Chest Pain Evaluation (NSW Chest Pain Pathway)

Question

Describe the Chest Pain Evaluation (NSW Chest Pain Pathway)?

Answer

1. Increased level of troponin is an indication of the heart’s muscle cell death. As after a heart injury, troponin is discharged into the bloodstream. Troponin is a biomarker for the heart disorder specifically for myocardial infarction. The troponin rise pathology and acute coronary syndrome pathology share a sturdy link between them. It is relevant to state that troponin is not present in the smooth muscles although heart muscles do consist of troponin (Cheitlin, 2008). The force generated by the heart muscles is dominated by the calcium concentration modifications. Muscles start to relax as the calcium concentration decreases, while they tend to contract with the increase in calcium. A protein complex is developed with tropomyosin and actin, troponin, which is the thin filaments element. The muscle force is produced with this complex and binding of calcium. The sub-units of these proteins experience a conformational change in the case of a cardiac complication. The condition of formation of plaque inside the heart arteries called ACS. In case of Mr. Lara, he experienced chest pain just before getting a cardiac arrest.

2. It is mentioned by the NSW chest pain pathway that ECG interpretation holds utmost importance in managing the ACS associated pathology. This is because it emphasizes the need of quickly identifying patients suffering from the acute coronary syndrome. In order to standardize myocardial salvage and reduce ‘door – to –needle’ time of just 30 minutes or even less; proper and prompt interventional care or thrombolysis is provided to the patient. Here the role and skill of cardiac nurses are very significant in validating and interpreting ECG reports, as the required treatment can be provided on priority. By this, Mr. Lara can get appropriate and better clinical upshot. The skilled nurse was able to give correct electrocardiogram analysis, which classified if Mr. Lara suffered ST – elevation or no ST – elevation (Branch, 2015). The conclusion drawn from this case study that the analysis of Mr. Lara having unstable angina is based on the cardiac marker (troponin). If the test result is negative then it confirms unstable angina and the positive result indicates towards myocardial infarction.

3. When a part of cardiac muscle receives less amount of blood oxygen supply, then the signs of discomfort, tightness, and pain are experienced, this state is called angina pectoris or chest squeezing (Jackson, 2008). It is important to understand that angina is a sign of a common form of cardiac disease i.e. coronary artery disease, not a disease. The contraction of coronary arteries due to the formation of plague leads to insufficiency of oxygenized blood supply to the heart. The medical term for this state is atherosclerosis. Contracted arteries increase the pain and consequently a heart stroke. The purpose of giving antianginal agents is to:

  • relieve severe chest pain,
  • ease the tightness in the chest by comforting cardiac blood vessels,
  • lessen the workload of the heart,
  • make sure that the heart receives sufficient supply of oxygenated blood.
  • The signs of headaches, lightheadedness, increased rate of heartbeat, shakiness, lethargy, vomiting, and nausea (CSONT and FERDINANDY, 2005) are some of the adverse effects of glyceryl nitrate. The supervision path comprises sub-lingual, intravenous, patches, topical (sprayer and balm). As the first step, one tablet should be placed under the tongue. In case of no relief, the dosage is given again after five minutes.

4. To identify any kind of abnormality in heartbeats detection of potassium level in the body is a must. Weak electrical signals produced by the affected heart muscles can lead to abnormality in the heartbeats. Hence, if the body has low potassium level then it can signify any complication arising in the heart.

To ensure good health of the heart it is must to have a proper and regular track of blood calcium level. As compared to C-reactive protein blood test and cholesterol-lowering stating medicines, testing calcium level in coronary arteries is a better method. It assists in a much-trusted way in recognizing the cholesterol condition of an individual.

For proper functioning of nerve, enzyme, and muscles, magnesium is an important and required electrolyte. Sodium and potassium can be moved in and out of the cells with the help of Magnesium. The weak muscles condition is a sign of the lower level of magnesium present in the blood. This reflects that human’s system has complications because of the low level of magnesium.

5. Defibrillation is the most prevalent treatment for heart dysrhythmias, ventricular tachycardia, and ventricular vibration. In this, electrical energy as a remedial dosage is provided to the patient. The treatment is supported by a defibrillator (‘Defibrillation’, 2011). Defibrillation given at the right time is considered as the only proficient treatment for ventricular fibrillation. The important point to note is that defibrillation will respond only if it is provided within the crucial initial few minutes of a sudden heart attack. The survival chances of the patient are high with this method.

6. The major compartments of body fluid consist of extracellular (interstitial fluid, trans-cellular fluid, and plasma) and intracellular fluid. The intracellular liquid in the form of cytosol is present in the cells. Cytosol, a complex mixture of components that includes ions, proteins, and organelles drooped in water. While the fluids of the body that is outside the cells are called the extracellular fluid. Protein reserve of human system is served plasma, having a fundamental activity in intravascular osmotic effect. As it maintains the balance of electrolytes, it also safeguards the human body from disorders and infections that are related to blood. Transcellular fluid holds water of the total system inside the epithelial cell lines. The high temperature of the body and prolonged fever increase the fluid loss and metabolic rate due to evaporation. Increase in the rate of heartbeat and upraising tachycardia signifies regular insufficiency of fluid in the body. Some of the prominent signs of massive deficiency are;

Low blood pressure, disorders, and infections, tachyarrhythmia, decreased peripheral pulses, reducing urine frequency, and diaphoresis.

Some of the prominent signs of massive overburden are;

7. Difficulty in breathing, pitting edema, and tiredness

  • A patient's neurological condition should be assessed by the nurse: it should be ensured that Glasgow Coma Scale assessment is documented properly and it comprises of limb and pupil assessment. Nurses should increase or decrease the frequency of their observation depending upon the state of the patient. A patient must be repositioned regularly once his respiratory system and pressures areas have been checked. Skin texture should be closely observed. For nervous thromboembolism prophylaxis, it is important to administer anticoagulants and anti-embolism stockings.
  • For accurate medical information, it is important to check the pulse rate manually. Nurses must assess the pulse strength, pulse volume, regularity, and rate. The symptoms of weak, fast and thready pulse rates signify dehydration. In this course, it is required that a patient's temperature and any change in skin must be regularly evaluated. It is seen that the patients who are vulnerable to dehydration easily develop cool peripheries. Severe dehydration also extends the limb coolness; this is because vasoconstriction happens in order to maintain blood pressure.

8. To keep Mr. Lara’s medical state of Atrial fibrillation on track, Digoxin tablets are prescribed. To treat cardiac glycosides, Digoxin is the tablet advised for it. The kidney is used to excrete the tablet Digoxin. It includes two types of activities one positive i.e. inotropic whereas other is negative named chronotropic. Digoxin plays a vital role in arterial fibrillation for controlling the ventricular rate. Digoxin helps in blocking the sodium-potassium ATPase. The heart electrical activity is well responded with Digoxin, also it amplifies the fourth phase of depolarization inclination. The system cutbacks the probable duration of the action and lowers the maximum diastolic possibility. Digoxin has a few risks related to toxic reactions; they are impaired renal function and exhaustion.

9. The dosage of Digoxin is 250 micrograms is prescribed to Mr. Lara and given twice a day.

Sodium (Na+)

To check the balance of water and electrolyte within the system, this process is performed. This balance signifies the development of problems that are associated with adrenal glands or kidneys. Sodium at the lower side signifies the failure of heart, diarrhea, and malnutrition. 

Chloride (Cl¯)

To check adrenal gland and kidney, this is performed. Varied level of chloride signifies muscle contraction, seizing, confusion, weakness, difficulty in breathing.

Urea

 

To check the existence of Helicobacter pylori in the stomach, this is performed. Its existence signifies peptic and gastric ulcer.

10. A medical method called airway management is used to ensure an open passage between the outer world and lung of the patient along with reducing aspiration risk. Airway administration holds a significant part of nursing care. In case of Mr. Lara, airway management is important to support his falling cardiac output and his state of dyspnoea. The steps of airway management consist of airway evaluation, airways acute management and airway exudation. Nurses must pay close attention and should be cautious enough in relation to airway management and deteriorating state. In any state of urgency, every effort should be made to maintain breathing. Preoxygenation measure at the cellular level allows denitrogenation or replacement of the nitrogen volume with oxygen in the lungs. If the patient experiences ventilation issues, oxygen saturation level of the patient may also fall speedily. Hence, it is imperative that the nurses should be well informed and educated about these factors while carrying out airway management. Preoxygenation is one of the preparatory steps that are part of nursing care. This step involves the administration of 100% oxygen with a facemask during impulsive breathing prior anesthetic stimulation.

Progress notes

Date – Time

Progress Notes

 

19 – March – 2015

9:00 AM

X-Ray of the chest, review awaited

IV administration in the left orbital fossa.

A sample of blood was taken for examination.

A score of pain is 1/10, hence ready to shift to CCU.

20 – March – 2015

10:00 AM

ECG monitor is connected to the patient, blood test result is awaited.

X-ray report of the chest does not show the presence of any disease and the intravenous channel is removed.

References:
Branch, A. (2015) Chest Pain Evaluation (NSW Chest Pain Pathway) - NSW Health. NSW Department of Health. Available at: https://www0.health.nsw.gov.au/policies/pd/2011/PD2011_037.html (Accessed: 20 March 2015).

Cheitlin, M. D. (2008) ‘Prognostic Value of Very Low Plasma Concentrations of Troponin T in Patients With Stable Chronic Heart Failure’, Yearbook of Cardiology, 2008, pp. 345–346. doi: 10.1016/s0145-4145(08)01032-0.

CSONT, T and FERDINANDY, P (2005) ‘Cardioprotective effects of glyceryl trinitrate: beyond vascular nitrate tolerance’, Pharmacology & Therapeutics, 105(1), pp. 57–68. doi: 10.1016/j.pharmthera.2004.10.001.

‘Defibrillation’ (2011) SpringerReference. doi: 10.1007/springerreference_224875.

Jackson, G. (2008) Angina. United Kingdom: Informa Healthcare.





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