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Poor Patient Outcome Assignment Help

• Ask yourself; Have you considered the likelihood of it and whether it needs to be ruled out by testing or referral? 

• Because many serious disorders are challenging to diagnose, have you considered ruling out the worst case scenario? 

• Ask yourself: Do you have sufficient understanding of the clinical presentation to offer an opinion on the diagnosis? 

• What other diagnosis could it be? How might the treatment to date have altered the patient outcome? 

• What other diagnostic and laboratory or imaging was needed in order to make a complete differential list? What support tools would you consider using in helping to create a differential diagnosis list? 

• Are you familiar with the current clinical practice guidelines for the investigation of a suspected condition such as chest pain?


Point 1:

Developing a list of possible conditions that might produce a patient''s symptoms and signs is an important part of clinical reasoning. 1.As an NP in primary care what would you have done differently?

One of the most important skills that nursing practitioners can bring into any situation is the ability of performing accurate assessment of the patient. In the present case, a 35-year old patient, otherwise healthy, is reporting to have sudden chest pain with non-productive cough.  He describes the pain to be sharp and becoming worse with movement are inspiration. The initial assessment information such as (i) nature of pain; (ii) vital signs of physical examination; (iii) ECG assessment; and (iv) blood pressure. The assessment that is made is also known as PQRST pain assessment (provoking factor, quality, radiation, severity, and time) (Mulvagh, 2018).

These reports suggest that blood pressure is normal however there is tenderness in the chest wall along with faint cardiac murmur. Importantly, since the patient is experiencing chest pain, it is important to determine if the pain is cardiac in nature and identifying the possibilities of cardiac problems which reference to the assessment. Being a nursing practitioner, I would have considered following evidences and learning to correlate the assessment with the corresponding intervention (Hollander & Chase, 2016):

• The pain become worse with repositioning, which perhaps is an issue related to musculoskeletal origin. This suggest possibilities of pleuritis (inflammation in the inner lining tissue of the chest cavity) or pericarditis (inflammation in the fibrous sac around the heart).

• The description of pain along with the region in chest associated is important. If the pain is described as crushing or constricted in nature, originating from the substernal region, it can give a hint of myocardial infarction. However not all patients show similar symptoms, as in the present case this is absent.

• The patient experiences radiating pain the words neck booster. However, there are no signs of nausea, vomiting, dizziness which excludes the possibility of having hypotension (low blood pressure) or bradycardia (reduced heart rate than normal).

• The chest pain in the given case is not intermittent and also lost up to 2 hours. these conditions exclude the possibility of having angina (cause with reduced blood flow to heart).

Another important consideration is related to the proper examination of ECG report. In such a situation of chest pain, 12-lead ECG is considered as a vital assessment that's going to help in determining the appropriate cause of chest pain. additionally, it will also help in determining if reperfusion therapy is required in the present settings. As an NP, the ECG must be consulted with cardiologist and the corresponding changes can indicate possibility of myocardial infarction cardiac ischemia (Florescu, 2018). However, in the case information, ECG report is mentioned normal without important details. The ECG interpretation must also include analysis of troponin level in blood which is one of the important cardiac enzyme and hence is considered as a marker of ischemia or infarction.

According to the guidelines for acute management of chest pain (Roffi, 2016), The patient should be given access to a defibrillator. This is important to avoid any possibility of reverse arrhythmia that might prove to be fatal with causes like early cardiac death.

Point 2:

Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome? If a serious diagnosis comes to mind based on a patient''s symptoms:

From the given case analysis, following differentials were important for the patient, which way are missing according to the given information (Nitta, 2018; Hollander, 2016):

• Transthoracic echocardiogram (TTE) must also be analyzed for accurate assessment of the patient condition. According to the guidelines, TTE is always recommended for patient with chest and abdominal pain with uncertain etiology. this assessment is important to evaluate conditions light intimate flap or failing at aortic root, and/or descending condition of aorta.

• Proper examination of ECG record was vital. In the present case, ECG report was misinterpreted, as the changes in the signal might be related to non-specific ST-T wave changes.

• Chest x-ray is one of the systemic interpretation, which in the present case is missing. Such assessment is important to evaluate the equality of airway, any injury associated to the chest pain, and the corresponding heart size, hemi diaphragms, and pleural effusions. Possible sign which are important include (i) mediastinal widening; (ii) appearance of double density in aorta, (iii) aortic knob disruption; and (iv) deviation of tracheal tube towards right.

• The full blood test must also include essay for detection of serum D-dimer in blood (Nitta, 2018). This is important to evaluate the presence of any blood clot (anatomic thrombosed lumen) that can indicate towards aortic dissection and related complications.

• The general medicine which is recommended in case of acute chest pain management is Aspirin. Assessment is also important for the Aspirin contraindication to the patient, and it should be prescribed in the given setting. This would reduce any risk associated with thrombus formation, platelet aggregation, and vasoconstriction.

• Blood pressure is only examined for right arm; however, it was important to assess the hemodynamic condition of patient body through proper examination. Such as this moment is important to evaluate the hemodynamic stability, for example systolic BP > 110 mHg with pulsus paradoxus < 10 mmHg is indicative of pre-tamponade (or haemodynamically stable) condition. In contrary, the reverse values (that is systolic BP < 110 mHg with pulsus paradoxus > 10 mmHg) is indicative of tamponade condition (or haemodynamically stable).

ECG along with TTE is often considered as a reliable and simple assessment tool to identify complications of aortic dissection which includes regurgitation of aorta and pericardial effusion. In my opinion, this must be assessed properly to rule out any worst case scenario.

Other possible diagnosis includes full blood test and proper blood pressure assessment. These assessments were important to clearly identify the risk associated with aortic dissection and tamponade condition. As a result of which, prophylactic drug like beta blockers (carvedilol, nebivolol, and metoprolol) and aspirin can be prescribed to reduce any risk of cardiac collapse (Nienaber, 2015). No decisions were made do include CT scanning or MRI (magnetic resonance imaging) to assess the conditions, suspecting aortic dissection. CT scanning is the definitive imaging assessment tool to detect aortic dissection, whereas MRI is secondary modality, which is available in limited healthcare settings.

The relevant discussion with reference to the guidelines for acute chest pain management are discussed in the above context. In addition to this, according to the best care practices, the NP responsibilities also include to maintain a calm and controlled environment that is important from the patient's comfort point of view (Mulvagh, 2018).


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