Question

The patient presents to the ER with recurrent headaches, fatigue, and a blood pressure of 185/102. Patient is a long-time smoker, lead a relatively sedentary lifestyle, and has a BMI of 39. History of acid reflux. Patient is going to be kept for over night observation and administer medications to help control his blood pressure.

Patient Blood pressure taken just before transferring to the Med/Surg. Floor 156/87.

Nursing assistant taking the Vital signs: Temp 98.8, Pulse 101, B/P 178/98 this was just taken when patient arrives to the floor.

The nursing assistant reports to the RN that patient is complaining of chest pain.

1.  What would be the priority nursing intervention for Mr. Davis based on the Electronic Health Record information?

Answer 1

Gastroesophageal reflux disease (GERD), the presence of symptoms or mucosal damage from gastroesophageal reflux, is a common, morbid, and costly medical condition in many countries (1). The prevalence of at least weekly heartburn or acid regurgitation ranges between 10–20% in Western countries, GERD treatments are costly (2–4), and GERD is associated with substantial morbidity, including esophageal adenocarcinoma (3, 5, 6–14). The identification of modifiable risk factors for GERD could potentially have a substantial public health impact. One potential major risk factor is obesity, the prevalence of which has increased markedly in recent decades (15). Obesity is a postulated risk factor for GERD, although individual studies have conflicting results (16–27). Some studies suggest that an increased body mass index (BMI) is associated with increased esophageal acid exposure (28) and with an increased risk of hospitalization for esophagitis (29). In contrast, other studies, including one of the largest population-based studies to date, have found no association between BMI and GERD (30–33). Potential explanations for the disparate results include a true lack of an association between BMI and GERD, differences in definitions or methodology, dissimilar study populations, or a lack of power to detect an effect in some studies. We evaluated the relationship between BMI and GERD using a systematic review and statistical synthesis; these methods can be valuable tools for the investigation of disease associations. Data pooling can help evaluate the influence of different study definitions, study designs, or study populations on the exposure-disease association. It can also help explore associations that individual studies may lack the power to investigate such as the influence of gender, levels of BMI, or the presence of confounding factors on disease risk. We thus performed an analysis of observational studies for the association between BMI and GERD with an emphasis on the evaluation of differences in study definitions, study design, and study populations and the creation of more standardized exposure definitions to better compare results among studies.

Nursing Management

The goal of nursing management is to help achieve a normal blood pressure through independent and dependent interventions.

Patient  will be monitored every 30 minutes by the nurse.-Nurse will assess patient chest pain every hour and educate the patient on reporting an increase in chest discomfort to the nurse immediately.

Troponins levels will be drawn at 0200, 0800, and 1400 per md order.
Nurse will administered Nitroglycerin 0.4mg Sublingual every 5 minutes for chest pain until relieved.

Nurse will obtain an EKG when patient reports chest pain level and report any ST elevation to the MD

Nursing Assessment

Nursing assessment must involve careful monitoring of the blood pressure at frequent and routinely scheduled intervals.

• If patient is on antihypertensive medications, blood pressure is assessed to determine the effectiveness and detect changes in the blood pressure.
• Complete history should be obtained to assess for signs and symptoms that indicate target organ damage.
• Pay attention to the rate, rhythm, and character of the apical and peripheral pulses.

Nursing Priorities

1. Maintain/enhance cardiovascular functioning.
2. Prevent complications.
3. Provide information about disease process/prognosis and treatment regimen.
4. Support active patient control of condition.

Chest pain doesn't always signal a heart attack. But that's what emergency room doctors will test for first because it's potentially the most immediate threat to your life. They may also check for life-threatening lung conditions — such as a collapsed lung or a clot in your lung.

Assessment of the patient with hypertension must be detailed and thorough. There are also diagnostic tests that can be performed to establish the diagnosis of hypertension.

Assessment

• Assess the patient’s health history
• Perform physical examination as appropriate.
• The retinas are examined to assess possible organ damage.
• Laboratory tests are also taken to check target organ damage.

Immediate tests

Some of the first tests your doctor may order include:

• Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show that you have had or are having a heart attack.
• Blood tests. Your doctor may order blood tests to check for increased levels of certain proteins or enzymes normally found in heart muscle. Damage to heart cells from a heart attack may allow these proteins or enzymes to leak, over a period of hours, into your blood.
• Chest X-ray. An X-ray of your chest allows doctors to check the condition of your lungs and the size and shape of your heart and major blood vessels. A chest X-ray can also reveal lung problems such as pneumonia or a collapsed lung.
• Computerized tomography (CT scan). CT scans can spot a blood clot in your lung (pulmonary embolism) or make sure you're not having aortic dissection.

Follow-up testing

Depending upon the results from these initial tests, you may need follow-up testing, which may include:

• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart in motion. A small device may be passed down your throat to obtain better views of different parts of your heart.
• Computerized tomography (CT scan). Different types of CT scans can be used to check your heart arteries for blockages. A CT coronary angiogram can also be done with dye to check your heart and lung arteries for blockages and other problems.
• Stress tests. These measure how your heart and blood vessels respond to exertion, which may indicate if your chest pain is heart-related. There are many kinds of stress tests. You may be asked to walk on a treadmill or pedal a stationary bike while hooked up to an ECG. Or you may be given a drug intravenously to stimulate your heart in a way similar to exercise.
• Coronary catheterization (angiogram). This test helps doctors identify individual arteries to your heart that may be narrowed or blocked. A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter) that's fed through an artery, either through your wrist or your groin, to arteries in your heart. As the dye fills your arteries, they become visible on X-rays and video.

Treatment

Treatment varies depending on what's causing your chest pain.

Medications

Drugs used to treat some of the most common causes of chest pain include:

• Artery relaxers. Nitroglycerin — usually taken as a tablet under the tongue — relaxes heart arteries, so blood can flow more easily through the narrowed spaces. Some blood pressure medicines also relax and widen blood vessels.
• Aspirin. If doctors suspect that your chest pain is related to your heart, you'll likely be given aspirin.
• Thrombolytic drugs. If you are having a heart attack, you may receive these clot-busting drugs. These work to dissolve the clot that is blocking blood from reaching your heart muscle.
• Blood thinners. If you have a clot in an artery feeding your heart or lungs, you'll be given drugs that inhibit blood clotting to prevent the formation of more clots.
• Acid-suppressing medications. If your chest pain is caused by stomach acid splashing into your esophagus, the doctor may suggest medications that reduce the amount of acid in your stomach.
• Antidepressants. If you're experiencing panic attacks, your doctor may prescribe antidepressants to help control your symptoms. Psychological therapy, such as cognitive behavioral therapy, also might be recommended.

Surgical and other procedures

Procedures to treat some of the most dangerous causes of chest pain include:

• Angioplasty and stent placement. If your chest pain is caused by a blockage in an artery feeding your heart, your doctor will insert a catheter with a balloon on the end into a large blood vessel in your groin, and thread it up to the blockage. Your doctor will inflate the balloon tip to widen the artery, then deflate and remove the catheter. In most cases, a small wire mesh tube (stent) is placed on the outside of the balloon tip of the catheter. When expanded, the stent locks into place to keep the artery open.
• Bypass surgery. During this procedure, surgeons take a blood vessel from another part of your body and use it to create an alternative route for blood to go around the blocked artery.
• Dissection repair. You may need emergency surgery to repair an aortic dissection — a life-threatening condition in which the artery that carries blood from your heart to the rest of your body ruptures.
• Lung reinflation. If you have a collapsed lung, doctors may insert a tube in your chest to reinflate the lung.