Critical Analysis of a Second Selected Scenario from Caseworld

Introduction

The purpose of current paper is twofold: two explore pathophysiology of angioplasty condition in a general context and to evaluate the effectiveness of an early mobilisation post-angioplasty. To accomplish the tasks, the present paper will draw – wherever applicable –on the case of Elizabeth Rose Green, who has recently undergone angioplasty. At the outset, the paper discusses the importance of mobilisation in connection with surgery and post-angioplasty and dwells upon the pathophysiology of angioplasty. Next, the paper critically analyses and discusses relevant patient care required and provided in case of Elizabeth Rose Green. It will involve the discussion of the nursing care based on the current best practice that will be administered to Elizabeth and the patient’s medication that will help her in early mobilisation. The paper also examines the role of other healthcare professionals in the process of administering care to Elizabeth and post-angioplasty patients in general. At the same time, it discusses psychosocial well-being of the patient experiencing angioplasty. In addition, the paper offers evaluation of the outcomes of nursing interventions provided and discusses the revision of the care plan for Elizabeth. While performing all the above-mentioned tasks, special attention will be paid to such aspects as best practice, pathopharmacology, relevant clinical pathways and inter-professional roles. Before concluding the paper, the author provides a brief but relevant discussion of ANMC competency standards 8.1 and 8.2.

Critical Analysis

Pathophysiology of Angioplasty Condition

The need for angioplasty is explained by the narrowing of arteries, which reduces the circulation of blood in the body. When arteries narrow, a person can feel giddiness, muscle fever, chest pain and other similar symptoms. Due to the fact that blood and oxygen do not penetrate the affected regions, tissue damages are common (Schmilowski & Swanton 2012). Angioplasty is aimed at relieving the unpleasant symptoms by improving blood flow. In the process, a thin, flexible catheter is inserted into a patient’s artery and moved to the site where the blood vessel is narrowed. The effectiveness of angioplasty is contingent on the size of the artery, the affected length of the artery and on its occlusion level (Schmilowski & Swanton 2012). Interestingly, angioplasty works better in large arteries and blood vessels with short narrowed areas (Schmilowski & Swanton 2012).

The concept of mobilisation, also referred to as ambulation, is closely related to post-angioplasty. In medical context, early mobilisation implies the ability of a patient to move after the operation. The debate has been traditionally focused on whether or not the patient should spend some time in bed following angioplasty. Once the procedure has been performed, a patient should stay resting in bed for not less than four hours, according to conventional knowledge. However, some authors oppugn the veracity of such standard recommendation, arguing that two hours may suffice. Yet others argue that patients can be ambulant immediately after angioplasty if the circumstances allow it, without specifying the circumstances (Butterfield 2000). According to Morgan and Walser (2010), bed rest times after manual compression during angioplasty are set arbitrarily. In a recommendation that is seldom embraced by healthcare practitioners, they suggest the following:

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Overnight bed rest is unnecessary. For example, in a study of early mobilisation following manual compression of 6F arterial punctures post-angioplasty, 90% of 128 patients were ambulant at 4 h following gradual mobilization after 2 h of supine bed rest. This was achieved with no major puncture-site complications and no delayed complications (Morgan & Walser 2010, p. 73).

One thing is sure: patients should eschew strenuous exercise for at least 24 hours following angioplasty to prevent bleeding. Once a patient has been transferred to Day Case Unit or the ward, his/her blood pressure, heart rate and foot pulse are measured. Puncture site is also frequently examined until the patient is discharged. While bleeding and other severe complications, such as closure of the blood vessel, blood clots, allergic reactions and kidney failure, are rare, less serious complications, including tenderness and/or swelling at the tube insertion site (as in the case of Elizabeth Rose Green) and small bruises at the tube insertion site, may take place in some instances (Schmilowski & Swanton 2012). While such unserious complications are common, they disappear within the next few days. Likewise, it sometimes occurs that cells and/or tissues, once exposed to any kind of radiation, may be damaged. For example, it may occur as a result of a low level of X-ray radiation during a cardiac stress test. However, it is true that benefits of cardiac stress test overweigh the risks of tissue damage associated with radiation.

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Relevant Patient Care Required and Provided to Elizabeth Green

The case chosen for the purposes of current paper is that of Elizabeth Rose Green, 78 years of age, living alone in her house. Elizabeth has a disturbing medical history, including gastro-oesophageal reflux disease, hypertension, hypercholesterolemia, osteoarthritis and diabetes mellitus type 2. Moreover, she went through hysterectomy when she was 48 years old. Medical records of her parents and some other close relatives, who had succumbed to chronic illnesses, suggest that Elizabeth Rose Green may be also prone to other chronic maladies. Until recently, the patient reported good health, as for a person of her age, but nevertheless used a 5-point list of medications. However, prior to hospitalisation she experienced occasional episodes of chest pain, but they quickly lapsed. She was hospitalised after a long-lasting bout of excruciating pain in her central chest area and left shoulder that reportedly frightened her. On her way to the hospital, Elizabeth was given a loading dose of IV Morphine, and the intravenous glyceryl trinitrate (GTN) infusion was soon commenced. Upon her assessment by a cardiac specialist in the emergency department, Elizabeth was transferred to the Cardiovascular Investigation Unit for an angiogram plus or minus stenting. A femoral angioplasty was performed thereupon, stenting a blockage in Elizabeth’s left anterior descending artery. The recovery process, which followed a procedure, began immediately, according to the generally accepted 4-hour immobilisation rule.

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Indeed, it is necessary to note that the recovery procedure began in line with the well-established 4-hour bed rest rule, which is considered to be the best medical practice following angioplasty. Although, early mobilisation following surgery has been shown to prevent post-surgical complications, such as respiratory problems (Westerdahl & Moller 2010), there is an overwhelming agreement in medical quarters that patients should be encouraged to remain in the supine position during the first four hours following angioplasty (Antoniucci 2009; Caplan 2015). Research has been carried out to prove the opposite. Thus, Gillane and Pollard (2009) suggest that “86.8% of patients suffered no vascular complications” (p. 137). Moreover, they have arrived at the conclusion that earlier ambulation “will enable cardiology units to treat more patients, thereby maximising efficiency and income generation” (Gillane & Pollard 2009, p. 137). Among other rare authors who disagree with the commonly accepted knowledge are Morgan and Walser (2010). However, it can be reasonable to question the validity of Gillane and Pollard’s (2009) and Morgan and Walser’s (2010) inferences, as hospital incomes should not be achieved at the expense of patients’ health and psychosocial well-being. In line with another commonly accepted post-angioplasty practice, the patient was encouraged to increase her post-procedure fluid intake to at least 1.5 litres. Hence, the conclusion that health professionals attending to Elizabeth Rose Green adhered to well-established clinical standards rather than some experimental suggestions.

The rationale for Gillane and Pollard’s (2009) study was that prolonged bed rest following angiogram with femoral puncture “increases patient discomfort during recovery” (Gillane & Pollard 2009, p. 137). Four hours of bed rest cannot lead to the appearance of decubital ulcers, but it can cause physical inconvenience and uneasiness. Elizabeth Green, in her turn, reported that she felt discomfort at being forced to remain in bed for more than roughly two hours and, possibly, every additional minute only heightened her discomfort. However, in accordance with another generally accepted practice, she was encouraged to perform arm movements and deep breathing exercises to improve breathing and stimulate circulation (Westerdahl & Moller 2010). After being supine for four hours, the sheath was removed from her leg and Elizabeth gradually increased her activities, as per doctor’s order, by sitting up at 30 degrees for two hours and then at 45 degrees for another two hours. After a total of eight hours spent in comparative immobility, the patient was allowed to mobilise as tolerated.

The importance of gradual increase in activities after angioplasty cannot be overstated. Once angioplasty has been performed, the patient’s heart has a much better blood supply and the patient may feel stronger and more energetic. However, to increase fitness and preclude potential risks and problems, activities should be performed gradually. Thus, post-angioplasty patients are encouraged to avoid strenuous exercise, such as heavy lifting and most sports, for five to seven days. Likewise, it is recommended that such patients should not overtax themselves during bowel movements to prevent haemorrhage at the catheter insertion site. At the same time, it is evident that post-angioplasty patients should not stay in bed all the time. They should take walks and engage in other similarly easy activities, because gradual exercise helps develop the strength of the heart. It is the reason why slight arm movements are encouraged by all doctors immediately after angioplasty, even though patients are required to stay in bed for several hours in accordance with the early-mobilisation rule.

As to the inter-professional roles, it is necessary to say that the work of different healthcare professionals in providing care to Elizabeth was thoroughly coordinated. Indeed, the hospital staff had taken meticulous care of Elizabeth at all stages of her short stay in the clinic. Cardio monitoring, visits by a vascular surgeon, duty doctor, ward physiotherapist and other health professionals, as well as half-hourly neurovascular observations following a Doppler ultrasound and two sets of hourly observations post-sheath removal changed each other in quick succession. A coherent simultaneous execution of all the procedures on the part of the hospital staff testifies the level of care which the hospital pays to clinical pathways. The fact that Elizabeth was visited by so many different healthcare specialists also attests to the high level of both inter- and intra-professional collaborations in the hospital.

Regarding pathopharmacology, it was properly ensured in the case scenario of Elizabeth Rose Green. Moeini et al. (2010) argue that it might be essential to check the hospital’s protocol in recommencing activity following angioplasty surgery. They maintain that even slow and easy movements following surgery may be painful and uncomfortable insomuch that it could even discourage the patient from moving (Moeini et al. 2010). Administering pain reliever helps a patient cooperate in the early mobilisation activities (Westerdahl & Moller 2010). In Elizabeth Green’s case, pain relievers were not administered immediately, but discharge medications have been ordered and sent through to the pharmacy. Similarly, following her discharge from the hospital, the patient was advised to see her general practitioner in the next few weeks to review her medications.

Likewise, Moeini et al. (2010) contend that it is essential that a patient’s wound site should be monitored, as some activities have the potential to increase strain on the catheter insertion site, which may result in wound site complications, including bleeding and infections. Such situations could be prevented, Moeini et al. (2010) reckon, by supporting the wound site with a pressure dressing whilst performing activities. In Elizabeth’s case, her wound site was inspected at least twice in the space of the first hour following angioplasty. Due to the fact that her left foot was found to be cool and pale one hour after the surgical operation ended, the cardiologist examined it to measure dorsal and pedal pulses and performed a Doppler ultrasound to determine if there was adequate blood flow. After the cardiologist’ inspection, neurovascular observation continued on a half-hourly basis. Also, because the patient was receiving GTN infusion, a small problem emerged immediately after its removal. According to the patient’s report, the cannula suddenly became “very sore”, but her general practitioner decided to persist, perhaps realizing that the pain would soon subside. In other words, health professionals treating Elizabeth Rose Green took all the necessary measures to make her experience in the hospital as painless as possible. However, the latter example also demonstrates that they cared more about the wholesomeness of the experience rather than its painlessness. It is also necessary to say that their actions in terms of pathopharmacology were prudent and well-accepted in clinical practice.

According to Moeini et al. (2010), early mobilisation also helps the patients regain their normal lives and be independent. Moreover, early mobilisation mollifies a patient’s hospitalisation experience and promotes psychosocial well-being. Although Elizabeth was denied early mobilisation in Gillane and Pollard’s (2009) understanding of the term, she was encouraged to make arm movements and otherwise increase her mobility. As to Elizabeth’s psychological well-being, she had a decent conversation with a psychiatrist and was discharged home to look after her beloved pet, as she felt anxious about parting with the dog from the very beginning of her hospitalisation. Switching from the concrete to the general, it must be said that coordination with other health care professionals, such as the physiotherapists, can assist a patient who has just underwent surgery in performing post-surgical exercises to promote physical activity in the hospital and after discharge (Westerdahl & Moller 2010).

Thus, the above discussion has shown that nurses, as well as other healthcare professionals should have a clear understanding of planning and evaluation of care. Planning is important as it prevents the possibility of important issues and procedures being neglected. In such way, planning outlines a road map for all individuals involved in the provision of care to the patient. Moreover, the effective planning is closely intertwined with accurate and comprehensive evaluations of the care provided. Regular assessments are essential, because they reveal the effectiveness of current care programme and can, therefore, help modify the programme, if necessary.

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As expected, effective planning, evaluation and, most important, administration of care have ensured complete convalescence of Elizabeth Green. Upon her discharge from the hospital, she was given a medication list and was referred to the cardiac rehabilitation unit within the hospital. Having combined the use of medications with attending the rehabilitation program for two weeks, the patient reported feeling much better. The fact that Elizabeth recovered from her surgery means that care programme was set properly and that nursing intervention outcomes were achieved. Hence, the conclusion that plan of care for Elizabeth does not need to be revised. The best recommendation for the patient is to make all the necessary changes to her list of medications and continue attending the rehabilitation program.

Achievement of ANMC Competency Standards

Before concluding the paper, it would be wise to discuss how the critical analysis above provides support for its author’s achievement of ANMC’s two specific competency elements: 8.1 and 8.2. Adopted first in the early 1990s by the Australian Nursing and Midwifery Council, current competency standards are used to assess the competency of a registered nurse in Australia. Competency element 8.1 holds that a nurse “determines the progress of individuals or groups towards planned outcomes” (Tollefson 2004, p. 226). The critical analysis performed for the purposes of current paper has clearly demonstrated that different individuals may require different treatment, as treatment outcomes depend on such decisions. Thus, while some patients require at least four hours of bed rest, others may require only two hours of immobility. The analysis has also taught the author to gear planned outcomes to specific cases and to evaluate individual responses to interventions, in accordance with the competency element 8.1 (Tollefson 2004). Competency standard 8.2 holds that a nurse “revises the plan of care and determines further outcomes in accordance with evaluation data” (Tollefson 2004, p. 226). While the critical analysis conducted above does not directly contribute to the development of the competency standard, it edifyingly shows how the plan of care can be modified in a particular situation, as general practitioner attending to Elizabeth Rose Green had to revise his plan of care due to the new circumstances.

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Conclusion

The present paper has shown that early mobilisation following angioplasty may be a difficult process. A patient needs to spend at least four hours in bed after the procedure. Anyway, some authors argue that two hours are enough. Regardless of both statements, one fact is obvious: a patient needs to refrain from strenuous exercise within 24 hours following surgery and gradually increase his/her exercise to strengthen the heart. As seen from the case of Elizabeth Rose Green, bed-ridden patients may be encouraged to perform slight arm movements in order to stimulate circulation immediately after angioplasty. In terms of pathophysiology, angioplasty is a largely harmless procedure. While bleeding, blood clots, artery closure, kidney damage and allergic reactions are rare, swellings at the tube insertion site and small bruises at the tube insertion site, as in the case of Elizabeth Rose Green, are more common. Overall, the fast recovery of Elizabeth Green after angioplasty attests to the effective coordination of healthcare professionals’ efforts. It also suggests that the programme of care for Elizabeth Green was set properly and that nursing intervention outcomes were achieved.

 

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