CPC306 Assessment 3 Case Study Analysis

Complex care using DETECT Framework

Detecting Deterioration:

For the sake of evaluatingthe deterioration of Alistair, a 74-year-old male who is currently experiencinga complex medical history revolving around hypertension, type 2 diabetes, ischemic heart disease (IHD), heart failure with reduced ejection fraction (HFrEF), depression, and a history of bowel cancer with a colostomy, there are intricate steps which are required to be inculcated in order to recognize the problem:

Gathering Information: The first course of action is to accumulate necessary information pertinent with the patient’s medical history as well as recent interventions that are incorporated in order to understand the changes in current landscape. In order to do so, reviewing vital signs that are recently taken along withlab results (e.g., elevated potassium of 6.7), and medications (e.g., use of salbutamol) should be carried out immediately.

ABCDEFG Algorithm: The reason of utilizing this algorithm is that it assists to systematically garner information regarding patient’s current status, on the basis of which drawing a comprehensive inference becomes much more seamless in nature:

• A (Airway): It is imperative to ascertain that the airway is unobstructed and intricately evaluate for any signs that can be equated tocompromise the airway (Bierle, Vuckovic & Ryan, 2021).
• B (Breathing): The next course of action is to assess the respiratory rate of the patient the rate of oxygen saturation and scrutinize whether the patient is currently experiencing any sort of respiratory distress.
• C (Circulation): Scrutinizing the blood pressure as well as heart rate and peripheral perfusion is required in this phase. Owing to the fact that Alistairhas been experiencing persistent hypertension aside from heart failure.Hence, it is necessary to continually monitor for symptoms that represent worsening circulation.
• D (Disability): Evaluating the neurological status, consciousness, and any signs of confusion or altered mental status should be the focal point of this phase.
• E (Exposure): Assessingsymptoms that would reflect any sort of infection or any issues related to his colostomy.
• F (Fluids): Determining the fluid balance, intravenous access, and fluid resuscitation status.
• G (Glucose): Monitoring the level of blood glucose while keeping the notion diabetic history of the patient.

Warning Signs: after intricately analyzing the overall case study an inference can be drawn that warning signs in this instance revolves around deteriorating of the shortest associated with decreased urine output.Apart from that drastic alteration of mental status coupled with enhanced heart rate and spike in blood pressure can be referred to as warning signs (Inagaki et al., 2023).

Evaluating the Likely Cause:

In essence, it can be stated that since Alistair has a complex middle record, it is fair to state that his current deterioration of health could be related to multifactorial aspects, which are mentioned intricately as follows:

• His heart failure attributed with reduced ejection fraction (HFrEF) along with persistent hypertension is a direct reflection of constant deterioration of the cariological working function and fluid retention.
• Elevated potassium (6.7) can be referred to as a depiction of renal dysfunction, which is inherently exacerbated by his co-morbidities as well as medications.
• The use of salbutamol in this case is also enhancing his cardiac condition, due to its potential impact on heart rate and contractility.

Multidisciplinary Team and Initial Management:

The multidisciplinary team attending to Alistair's deterioration inculcates the following specialists:

• Cardiologist: To manage his heart failure and hypertension.
• Nephrologist: To resolve his elevated potassium levels and renal function.
• Critical Care Nurse: To keep an eye on his vital signs and substantiate necessary interventions accordingly.
• Endocrinologist: To manage his diabetes and its potential ramification on his current condition.
• Gastroenterologist: To regard the effects of his colostomy and keep a track of any further complications.
• Respiratory Therapist: To evaluate and manage his respiratory status due to the administration of salbutamol.

Early Communication:

• It is imperative for the team to maintain an open flow of communication in order to identify problems and promptly devise a comprehensive care plan, so that Alistair can initiate his journey of recuperation.
• Upgrading the Electronic Health Record (EHR) is the first course of action that is necessary in this juncture.
• Channels that can facilitate direct communication flow between team members, such as in person or well telephonic conversation should be taken into account.
• Incorporation of a hospital application system to request immediate attention from relevant team members is also necessary to get prompt services.

The multidisciplinary team's involvement and early communication are critical for his optimal care and management.

Treatment Prioritization and Rationale:

During the episode of Alistair's deteriorating health, it becomes paramount to accord priority to his care, factoring in the gravity of his condition and his intricate medical history. In this regard, a constellation of treatments emerges, each underpinned by its own tenets of evidence-based rationale:

Oxygenation Therapy: In accordance with NICE Guideline [NG106], 2018, it is imperative to proceed with the administration of supplemental oxygen, in sustaining optimal oxygen saturation levels and ameliorating tissue oxygenation. Since Alistair's historical entanglement with heart failure and the plausible vulnerability of his respiratory function, the employment of oxygen therapy serves to mitigate hypoxia while concurrently alleviating the burdens imposed upon the cardiac milieu (Taylor, Moore & O’Flynn, 2019).

Intravenous Fluid Management: As mentioned in the ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2021, vigilant orchestration of fluid dynamics surfaces as an imperative facet to optimize the equilibrium of hemodynamics. In light of Alistair's extensive tryst with heart failure, incorporating meticulous surveillance of fluid intake and output becomes imperative, thereby forestalling the exacerbation of cardiac insufficiencies and ensuring the maintenance of renal perfusion at requisite levels (McDonagh et al., 2021).

Pharmacotherapeutic Endeavors: Diuretic Regimen (e.g., Furosemide): As per ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2021, the judicious initiation of diuretic regimens emerges as an efficacious stratagem to counter fluid engorgement and attenuate the manifestations of heart failure is necessary as of this point.

Efficacious Potassium Governance: The exigency of addressing hyperkalemia is evident, warranting interventions such as calcium gluconate, sodium polystyrene sulfonate, or loop diuretics (Ryan, Bierle & Vuckovic, 2019). Such interventional measures are underpinned by a sagacious appraisal of the potential proclivity towards arrhythmias, a sequela intrinsically linked to elevated potassium levels.

Vasodilatory Deployments (e.g., Nitroglycerin): The initiation of vasodilatory therapies, foremost among which is nitroglycerin, emerges as a propitious endeavor aimed at attenuating preload and after load, thereby affording reprieve to the overburdened cardiac apparatus. Such therapeutic interventions not only alleviate the symptoms attendant to heart failure but also extend their ameliorative sway over the ambit of hypertension (Vuckovic, Bierle & Ryan, 2020).

Equilibrium in Electrolytic Milieu: The imperative of rectifying the perturbed equilibrium of electrolytes, particularly in the context of potassium, is manifest. Elevated potassium levels bear the propensity to instigate arrhythmogenic cascades and precipitate cardiac perturbations. That is why both intravenous insulin and glucoseare calibrated to restore the equilibrium of potassium levels.

Cardioactive Pharmacotherapy:

Beta-Adrenergic Blockades (e.g., Metoprolol): In the absence of contraindications, the contemplation of the initiation or titration of beta-adrenergic blockade looms significant. This deliberation stems from their capacity to orchestrate a reduction in heart rate, enhance contractility, and subdue the tenacity of hypertension.

Angiotensin-Converting Enzyme Inhibitors (ACEIs) or Angiotens in Receptor Blockers (ARBs): The judicious induction or fine-tuning of ACEIs or ARBs assumes significance as a harbinger of improved prognosis within the ambit of heart failure with compromised ejection fraction (Sanchis-Gomar et al., 2020).

Interdisciplinary Discourse: Sustaining an incessant dialogue within the precincts of the interdisciplinary cohort is a sine qua non, ensuring the seamless amalgamation of collective expertise.

Continuous Vigilance: This unceasing vigil is vested with the prerogative of gauging the trajectory of treatment response and promptly flagging any potential adversities or intricacies that may surface.

Escalation:

If under any condition, it is perceived that the status of the patient is deteriorating, then the first prompt action that is imperative in this juncture is to notify clinical supervisor as well as senior physician, so that necessary actions can be incorporated before it spirals out of control. Aside from seeking assistance from cardiologist, I would also seek input from other response team, so that special care can be provided to Alistair in order to alleviate him from his critical condition.

Communicating in Teams:

ISBAR Framework:

• Introduction: "Hi, my name is [Name], I am currently the registered nurse managing Alistair."
• Situation: "Alistair is a 74-year-old male who has been experiencing hypertension, heart failure, and has a history of colostomy. Aside from that he is also diagnosed to be having elevated potassium, and worsening heart failure symptoms."
• Background: "Alistair history of heart failure has immensely worsened the condition. Moreover, with reduced ejection fraction and constant administration of medications for his conditions, he is not feeling well. His potassium is high at 6.7, and despite interventions, his symptoms are not improving."
• Assessment: "His respiratory status is compromised, and his current cardiac status cannot be regarded as stable and the same goes for the electrolyte balance."
• Recommendation: "I recommend intricate monitoring and amending the administration of medications as per requirements, and consideration for higher-level care if his condition doesn't improve."

Teams:

The approach of leadership that is necessary in this instance during the course of patient’s healthcare management should be flexible, so that adapting necessary measures and amending the care plan as per requirement can be carried out in a seamless manner. In addition to that, this care plan management should also be collaborative, so that multidisciplinary assistance can be inculcated whenever required, where inputs from nephrologist, cardiologist as well as other specialists, who are working cumulatively in order to resolve Alistair’s current complex condition, can contribute in order to formulate informed decision. Fundamentally, the role of the leader in this instance is to nurture effective communication and foster comprehensive patient care plan that can optimize the journey of recuperation swiftly.

References:

Bierle, R. S., Vuckovic, K. M., & Ryan, C. J. (2021). Integrating palliative care into heart failure management. Crit Care Nurse, 41(3), e9-e18.

Inagaki, N., Seto, N., Lee, K., Takahashi, Y., Nakayama, T., & Hayashi, Y. (2023). The role of critical care nurses in shared decision-making for patients with severe heart failure: A qualitative study. PloS one, 18(7), e0288978.

McDonagh, T. A., Metra, M., Adamo, M., Gardner, R. S., Baumbach, A., Böhm, M., ... & Kathrine Skibelund, A. (2021). 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. European heart journal, 42(36), 3599-3726.

Ryan, C. J., Bierle, R., & Vuckovic, K. M. (2019). The three Rs for preventing heart failure readmission: review, reassess, and reeducate. Critical care nurse, 39(2), 85-93.

Sanchis-Gomar, F., Lavie, C. J., Perez-Quilis, C., Henry, B. M., & Lippi, G. (2020, June). Angiotensin-converting enzyme 2 and antihypertensives (angiotensin receptor blockers and angiotensin-converting enzyme inhibitors) in coronavirus disease 2019. In Mayo Clinic Proceedings (Vol. 95, No. 6, pp. 1222-1230). Elsevier.

Taylor, C. J., Moore, J., & O’Flynn, N. (2019). Diagnosis and management of chronic heart failure: NICE guideline update 2018. British Journal of General Practice, 69(682), 265-266.

Vuckovic, K. M., Bierle, R., & Ryan, C. J. (2020). Navigating symptom management in heart failure: the crucial role of the critical care nurse. Critical Care Nurse, 40(2), 55-63.

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