History of Present Illness:

Mr. AS, an 85 year old, Caucasian male, with a history of hypertension and chest pain presents today not knowing how he got to the assisted living facility. The patient states he arrived at the facility 3 years ago, unaware of how he got there or why (the chart states his arrival as April 28, 2009). Mr. AS states that he was told he had a stroke, and was aware that his legs were not working correctly. He doesn’t remember having the stroke, but states that he was 83 years old when it happened. He now has lost the ability to walk and has also given up trying. His legs and arms feel weak. His arms hurt from trying to use his walker.

He currently does not lift weights to strengthen his arms so that they don’t get as exhausted when using his walker. Patient denies any prickling or tingling sensations. He also only exercises with his walker when he is made to, once a day during physical therapy. He states that he would rather use his wheelchair. He states that he has accepted the fact that he will not walk again, but is content just breathing and talking. He is not in any pain currently, still has feeling in his legs, but cannot move them. He also states that he was diagnosed with early stages of Alzheimers’ 30 years ago. His chart states that he was diagnosed with dementia at 55 years old. Patient is oriented to time and place, however, he has trouble remembering what he did yesterday. He can recall memories from years ago. He also states that he spends most of his day sleeping, but doesn’t feel tired, rather feels rested. Mr. AS also complains of coughing, that sometimes produces a clear sputum. He states that he was a smoker 20 years ago, for 40 years, with a 160 pack year history. He occasionally wheezes.

Past Medical History:

Current Medication List:

Mirtazapine 15 mg tablet PO once at bedtime for depression.

Namenda 10 mg tablet PO every 12 hours for Alzheimer’s.

Allopurinol 300 mg tablet PO 1 daily for hyperuricemia.

Aspirin single tablet chewable PO 81 mg to reduce the risk of heart attack and stroke, and pain relief.

Certavite antioxidant tablet 18 mg PO 1 daily as multivitamin and mineral supplement.

Loratadine 10 mg 1 tablet PO 1 daily for rhinorrhea/allergies.

Nifedipine 90 mg tablet PO 1 daily for chest pain and hypertension.

Metoprolol tartrate 25 mg PO 1 tablet daily for chest pain hypertension.

Nasal decongestant 0.05%SP 2 sprays per nostril 2 times a day for rhinorrhea/allergies.

Omeprazole 20 mg 1 table PO 2x a day for ulcers/ GERD.

Aricept 10 mg 1 tablet PO at bedtime for dementia.

Tamsulosin HCL 0.4mg capsule 1 PO at bedtime for benign prostatic hyperplasia.

Zolpidem tartrate 5 mg tablet 1 PO at bedtime as a sleep aid.

Acetaminophen 500 mg tablet give 2 tablespoon PO every 6 hours as needed for high temperatures.

Patient diagnosed with hypertension when he was 40 years old (currently controlled with medication). Patient states that he had a pace maker put in when he was 45 years old, and thinks it was to relieve chest pain. Patient thinks that he has been told he has high cholesterol, but he is unsure. Patients’ chart states that he has a history of hypertension, respiratory treatment, and chest pain. Patient was diagnosed with dementia at the age of 55, and had a stroke at 83 years old. Patient also had appendectomy due to appendicitis and an inguinal hernia repair when he was 10 years old. Patient has no known allergies.

Family History:

The patient states that he has one living adult son who calls often, but doesn’t visit much as he is overweight and has back pain. He remembers that one of his grandmothers’ passed away from TB, but he could not recall when. He has no grandchildren, and does not recall how anyone else in his family passed away. He states that he has no family history of hypertension, cancer, heart disease, diabetes mellitus, or psychiatric disease. He was married twice, and both wives are now deceased, but he does not remember when or the cause of death for either wife. No other information could be appreciated from the chart or patient, so a family member will need to be contacted to assess his risk for diseases.

Social History:

He currently has a girlfriend who lives in Miami Beach. The patient states that he currently is not sexually active, does not drink, do drugs, or smoke nicotine. He stopped smoking 20 years ago, but before that he smoked for 40-50 years, 4 packs a day (160 pack year history). Currently he does not follow a diet at the ALF, but eats what they feed him every day. He states that he builds clocks during the day as a hobby, and this keeps him happy.

Review of Systems:

General: Patient denies any fatigue, weight or appetite changes.

Skin: Patient denies any changes.

Head: Patient denies headaches, bumps/bruises, or dizziness.

Eyes: Patient states that he no longer needs to wear glasses since the stroke, as he can now see.

Ears: Patient can’t hear out of the left ear, but states that his right ear is fine.

Nose/Throat/Mouth: Patient denies any changes in smell or taste, or problems swallowing. He feels tickling in his throat when he talks too much.

Respiratory: Patient states that he has a constant cough, which sometimes produces clear sputum. He also occasionally wheezes and states that he had asthma as an adult and has used an inhaler.

Cardiovascular: Patient denies any pain, but states he has a pace maker. He denies palpitations as well.

Gastrointestinal: Patient denies any pain or cramping. Patient has been constipated for the past 20-30 years, only defecating once a month.

Genitourinary: He urinates 2-3 times a day, but has no control, and must wear a diaper. Patient denies polydipsia or hematuria.

Neurologic: See HPI

Musculoskeletal: See HPI

Endocrine: Patient denies any excessive thirst, changes in appetite, or weight changes.

Hematopoetic: Patient denies any skin color changes, easy bruising, or bleeding.

Psychiatric: SIGECAPS negative, and patient denies depression, fluctuating moods, or suicidal thoughts. See HPI

Physical Examination:

Vital Signs: Temp afebrile to touch, BP 132/72, pulse 60 bpm, RR 16 bpm, BMI 29

General: Overweight male currently not in respiratory or cardiac distress.

Skin: Darker brown discolored non-raised plaques on both arms, skin dry and warm to touch. Ulcers present on right ankle (2 cm wide, circular, and 1 cm above medial malleolus) and left shin (3 cm wide, circular, and 6 cm below tibial tuberosity). Left leg is erythematous, at the mid-tibia region.

HEENT: No icterus and no jaundice present, head is normocephalic, with normal hair distribuition. No lymphedenopathy present in occipital, periauricular, postauricular, tonsilar, submandibular, subtonsilar, anterior chain, posterior chain, and supraclavicular lymph nodes. Patient can’t hear out of left ear. Both ears have compacted cerumen present. Patient does not wear corrective lenses, and could not see the eye chart to assess visual acuity. His eyes react slower than normal to light, but EOM are bilaterally intact. Patients’ mouth is moist, with a few teeth missing on top and bottom, and no signs of central or peripheral cyanosis. No carotid bruits, no jugular venous distention, and the trachea is midline. The thyroid is non-papable.

Lung: Chest is symmetrical, with diaphragm excursion 6 cm bilaterally. Left lung field breath sides decreased compared to the right lung field. There is also wheezing heard in the right lung field. Right lung field is resonant to percussion, but the left lung field is dull to percussion. Vibrations felt throughout for tactile vocal fremitus. No crackles or rales heard.

Heart: No thrills, murmers, bruits over the carotid, or extra heart sounds heard. Rate and rhythm are regular, and also symmetric at radial, femoral, dorsalis pedis and posterior tibial pulses. S1 and S2 heard in all regions.

Abdomen: Scar preset from a stomach tube that was placed for feeding. Patient doesn’t recall when or why the tube was placed. Chart did not specify why either. No bruits heard over the abdominal aorta, renal, or iliac arteries. Borborygmus present. No tenderness, guarding, or rigidity present. There are bulging flanks and spider nevi present. Liver span is 6 cm. Spleen and kidneys non-papable. i

Extremities: Patient has weak dorsalis pedis and posterior tibial pulses present (1+ bilaterally). Ankles are swollen, there is no pitting edema present.

Musculoskeletal: Lower extremities have normal passive ROM present, but decreased active ROM. Normal passive and active ROM present in upper extremities. Motor strength is decreased in upper(4/5) and lower limbs(3/5).

Nervous System:

Mental Status: Patient is alert and oriented to place and time, but cannot remember events from yesterday. He can remember events from years ago, and is aware that he is forgetful now with memory loss.

Cranial Nerves: Intact, no facial dropping or weakness on either side.

Sensory: Lower extremities showed pain sensation and proprioception intact, but no vibration sense present.

Reflexes: Lower extremity reflexes were not assessed as patient could not move his legs. Upper extremity reflexes intact.

Cerebellar: Babinski intact. Patient could not get out of bed to assess gait.

Laboratory Data: Labs taken Dec. 31, 2010

Glucose elevated 122 (normal 70-105 mg/dL)

BUN/Cr elevated 1.35 (normal 0.7-1.3 mg/dL)

Problem List:

1) Dementia

2) Chest pain

3) Wheezing and Cough

4) Depression

5) Leg/Arm weakness

6) Preventative medicine- routine physical exam, mini mental status exam, psych evaluation, colonoscopy and rectal exam, pneumovax vaccine, influenza shot

Assessment:

Dementia: Dementia is an impairment of cognitive function, affecting memory, attention, language, and/or problem solving. This impairment has to be lasting 6 months or longer. The first sign of dementia is usually short term memory loss, progressing to memory forming impairment, and later an inability to learn new things. Usually the patient is aware of the memory loss. Eventually the memory loss is too great, and there is a loss of personal hygiene, eating, and other activities of daily living. This also affects mood, and there can be fluctuations between happiness, sadness, and anger. There can be sleep disturbances and personality changes. Depression is one of the major illnesses that can present with dementia. Lastly, there is a complete dependence on others, as the patient can no longer take care of themselves, is disorientated, has memory loss, and in many cases, cannot swallow properly.

There are many types of dementia, and once a person has met the requirements to be diagnosed with dementia, the type must be determined. Each type is caused differently, so treatment can vary slightly. The most common type is Alzheimer’s dementia. Patients with Alzheimer’s can be differentiated from other types, as these patients are more likely to get lost in familiar places, try to leave home, have difficulty communicating, and have memory problems. This can occur from tau neurofibrilllary protein tangles in the brain and plaque formation. Also there can be a loss of acetylcholine in the brain. Patients with multi-infarct dementia can be differentiated based on a history of smoking, stroke, atherosclerosis, and hypertension. Multi-infarct dementia occurs from many small strokes affecting the brain. Patients with vascular-type dementia usually have aphasia, apraxia, a difficulty learning math skills, and often present with neglect. This type of dementia occurs due to cerebrovascular disease or stroke. Lewy-Body dementia presents with recurrent visual hallucinations, motor impairments similar to Parkinson’s disease, and varying levels of attention throughout the day. This can occur due to Lewy bodies (abnormal protein) deposits in the brain, and sometimes a loss of dopamine too.

Currently, our patient has been diagnosed with dementia. He meets the criteria for this diagnosis: he has memory loss, is aware of his memory loss, has lost the ability to care for himself, has lost some autonomic function and must wear a diaper, and has been having sleep disturbances. Mr. AS does not recall how he got to the facility, and states that he can’t remember what he did yesterday, but can remember stuff from years ago. He no longer can live alone at home without someone to care for him, and has been living at the facility since April 2009. He also states that he sleeps more than he used to, sleeping now for most of the day. A family member must be contacted to assess the changes that have occurred prior to his admittance to the facility, as our patient is unable to tell us of any changes in his status. We also need to contact his family to narrow down which possible type of dementia the patient has based off of his previous behavior prior to entering the facility. If he was experiencing getting lost in familiar places, it could be Alzheimer’s; he has the risk factors of multi-infarct dementia, especially if he has had more than one stroke; lastly we would need to assess his function before and after the stroke to determine if it was vascular type dementia. He currently has no signs or symptoms of Lewy- body dementia. Our patient is also on medications for Alzheimer’s type of dementia: Mirtazapine, Namenda, Aricept, and Zolpidem tartrate. These medications help relieve some of the symptoms that our patient has, such as depression and sleep disturbances, and can increase the acetylcholine levels in the brain.

Chest Pain: Chest pain can be caused by angina, coronary spasm, MI, pericarditis, gastroesophageal reflux, aortic dissection, and many more causes. Our patient is not currently in any chest pain, but he does have a pace maker. He states he does not know why he was given a pace maker, but states that he has never had any problems or complications with it. A family member needs to be contacted to find out why the pace maker was placed. His chart did not state a reason for the pace maker or state why he was having chest pain. The most common reason for a pace maker is to regulate an arrythymia. An EKG record prior to his placement of his pace maker, can help to determine if an arrhythmia was the reason he had one inserted. A recent EKG will tell us if his heart rate is normal, and if there are any associated pathologies. His medications include: Nifedipine, Metoprolol tartrate, and aspirin, which are all given for chest pain, usually angina and hypertension. He is also taking Omeprazole for GERD.

Wheezing and Cough: The most common cause of wheezing is due to a constriction of the airways. This can be an inflammatory response, such as with asthma. Asthma, however, would also cause shortness of breath, which our patient is currently not experiencing, and would be bilateral (unlike only in one side as with our patient). COPD, emphysema, or a lung tumor could be possible causes for his wheezing and coughing. Smoking is a risk factor for all 3, and our patient has a 160 year pack history. It needs to be determined if his wheezing is occurring in the expiratory phase or the inspiratory phase. During the expiratory phase would indicate bronchial disease, but during the inspiratory phase would indicate a foreign body (such as tumor) or scarring. Wheezing heard in both phases could indicate a collapsed lung or portion of lung. Unilateral wheezing also would be more indicative of a lung tumor. There also are no crackles or rales heard in our patient, so fluid in the lungs or turbulent flow does not seem to be the problem.

Depression: The cause of depression is unknown, but it is known to be caused by chemical imbalances in the brain. It can also be caused from stress, or a life changing event, such as death of a loved one or social isolation. Depression can present with a number of symptoms such as: fatigue, lack of energy, feelings of worthlessness, feelings of hopelessness, anger, discouragement, irritability, changes in appetite, changes in weight, sleep disturbances, and thoughts of death or suicide. Although our patient has had sleep disturbances, a SIGECAPS interview was negative. His sleep disturbances can be due to dementia. Currently our patient is on medication for depression, Mirtazapine, and should remain on it, so that he does not become depressed.

Arms and Leg Weakness: Arm and leg weakness can be caused by a number of things, such as stroke, infectious disease, amputations, and trauma. Our patient suffered a stroke, after which he states he has not been able to use his legs anymore. His legs may be weak, as the nerves may have been damaged from occlusion, and are not able to send complete signals anymore. His arms may be weak from overuse, as he has been learning to use a walker as part of his physical therapy. His arms have to hold up his body now, as his legs can’t.

Preventative Medicine: Our patient needs to have continuous routine physical exams to assess his ever changing status. A mini mental status exam also should be performed to monitor any changes, or the rate of progression of his dementia. A psych evaluation is needed to determine the extent of his depression and if it is getting better from his medication, or if he is having a more positive outlook on life. Our patient is at the age where a routine colonoscopy and rectal exam should be performed to monitor for colon cancer, prostate cancer, and BPH. Currently our patient is on Tamsulosin for BPH, so it is essential to continually monitor him. Additionally, our patient is elderly and should have a pneumovax vaccine and an influenza shot as prevention for illness.

Plan:

In addition to the preventative measures listed, in order to assess the patient fully, we will need to contact his family and inquire about if there were any changes in the patient’s mood, demeanor, physical abilities, and mental status before he was admitted to the facility. His family will also be questioned about their family history of disease, as the patient could not recall how most of his family passed away. To prove our diagnosis, brain scans (CT and MRI) should be performed on the patient and assessed for changes, loss, or infarcts. The patient is also experiencing a constant cough, with a 160 pack year history of smoking so pulmonary function tests should be performed. A chest xray should also be performed to determine if there are any pathological changes within his lungs (such as a tumor) that are causing his wheezing and decreased lung field sounds. This xray can also be used to assess if there have been any cardiovascular changes. Due to the patients past history, he will need to be continually monitored for changes. He will also need a CBC to monitor these changes. The patient also will need to have his medication list continually reassessed (additions or deletions) with changes. Currently he is on medication for allergies or rhinorrhea, but he is not experiencing any symptoms of allergies or rhinorrhea, so Loratadine and his nasal decongestant may be removed.

Oxygen therapy is the administration of oxygen at a higher concentration than that of ambientair. The main intention of this process is to either treat or prevent the symptoms and manifestations of hypoxia. Oxygen therapy decreasesthe work of breathing by increasing alveolar oxygen tension. As an essential part of clinical practice, oxygen therapy is widely used in cardiac care. Despite all thiswide uses of this therapy have been criticalin cardiac care. Studies have provedthat excessive use of oxygen, results incritical conditionsinthe areas that it is applied. This essay aims at examining the concentration required, different conditions, where it could be needed and the effects of use of high concentration oxygen for the client with chest pain.

When there is airway obstruction as a result of cardiac effects such as asthma, pneumonia, breathing system of the client becomes complicated. This client can only breathewhen the oxygen level climbs above a setlevel. This will maintain functional ability and at the same time minimize the chest pain, which may have been caused by breathing problem. It is very important to note that there are several causes or condition that may arise to chest pain(Fritz&Faber, 2012). The different approachesproposed, suggestthat these statementsandsolutions do not conform withthe available evidence in the cardiac care. Also, inthe treatmentof a patient with cardiacproblems, the main issueto be consideredis the balance ofevidence for both the safety andefficiency of oxygen administrationin cardiac care.

Arterial oxygen tension is one of thesigns todeterminant coronary artery tone. Slightincrementin arterial oxygen reducescoronary flow irrespective of priorsaturation(Atar, 2010). The human study of patientswith cardiac problems hyperoxia from concentrated oxygentherapy reducescoronary blood flow(Atar, 2010). Administering oxygen therapyto patients with myocardial infarction, oxygen therapy canreduce cardiac outputvolumes, and blood pressure and vascular resistance(Atar, 2010). Thereevidencein determiningsafety and efficiency ofoxygenadministration in cardiac care. The evidence supportsuseofoxygentherapyin minormyocardial infection resultsinincreaseddeath rates tothe patients.

Research has approved that resuscitation from cardiac arrest; administration of high oxygenresults in hypoxia. Thisis directly associatedwith more deaths to patients incomparison to either normoxia or hypoxiaproblems. Continuoususe of oxygen therapy in cardiac careis harmful to the patient of cardiac problem and this approach is not the best. It is recommended that, the administration of oxygentherapyshould be at the level of 96% to keepstandardizedsaturation(Bersten&Soni, 2009). Also, oxygen needbe administeredfordefinitecardiac cares, in which benefit of oxygen therapyoutweighs the risks it may impose to the patient. Healthcare professionals should take into account that the method, doseand delivery periodis clearly speltand patient’s reaction to oxygenadministration is thoroughly monitored (Fritz&Faber, 2012).

Since oxygen is a drug, its administration requires a medical order. Each of the episodes of oxygen delivery should be ordered on the medicationchart either as on-going or one-off treatment. There are some conditionsthat should be examined before the nurse initiatesoxygen. First, the nurse should realize that the patient hasbreached expected normal parameter of oxygen saturation, also a medical review is required within thirty minutesand then at the time of the medical review, the right prescription of oxygen should be written. Before the selection of the delivery method, caregiversshould check at the individual flow meter for where to read the ball when setting the flow rate (Straface et al. , 2008). Some of the flow metersmay register greater than the maximum flow indicated in the meter in the case of the ball being set above the highest amount(Hunt, 1999). The nurse is required to use caution when adjusting the flow meter. All of the high concentration or delivery requires humidification. The selection ofthehumidification will depend on the oxygen delivery system in use. It should be noted that, air entrainment devices are not effective when it comes to delivering FiO2that is greater than 50%. Administration of high concentration of oxygen to clients with chest pain may worsen the pain, when breathing elevated pressure of oxygen is extended for a longer period(Myers et. al. , 2008).

There has been a growing debate and concern on the administration of high oxygen concentration to those clients with chestpain(Frey&Shann, 2003). Traditionally, for over a decade, patients who complained of chest pain were instantly administered high flow of oxygen, this process initially started when medics realized that oxygen would ease myocardial ischaemia in patients with acute coronary syndrome (ACS). Also, highoxygen concentrationmay cause atelectasis. The alveolirelies onnitrogen topreservesurfactantcreationand alveolarpower. The high concentrationof oxygen, when administered may wash out nitrogen and leave the alveoli susceptible to a lack of gas asthegas diffuses to blood(Shekhar et. al. , 2010).

It is important to note that; high oxygen concentration to thosepatients with cardiac problems, do not yield much advantage. Thispractice quickly became a routine in patients presenting with acute chestpain(Robyn and Coffee, 2012). Recently there has been a report indicating that harmful effects of high flow of oxygen in ACS patients where the patient may not be hypoxic. High flow of oxygen has previously been associated witha reductionof cardiac output, attribute to arterial vasoconstriction and also it increases systemic vascular resistance. Inmorerecent evidence, systematic review shows that the routine use of high concentration on chest painmay lead to greater infarct size increasing the risks of mortality.

From a physiological perspective, treatment of ACS’ patientswith oxygen seems reasonable. For apatient suffering from ACS, there isalack of myocardial perfusionsand less oxygenation of the myocardium. In thiscontext, itseems logical to increase the oxygenation of the blood. Thistreatment is not well thought and can lead topatient harm, if not well monitored. The bottom line is that, the drug that is often usedcan cause harm if it is given without a good reason, when there isless saturationof oxygenin apatient’s blood, oxygen cannot help them with shortness of breath, and it may hurt them instead. The same idea holds truefor the neonates and any ofpatients with ongoing tissue injury from MI, stroke or trauma it is true that oxygen can be badwhen not wellmonitoredin administration (Myers et. Al. , 2008).

The hemodynamic effect of high flow of oxygen in the myocardial was explored bygroups to improve on the cardiac care. The cardiovascular response to high concentration of oxygen was primarily attributed to arterial vasoconstriction; this has been demonstrated in retinal blood vessels. This method was also thought to be the reason behind the reduction in renal blood flowofcerebral blood flowwith oxygen therapy. Research has demonstrated that high concentrationof oxygen cannot increase itstransport inpatients with arterial oxygen saturation to a level of less than 90%. This is explainedbythe notionthat the reduction in cardiacoutput in excess leads toincreases in oxygen content. In patients with arterial oxygen saturation of less of 90%, this shows that oxygen administration increased oxygen transportation(Campbell&Silver, 1998). This is due to both increased cardiac output and oxygen content. In therecent years, researchers have providedclearand direct evidence that the administration of high flow oxygen reduces coronaryartery blood flowfor the stable patient with ischaemic heart effect. This evidence wasprovided over a decade ago, and this has been confirmedthe method of high oxygen concentration may change, but the effects of oxygen on the cardiac care remainthe same.

In conclusion, it is important to note that it is not clear whether routine administration of oxygen in patients’ with cardiac problemsin relation to chest pain has all the positive impacts on the outcome(Hunt, 1999). This systematic review challenges the status quo predicted by the international guidelines on the treatment of the chest pain caused by cardiac problems. The argument of reduced mortality due to administration of concentrated oxygen topatients with cardiac problem is disturbing. There is no need to administer a method of treatment on a patient in which the negative impacts outweighs the gain. The different approaches in tackling this major problemofchest paingives a clear evidence and explanationofthe conditions in which a patient is to be administered with concentrated oxygen. Before any treatment is done forpatientswith chest pain, caregiversshould try to understand the cause of the pain(Campbell&Silver, 1998). For example, the pleuritic pain is triggeredby chest movement and it is severe during coughing. Splinting the chest wall will help in reducing the discomfort of coughing. Cardiac care is involved with a lot of approaches that need to be looked at before treatment is undertaken.

References

Frey, B. , & Shann, F. (2003). Oxygen administration in infants. Archives of Disease 2in Childhood – Fetal and Neonatal Edition, 88, F84 – F88.

Bersten, A. & Soni, N. (Eds). (2009). Oh’s Intensive Care Manual 6th Edition. China: Butterworth Heinemann Elsevier

Campbell, E. ; Baker, D. , & Crites-Silver, P. (1998)” Subjective Effects of Humidification of oxygen for delivery by nasal cannula” ChestVol 93: 2 289 – 293

Shekhar, R. , N. Garg, A. Chockalingam, A. Tharakan, and A. Senthilkumar. (2010)”A Young Adult With Atypical Chest Pain. “

Chest

138. 4 MeetingAbstracts: 95A-95A. Print

Beyar, R. (2009)”Acute Cardiac Care-From Symptoms to Diagnosis and to Interventions. ”

Acute cardiac care

11. 3: 129-130. Print.

Clark, R. A. , &Neil, C. (2012):”Can the Cardiac ARIA Index Improve Cardiac Care for Australia’s Indigenous Population?. “

Journal of Cardiac Failure

18. 8:S89-S90. Print.

Hunt, J. m. (1999):”Cardiac sugical patients’ expectations and experiences of nursing care in the intensive care unit. “

Australian Critical care

12. 2:79. Print.

Fritz, A. , & Faber, P. (2012). Chronic cardiac chest pain.

Continuing Education in Anaesthesia,


Critical Care & Pain

,

12

(6), 302-306.

Straface, A. L. , Myers, J. H. , Kirchick, H. J. , & Blick, K. E. (2008). A Rapid Point-of-Care Cardiac Marker Testing Strategy Facilitates the Rapid Diagnosis and Management of Chest Pain Patients in the Emergency Department.

American journal of clinical


pathology

,

129

(5), 788-795.

Atar D. (2010)Should oxygen be given inmyocardial infarction? BMJ; 340: c3287.

I had seen many patients’ complains of complex wounds that need long time to cure. Complex wounds are considered as a real challenge to the health care providers especially when it is accompanied with factors that can play role in impaired and complicate wound healing such as Surgery, infection, the presence of diabetes, Trauma, Radiation, Autoimmune diseases and arteriosclerosis. As stated by Ferreira. M, 2006: The most commonly seen complex wounds that require special care and attention are Wounds in the lower extremity of diabetic patients, Pressure ulcers, Chronic venous ulcers, Wounds following extensive necrotic processes caused by infections and Chronic wounds related to vasculitis and immunosuppressive therapy that have not healed using simple care.

There is no specialized and responsible team who can determine the best type of management for the patients with complex wounds. The health care provider in the hospital is providing the same care and management to the patients who complaining of simple or complex wounds. They need to know that There are striking differences between simple wounds, for example surgical wounds or skin scratches, and those chronic wounds that do not heal primarily and demand specialized care, mostly in hospitals (Ferreira. M, 2006) .This will harm the patient (physically and emotionally), decrease the quality of care that provides to the patients, delay wound healing and increase the period of hospitalization.

The care provided for patients with wounds can be described in one single word which it’s DRESSING. While the treatment of the complex wound is much complicated. Determining that the majority of these complex wounds should be considered surgical cases and not just cases for dressings as stated by Ferreira. M. 2006. The treatment of complex wounds should be by using surgical procedures instead of the clinical measures. In addition to debridements, skin grafting, and flap coverage.

Health care providers (doctors, nurses, etc) need to increase their awareness about the important of the presence of wound management team in each hospital to decide the best type of management, decrease the complexity of the treatment and choose the best surgical approaches that will increase the quality of life to the patient.

Step 2

A complicated wound needs more than just a bandage to recover and heal. It needs special attention; compassion of a wound care team who are specializes in non-healing and slow to heal wounds. As stated by Tjandra. J, 2001Wound healing is the replacement of destroyed tissue by living tissue, and is fundamental to survival.

My vision is to form a team of professionals who work together to assess patient’s wound and provide input regarding their treatment. This team consists of physicians, physical therapists, dietitians and nurses “wound therapy nurses and nurses specialized in complex wounds”. These specialized wound nurses may visit patients in their home in order to provide an effective plan to heal their wounds.

They have to work on providing appropriate wound care to the patients that will help the complex wound to heal faster. As well as they should know that “Wound healing may be impaired by general factors such as malnutrition, corticosteroids, diabetes mellitus and anaemia, which affect the patient as a whole. And local factors such as infection, ischaemia and hematoma which affect the site of the wound (Tjandra. J, 2001)”.

In addition to cleansing, control bacterial growth and prevent infection. This team will also provides education to patients and their families to help prevent any future complications, increase there awareness regard complex wounds and their demands to heal, encourage them to collaborate with the team and participate in the treatment. This change will enhance the quality of care patients received; improve the quality of life, decrease the period of hospitalization and promote the process of healing.

“It is important that all practitioners are aware of the pathophysiology and aetiology of pressure ulcers and mechanisms to prevent pressure ulcer development (Ousey, K, 2005) because Patients with complex wounds need to spend long period in the hospital so they will be at high risk of develop bed sore. Team members should coordinate program to prevent pressure ulcer that will protect the patient from getting this series skin problem.

This change will build up a very strong team who are able to put the patient on the right way of cure and make them able to treat the complex wounds in time less than the expected. It is a real chance for all the health care provider specially nurses toward increasing their knowledge and improving there skills. Wound care team consider as a good step towards improving the health care services in the hospital.

Step 3 & 4

Leadership is a very important concept in nursing professional that helps to develop the skills of nurses and the other health care professionals. I will be able to achieve my vision by using one of the most important models in leaderships and management. It is John Adair’s Leadership model. Adair has developed what he calls a functional approach to leadership based on three overlapping circles of needs which are achieving the task, managing the team or group and managing individuals (Cipd 2010).

By adopting this model of leadership, my responsibilities as a leader to achieve the task are as follows: sharing my vision, goals, and objectives with the team members. Then, create an action plan to achieve the task, considering timescales and strategies. It is important to share my action plan with the members and ask them for feedback or suggestions. After that I will distribute responsibilities by agreement and delegation, monitor and maintain overall performance against plan and report the progress toward the team aim continuously. Finally review, reassess, adjust plan, methods as necessary.

In addition to that I will encourage and motivate the members to be involved in making decisions and giving suggestions, to make the task a success and meet our goals. The leader should try to resolve any groups’ conflicts and look for ways to develop a cooperative team working. However, to develop each nurse and improve her skills, we will recognize the team member as individuals, and get to know their strengths and needs, we have to help them and encourage them to challenge the complex cases of wounds. It is very important to give awards and recognitions to the individual’s hard efforts and work.

Therefore, to achieve my vision and reveal the benefits of this change I will apply Lewin’s three- stage model of change. It is a holistic model that helps people to think about the change and gradually adopt it as pointed out by martin (2003). Lewin proposed 3 stages for any changes to occur, including: the unfreezing stage is when people start to believe that there is a need for change, the moving stage, when it is possible to make changes, and the refreezing stage is when the change is strengthened and becomes the new normal state (martin 2003).

In the unfreezing stage team members must realize that they will be able to treat any type of complex wounds and promote wound healing if they work on improve their knowledge and skills. They will see the importance of act as one collaborative group to enhance the quality of care and promote wound healing.

As stated by Reinelt (2010) Evidence-based practice (EBP) is commonly used to inform practice decisions in the fields of medicine, nursing, social work, child welfare, and criminal justice. So it is important to provide the team with some evidence based research that will guide decision-making about what treatments and protocols to use with individual patients, and offenders to ensure the highest possible accountability for producing good results. Reinelt (2010). In addition to that, I will invite nurses and doctors from other countries that are already implemented this idea in their hospitals and ask them to give presentation to our health care providers about their experience and discuses how this change can improve the quality of care and increase the benefits to the patients.

Throughout this stage, I will be expecting initial resistance to the change by some people but I will listen carefully to their opinions and issues, I will try to convince them of the important and the benefits of implementing this change. I will also encourage them to give suggestions that would help in achieving my vision.

In the moving stage, we will see the possibility of forming complex wound team in the hospital and improve member’s skills and knowledge. In this stage I will arrange for different teaching sessions and workshops that will help in increase members knowing, improve their therapeutic and communication skills, and enhance their confidence. One of the most important nursing leadership qualities is supporting your team, If the members of the team wish to develop new skills, or apply their theoretical knowledge in a practical environment, it is important that the leader provide a supportive environment for them to try out these skills. This will provide them with the true method of learning, and develop their skills in a competent manner (Lalwani, P. 2010). In addition, there will be a team supervisor who will distribute and organize the work between the members and promote team collaboration.

In the refreezing stage, the change is carried out and implemented, the team is working together to treat and promote healing of any difficult wounds. Leader should keep in mind that not every member can deal with stress and other such aspects of the profession very well. So, as a leader, I will need to support them, and understand and help them in a way that proves useful for them (Lalwani, P. 2010). The Leader is responsible of solving problems, encourage and motivate the members and introduce feedbacks, as stated by Lalwani, P. 2010, Feedback can, and should also be positive, as this will further encourage your team members to perform better and keep introducing innovative yet efficient ways of becoming independent. Therefore, there will be monitoring committee to observe team achievements, evaluate their understanding, knowledge and skills and recognize the benefits of this change for patients, families, and the healthcare providers. The findings will determine if we will carry on this change, stop it or create another action plan to overcome the difficulties and improve the outcomes.

Step5

As stated by Lalwani, P. 2010, my goal is ensure the betterment of the organization I am work for, by improving the quality of patient care, which I can do with the application of various creative leadership qualities and management strategies, and the different leadership styles in nursing. My action plan included many steps and events which will aid to achieve my vision and create wound management team consist of physicians and nurses specialize in the complex wounds. This will help to achieve my goals such as enhance the quality of care patients received, improve patient’s quality of life, and promote healing of the difficult wounds. In addition to improve health care provider’s knowledge and skills regarding the difficult wounds and the most important thing is create nurses specialize in wound therapy and make them able to treat any complicated wounds. So I think my action plan is fit well with my previous explanation and rational for change.

Conclusion

By the end of this assignment I discover that there are at least 8 qualities that successful leaders have: Responsibility, Integrity, Decision takers, Deal with facts, Vision and inspiration, Optimism, Resilient, and Excellence (Brodie, D. 2008). The Successful leaders are not just working to put themselves in good senior position but to use their skills, knowledge and all the leadership qualities for the growth of the organization that they are working for, provide high quality of care to the patients that will lead to patient satisfaction and play role in the progress of their health and well being. I can understand now that the leaders are those who are willing to follow. They must be perfect in whatever they do, because by doing their best; they will discover that only the best is expected from their team members.

– http://www.scielo.br/scielo.php?pid=S1807-59322006000600014&script=sci_arttext

– Tjandra, J. Clunie, G. Thomas, R (2001). Text Book of Surgery/ Wound Healing and Wound Management. USA, Canada, Australia. 2nd ed., Pp 20, 23, 24, 25.

– Ousey. K, (2005) Pressure Area Care, UK.1st ed., Pp 13

– http://www.cipd.co.uk/subjects/maneco/leadership/leadshipovw.htm?IsSrchRes=1

– Martin, V. 2003 Leading change in health and social care, 1st ed., Routledge: London and New York, Pp. 104-06.

– http://leadershiplearning.org/blog/claire-reinelt/2010-06-29/use-evidence-based-practice-field-leadership-development

– http://www.buzzle.com/articles/nursing-leadership-qualities.html (Lalwani, P. 2010)

– http://ezinearticles.com/?The-8-Qualities-of-Successful-Leaders&id=760414