Jennifer Culbreath
Experience in Discipline
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Throughout Nursing school there have been many opportunities to care for patients in all nursing fields. One field that provided me with alot of experience was working on a Medical-Surgical Floor. Below is a case study of one patient that was provided care.
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Jennifer Culbreath
This is a case study on a patient with severe pericardial chest pain. R.D.’s chest pain was hard to control and took the entire shift to get below a pain level of 5. Her history and physical shows that these pain attacks occur about every three months; however, this occurrence is increased with the anxiety due to the death of her sister a few days before admission. Also, this case study includes a review of three articles that relate to pericardial pain and anxiety and preventions for both.
R.D. was admitted to the hospital on October 29, 2007 with acute pericardial pain and anxiety. Her care for this case study occurred on October 30, 2007. She admits that her anxiety attacks are related to her sister’s death and that in turn makes her pain worse. She finds it hard to talk about her sister and is still in the beginning stages of grieving.
Biographical Data
R.D. is a 31 year old female admitted October 29, 2007. She lives with her boyfriend in an apartment over his shop in Woodbury. They have no children together and she has no children from previous relationships. She does not have a church she regularly attends or a religious preference. She works at Office Max and also runs her own business from home with her boyfriend.
History & Physical
R.D. came to the emergency room complaining of chest pain related to pericarditis. She is also having anxiety attacks related to her sister’s death just a few days ago. She had a Coronary Artery Bypass Graft (CABG) in 2004 and surgery on her left ankle in 1998. R.D. has a history of hyperlipidemia, hypertension, and GERD. Her father had a myocardial infarction (MI) in his thirties. She has not had the influenza immunization and does not know if she has ever had a pneumonia vaccine. The tuberculin skin test has never been done.
Allergies that R.D. has are to avelox, morphine sulfate, and zithromax. She denies ever smoking and states that she drinks alcohol occasionally in social situations. R.D. says that she does not follow any certain diet but usually will drink a cup of coffee in the morning and then eat lunch and dinner. She says that any type of exercise makes her short of breath, even walking up the stairs to her apartment. She can complete all activities of daily living (ADLs) by herself.
R.D.’s primary language is English. She is experiencing a lot of pain, a rating of 9, over her heart. Her pain is increased when she takes a deep breath or when she gets up. She has received oral pain medication but it has not decreased the pain; therefore, repositioning, relaxation, and distraction are tried and she stops complaining about the pain and seems much more relaxed. She is alert to person, place, and time, and has appropriate recent and remote memory. Her pupils are 4mm and movement of all extremities are appropriate but she does state that it hurts in her chest when she moves because she has to breathe more.
During the morning assessment her blood pressure (B/P) was 98/68, pulse was 76, respiratory rate (RR) was 20, O2 saturation 98% and oral temperature 98.3. No telemetry has been ordered. Capillary refill is less than three seconds, there is no edema present, and skin is cool and appropriate color for ethnicity. There are no adventitious lung sounds, A: P diameter is 1:2, and has no cough or sputum production. R.D. is 65 in. tall (5 ft. 5 in) and weighs 177 pounds (lbs.). Her mouth is pink and membranes are intact and moist. There is a 20 gauge saline lock in the right forearm started on admission date. R.D. has no complaints of bowel or urinary irregularity and has used the bathroom in the AM.
R.D. is sexually active with her boyfriend and he is her only partner. She does have a history of ovarian dysfunction and does not ovulate; this is the reason she cannot have children. She does self breast exams once and month. R.D. is very worried about her family and how they are dealing with the death of her sister. She is still upset and has taken on the family responsibilities of claiming the body and planning the memorial service. She does not always feel rested when she wakes up, especially since her sister died. Also, R.D is very upset and becomes slightly agitated because the doctors cannot seem to figure out how the handle her pain because she has come in about every 3 months with the same pain and problems.
Review of Pathophysiology
Pericarditis is very painful and can be caused by different events. It is “an inflammation or alteration of the pericardium, the membranous sac that encloses the heart” (Ignatavicius & Workman, 2006). What causes the patient’s pericarditis determines its length and presentation. Examples of what causes pericarditis are infectious organisms, renal failure, Dressler’s syndrome, and systemic connective tissue disease (Ignatavicius & Workman, 2006). However, R.D.’s pain is most likely caused by her history of coronary artery bypass graft (CABG) which could have caused trauma to the pericardium. The pain associated with pericarditis usually radiates to the left side of the neck, the shoulder, or the back and can be aggravated by breathing, coughing and swallowing (Ignatavicius & Workman, 2006).
Evidenced Based Practice
According to the National Guideline Clearinghouse, a patient’s pain level should be checked once a day and the nurse should always listen to the patient’s self report of pain (Howell, Beadle, Brignell, et al. 2007). Also, ask the location of pain, type of pain, and how it influences the patient’s life. Furthermore, the nurse needs to know what causes the pain, what makes it better or worse, and when it happens (Howell, Beadle, Brignell, et al. 2007). For, R.D. her pain was checked every hour due to hospital protocol because her pain was not below a level of 3. She described her pain as increased when breathing and radiating to her left shoulder and arm. The nurse helped her find a position in bed that was more comfortable for breathing and that would not cause as much pain with death breaths.
R.D. was also given oral pain medication dilaudid. However, she felt that an oral medication was not going to be enough to control her pain. Therefore, the doctor ordered her to have a continuous patient controlled intravenous (IV) pump with dilaudid. The change over to IV medication changed the patient’s perception of pain to a level of 3. She was also much happier and more relaxed.
Utilization of Nursing Research
Chest pain can be the cause of great distress in a person’s life. Even if the patient has had the pain before, they may still wonder if this pain could mean impending cardiac failure. In one study focused on patient’s perceptions of pain and how it affects their lives, it was found that chest pain greatly hinders a person’s daily life (Jerlock, et al, 2005). The research shows that when they pain did become worse or was not resolved as quickly as it has been previously, the patient would seek emergency help and fear a major cardiac problem. The article suggests a program where when the patients have chest pain they can call a nurse line and decide if it emergency help was needed. This would decrease the amount of emergency department visits.
Anxiety can also increase the level of pericardial pain that a patient experiences. Fear of what the pain is and how to control it adds to anxiety levels. Treatment for anxiety does include medications but also education and lifestyle changes. The patient and family need to be taught what things, such as caffeine, alcohol, drugs, stress, and exercise, need to be avoided or implemented into routine. Decreasing levels of caffeine, alcohol, drugs, and stress will help the patient deal with anxiety and may prevent it. Increasing exercise can help distract the patient and relieve some stress (Mynatt & Cunningham, 2007).
Anxiety and increased pain levels can cause the patient to become aggressive when they feel that they are not being heard or their needs are not being met. Miscommunication is one of the biggest complaints that patients have. A way to decrease miscommunication is to listen to the patient and let them know that you have heard them by repeating back what they have said. Patient also state that not understanding their diagnosis or treatment heightens their anger. This can be fixed by simply asking the patient if they understand and giving the patient as much of the information they want as you can give (Ferns, 2007).
Role of the Nurse
For a patient with such severe levels of pain the priority nursing diagnosis is acute pain related to breathing and movement secondary to pericarditis. R.D.’s defining characteristics was statement of a pain level of 8 and patient’s expression of pain while breathing and increased activity. A short term goal for acute pain is that patient will report that pain has decreased to a level of 5 by end of shift. This can be accomplished by helping the patient reposition and by giving oral or IV pain medication. The patient will also express ways to practice deep breathing to increase lung capacity and decrease pain while breathing. The nurse will educate the patient on deep breathing techniques and show how to correctly use the incentive spirometer to increase lung capacity (Ignatavicius & Workman, 2006).
Another goal is that the patient will be able to walk around in room without and increased level of pain. This is possible by slow movements and not overexerting herself to prevent having to breathe harder. The patient can walk from the bed to the chair and then to the door and back if possible. Furthermore, another goal is that patient will perform all activities of daily living without increased pain above 8. This is achieved by teaching the patient to space out activities instead of clumping them all together (Ignatavicius & Workman, 2006).
A second diagnosis for R.D. is anxiety related to pain and sister’s death. The defining characteristics include the patient’s statement of anxiousness when discussing her sister’s death, agitation with the doctor, and increased anxiety with increased pain level. The first goal for this diagnosis is to help the patient cope with her sister’s death. This is done by letting R.D. talk about her sister and her feelings about the funeral. Another goal is that the patient will have decreased agitation with the doctors and the nurses. This is accomplished by first listening to the patient and second by controlling the pain level (Ignatavicius & Workman, 2006).
Thirdly, the patient should express proper ways to control anxiety and what to do when she begins to feel anxious. The nurse would educate the patient on correct techniques of relaxation and distraction to reduce anxiety. Lastly, the patient will express ways other than medications to control pain. The nurse would educate the patient on distraction, relaxation, and repositioning methods that will alleviate pain (Ignatavicius & Workman, 2006).
References
Ferns, T. (2007) Factors that influence aggressive behavior in acute care setting.
Nursing Standard, 21(33), 41-45. Retrieved November 15, 2007 from
http://ebscohost.com.ezproxy.mtsu.edu
Howell, D., Beadle, M., Brignell, A., Deachman, M., Lackenbauer, H., Palozzi, L., et al.
(2007). Assessment and management of pain. National Guidelines
Clearinghouse. Retrieved November 12, 2007 from http://www.guideline.gov
Ignatavicius, D., & Workman, M.L. (2006). Medical-surgical nursing: Critical thinking
for collaborative care (5th Ed).
Jerlock, M., Gaston-Johansson, F., & Danielson, E. (2005). Living with unexplained
chest pain. Journal of Clinical Nursing, 14, 956-964. Retrieved November 15,
2007 from http://www.ebscohost.com.ezproxy.mtsu.edu
Mynatt, S., & Cunningham, P. (2007). Unraveling anxiety and depression. The Nurse
Practitioner, 32(8), 28-37. Retrieved November 15, 2007 from
http://ebscohost.com.ezproxy.mtsu.edu
