in the position. It will help clear airway and facilitates oxygen delivery. Further educate the patient about the relaxation technique t decrease the work of breathing (Gulanick & Myers, 2013).
• Medication- diuretics (Thiazide) can be administered to reduce the alveolar congestion and improve the exchange of gases. Administration of the bronchodilators will allow increased oxygen delivery. It will help dilates small airways and reduces pulmonary congestion (Vandse et al., 2012). In addition to the diuretics the vasodilators are also administered to minimise the risk of the fluid overload.  After administration of the vasodilators the nurse must regularly monitor the urine output to avoid hypovolemia  (Gulanick & Myers, 2013).
• Monitor- the   nurse must observe the breathing pattern for SOB. Further the nasal flaring pursued lip breathing and increases the accessory muscles. It will help identify increased breathing work. the nurse must measure the  Vital capacity and tidal volume. The nurse must maintain the fluid balance chart to monitor the oedema. The patient may be advocated to take 2 liters of fluid per day (Granado & Mehta 2016).  The nurse must monitor the level of confusion of the patient using the AVPU assessment. Headache and confusion are common in the     Further any risk of deterioration may be monitored by the clinical review.
• The nurse must use the compression stockings to minimise oedema and improve circulation. There is need of regular monitoring of the odema by pressing over the bony surface and categorise as mild indent or moderate or deep (Cooper, 2013).

The patient may be monitored if the respiratory pattern is effective without fatigue.  The oxygen saturation if achieved till 99%. Further, the input and output must be carefully regulated. If the input and the output is not appropriate then it must be followed by the clinical review. The patent may be monitored for mobility issue and risk of fall through fall risk assessment. If the patient has clear airway, without coarse crackles and deceased leg oedema, then the nursing goals are said to be achieved. The patient should be carefully monitored for any other   complications (Powell et al., 2016)

References

AlGhatrif, M., & Lindsay, J. (2012). A brief review: history to understand fundamentals of electrocardiography. Journal of community hospital internal medicine perspectives, 2(1), 14383.

Authors/Task Force Members, McMurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A., Böhm, M., … & Gomez-Sanchez, M. A. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European heart journal, 33(14), 1787-1847.

Azzolin, K., Mussi, C. M., Ruschel, K. B., de Souza, E. N., de Fátima Lucena, A., & Rabelo-Silva, E. R. (2013). Effectiveness of nursing interventions in heart failure patients in home care using NANDA-I, NIC, and NOC. Applied Nursing Research, 26(4), 239-244.

Nursing Goals and Interventions

Belen, E., Tipi, F. F., Helvaci, A., & Bayyigit, A. (2015). Concurrent early-onset peripartum cardiomyopathy in a preeclampsia patient with acute pulmonary edema. Internal Medicine, 54(8), 925-927.

Collins, S. P., Pang, P. S., Fonarow, G. C., Yancy, C. W., Bonow, R. O., & Gheorghiade, M. (2013). Is hospital admission for heart failure really necessary?: the role of the emergency department and observation unit in preventing hospitalization and rehospitalization. Journal of the American College of Cardiology, 61(2), 121-126.

Cooper, G. (2013). Compression therapy in chronic oedema and lymphoedema. Nursing & Residential Care, 15(3), 134-139..

Gazewood, J. D., & Turner, P. L. (2017). Heart Failure with Preserved Ejection Fraction: Diagnosis and Management. American family physician, 96(9).

Granado, R.C. & amp; Mehta, R.L. (2016). Fluid overload in the ICU: evaluation and management', BMC Nephrology, vol. 17, no. 109, pp. 1-9

Gulanick, M., & Myers, J. L. (2013). Nursing Care Plans-E-Book: Nursing Diagnosis and Intervention. Elsevier Health Sciences.

Innovation, A.f.C. (2016), Cardiac Monitoring of Adult Cardiac Patients in NSW Public Hospitals, viewed 11th April 2018, <https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2016_019.pdf>.

Lenglet, H., Sztrymf, B., Leroy, C., Brun, P., Dreyfuss, D., & Ricard, J. D. (2012). Humidified high flow nasal oxygen during respiratory failure in the emergency department: feasibility and efficacy. Respiratory Care, 57(11), 1873-1878.

Martin, D. S., & Grocott, M. P. W. (2013). Oxygen therapy in critical illness: precise control of arterial oxygenation and permissive hypoxemia. Critical care medicine, 41(2), 423-432.

Miller, A. H., Carreras, M. T. C., Miller, S. A., Miller, H. E., & Page, V. D. (2015). Is there coronary artery disease in the cancer patient who manifests with chest pain, shortness of breath and/or tachycardia? A retrospective observational cohort. Supportive Care in Cancer, 23(2), 419-426.

Platz, E., Jhund, P. S., Campbell, R. T., & McMurray, J. J. (2015). Assessment and prevalence of pulmonary oedema in contemporary acute heart failure trials: a systematic review. European journal of heart failure, 17(9), 906-916.

Powell, J., Graham, D., O’Reilly, S. & Punton, G. (2016). Acute pulmonary oedema, Nursing Standard (2014+), vol. 30, no. 23, pp. 51-4.

Sheldon, R. S., Grubb, B. P., Olshansky, B., Shen, W. K., Calkins, H., Brignole, M., … & Sutton, R. (2015). 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart rhythm, 12(6), e41-e63.

Vandse, R., Kothari, D. S., Tripathi, R. S., Lopez, L., Stawicki, S. P., & Papadimos, T. J. (2012). Negative pressure pulmonary edema with laryngeal mask airway use: Recognition, pathophysiology and treatment modalities. International journal of critical illness and injury science, 2(2), 98.

Vital, F. M., Ladeira, M. T., & Atallah, Á. N. (2013). Non?invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. The Cochrane Library.

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