Case Study 2 – HL’s Online Case Study Nursing Assessment

Case study 2 – HL’s

Introduction

Chest pain is one of the possible complaints in a healthcare setting. When patients complained of it, its impact ranges from life-threatening that needs immediate treatment such as acute myocardial infarction to mild disorders such as muscle strain. (Abbas, 2015) This case study will discuss the patient who had an episode of chest pain post-operatively. I mainly explore my experience in relation to the clinical reasoning process and critical reflection.  

Case Study

Jenny is a 76 years old patient who admitted to our ward after split skin graft surgery under general anesthesia. She had a history of high cholesterol, GORD, Osteoarthritis, AF, and hypertension. On day 1 post-operative period, the patient complained of sudden onset of chest pain. Jenny stated that she never diagnosed with chest pain before. She could not clearly describe the pain, but she stated that it is a severe heart burning sensation and chest tightness pain on her left side of the chest. One patient complained of chest pain; it needs an urgent investigation to treat or exclude MI (Myocardial Infarction). Jenny was asked questions if she had a history of the common symptoms associated with her chest pain, in relation to the site, radiation, character, exacerbating, or relieving factors, duration, frequency, associated symptoms. (Tough, 2004) At that time, I learned that a nurse needs to prompt questions in terms of the pain as some patients have difficulty in describing their chest pain symptoms due to an uncommon presentation or vagueness of their symptoms. (O’Donovan, 2013) Pain level was 9/10. Oxygen was stable 97% on room air. BP 160/70. Afebrile. GCS 15, Heart rate was 99 bpm. I observed that she did not use the accessory muscle to breath. The pain was not radiating to the other area. It was notified to the physician, applied oxygen via nasal prongs and performed ECG and necessary blood tests for cardiac marks performed as per advice. Also, stat order of GTN spray medication was taken to give. Exertion usually aggravates typical anginal pain and alleviated by rest of Nitrate medication. It needs to be investigated if there are other aggravating/associating symptoms to examine differential diagnosis by health care professionals (Oriolo and Albarran, 2010) 

Jenny usually takes medication, including Targin, Atorvastatin, Metoprolol, Eliquis, and Keflex. O' Donovan (2013) states that the assessment of chest pain should focus on the history of the pain, previous medical history, cardiovascular risk factor, and prior relevant investigations. This information is crucial to guide further investigations and treatment. On my history taking, Jenny stated that she used to take Rabeprazole tablet in the past when she needed, but she stopped taking while she is in the hospital. 

This cue acquisition is the first step in a systematic approach to decision making. Following the cues, hypothesis generation which is the formulation of a diagnosis based on the cues is available. (Ellis, 2017) Based on what Jenny described her history and symptoms, I realized that I did not take into consideration that she has a history of GORD. Definition of GORD includes reflux-induced chest pain as a distinct symptom. The expert also agreed that oesophageal and cardiac chest pain may be indistinguishable, and the reflux-induced chest pain can occur without coexisting heartburn and regurgitation. (Kahrilas et al., 2011) There are numerous causes of chest pain, including cardiovascular, pulmonary, musculoskeletal, gastrointestinal and non-organic. In Jenny's case, her chest pain was induced by gastrointestinal cause. Chest pain that results from gastro-oesophageal reflux disease (GORD) brings symptoms of burning sensation. This is caused by direct stimulation of the hypersensitive oesophageal mucosa and spasm of the distal oesophageal muscle. Heartburn sensation in the epigastric or central chest area is made worse by a positional change such as bending, lying down and sitting. This symptom usually relieved by antacid medication. (Tough, 2004) Jenny's pain was eased after taking stat Mylanta 20mls orally.

If I had brought into my mind that numerous reasons can cause chest pain, I could have initiated Jenny's treatment early. This case study made me reflect on how to synthesize facts or cues and inferences to consider a definitive nursing diagnosis, to choose clinical a course of action between different alternatives available. (Levett-Jones et al., 2010) I also learned that my prejudices or assumptions interrupt my cue collection process, which I excluded other potential causes of chest pain. Thereby, it is essential to understand and view a broad picture of physiology, pathophysiology, pharmacology, ethics, and context of care. (Levett-Jones et al., 2010)

According to Benner et al., (2008, p92) “clinical decision making is mostly influenced by interpersonal relationships with colleagues, patient conditions, availability of resources, knowledge, and experience." Reflecting on this case, the ability to make a quick decision, reduced decision errors, support the identification of important cues and promote the recall and action on patterns of information remains challenging feature for me to utilise in the future my nursing practice. But this case study recaps my mind that the clinical reasoning must be based on every nursing assessment and practice I perform. 

References

A. D. Abbas., (2015)' Nurses’ Knowledge Concerning Chest Pain Management in Emergency Units,' Asian J. Nursing Edu. and Research, 5(1) 

J. Tough., (2004) ‘Assessment and treatment of Chest pain.’ Nursing standard. 18. 37. 45-53

K. O’Donovan., (2013) ‘Nursing assessment of the causes of chest pain,’ British Journal of Cardiac Nursing, Vol 8 No 10, 483-488 

N.Ellis.,(2017), 'Decision making in practice: influences, management and reflection,' British Journal of Nursing, Vol 26, No 2 

P. Benner., R. G. Hughes, M.Sutphen., (2008), 'Chapter 6. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically', Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1 

P. J. Kahrilas., N. Hughes, C. W. Howden., (2011)’Response of unexplained chest pain to proton pump inhibitor treatment in patients with and without objective evidence of gastro-oesophageal

reflux disease’, Gut, 1473-1478 

T. Levett-Jones et al., (2010), 'The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients,' Nurse education today, 30, 6, 515-520

V. Oriolo., & J. W. Albarran., (2010)'Assessment of acute chest pain,' British Journal of Cardiac Nursing, Vol 5 No 12, p587-593