FACULTY HEALTH & SOCIAL WORK                     

UNIVERSITY OF PLYMOUTHASSESSMENT OF THEORY

NUR 258Nursing 0ne

                                                ACADEMIC YEAR

                                                        2007 – 2008

Assessment of priories, rationale of care of individual experiencing cardiac chest pain within the general ward environment, focusing on pain as the key

priority. Student Name:                                                       ALAN P JACK

University Registration number:                                    001255

Faculty of Health and Social Work Partnership Site:

                                                 CORNWALL (KNOWLEDGE SPA)

Hand in deadline:                                                18th January 2008

Word count:                                                             2688 Words

 Module Leader

Carole ColemanC417Portland SquarePlymouth, PL4 8AA

Tel: 01752-233862 clcoleman@plymouth.ac.uk

Modular Teacher/Personal Tutor: KIM YOUNG (kim.young@plymouth.ac.uk)

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List of Contents

Front sheet                                                                                                   Page 1

List of Contents                                                                                            Page 2

Confidentiality statement                                                                               Page 3

NUR258 Assessment of Theory: Assignment Guidelines                          Page 4

Assignment      Page 6

References                                                                                  Page 16

Appendix 1 : Example of a Modified Early Warning System Chart after Stenhouse, C. Coates, S. Tivey, M. Allsop, P. and Parker, T. (2000) Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. British Journal of Anaesthesia, Vol. 84, (5) 663.

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Confidentiality statement

 “An NMC Guide for Students of Nursing and Midwifery” (NMC 2002)

 states:

“If you want to refer in a written assignment to some real life situation in which you have been involved, do not provide any information that could identify a particular patient” (page 5).

 

This has been complied with in this assignment as all individuals

mentioned have been given pseudonyms

 

 

 

 

 

                      

 

 

 

 

 

 

 

 

 

 

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 NMC (2002) An NMC Guide for Students of Nursing and Midwifery.  London, NMC

NUR258 Assessment of Theory: Assignment Guidelines

September 06 IntakeModule Assessment

NUR 258 Adult Nursing 1 – 20 level 2 credits. Aims of Assessment In common with other modules that you will study, NUR 258 contains elements of theory and practice and seeks to integrate these into the modular assessment processes Summative Assessment The summative assessment for module NUR 258 is in two parts. Theoretical Assessment:  A 2500 word essayThis assignment requires you use a problem solving approach to demonstrate ability to assess and prioritise care needs for your patient. It must go beyond the purely descriptive (Please refer to the programme handbook re level two assignment guidelines.) 

Choose a patient you have looked after in your current practice area. Discuss your assessment of the patient & identify the priorities of care, giving

a rationale for your decision. Identify one key priority and discuss the care needed.

  Essay on competent assessment and care planningSection Content Suggested word limitIntroduction Offer introductory definitions to

set the scene.  Identify key aspects you will include in the main body, with short rationale for choice.

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Main body of the essay

Discuss your assessment of the patient and identify & rationalise thepriorities. Discuss nursing interventionsfor the key priority for this patient, with reference to appropriate literature. Safe and appropriate care and your accountability must be evident. 

1000    1000

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Conclusion Summarise the key points of learning in this assignment.

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 2500 word count. + /- 10%  Marking  Criteria  Please refer to your programme handbook for information on the University of Plymouth’s marking criteria, referencing and correct presentation.

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This assignment will discuss nursing assessment, the ramifications of accountability

within the scope of pain and chest pain. It will explore the use of ALERT (Acute Life-

threatening Events Recognition and Treatment) and MEWS (Modified Early Warning

System), pain assessment and tools and nurse biases. Andrew was a 53-year-old

gentleman who was admitted with chest pain and had been found to have an

Anterior Myocardial Infarction (MI) with a past medical history of Coronary Heart

Disease and Unstable Angina Pectoris.  He had been admitted to the acute medical

ward on which I was working from the Medical Admissions Unit where this had been

diagnosed.  He had been on the ward for three hours when he reported that he had

pain in the centre of his chest.  As a result, Oxygen was administered, observations

were taken and recorded and a MEWS score calculated.  A doctor not that an

electrocardiogram (ECG) showed no changes compared to older examples.  

McCaffrery (1968: 95) states ‘Pain is whatever the experiencing person says it is,

existing whenever the existing whenever the experiencing persons as it does’. More

specifically, Mackway-Jones (2002: 57) defines cardiac pain as ‘Classically, a severe

dull ‘gripping’ or ‘heavy’ pain in the centre of the chest, radiating to the left-arm or to

the neck.  May be associated with sweating and nausea’. 

Upon assessment, Andrews care priority was reducing his cardiac chest pain. 

Recently, having had an MI, thus he needed to rehabilitate safely. His chest pain

took precedence as it was a symptom that, if attended, could have resulted in life

threatening complications, namely a further MI.

Dougherty and Lister (2004e: p25) explain ‘nursing assessment includes gathering,

validating and organising data, identifying patterns, and reporting and recording

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relevant data’. They add that it is a continuous dynamic, used collaboratively by the

nurse to establish clients’ needs so care plans can be.  Assessment is the first step

of the nursing process, popularised by Logan, Tierney and Roper (1980), which

comprises assessment, planning, implementation and evaluation of care.  With the

communication skill such as active listening and appropriate use of questioning, the

nurse can determine what needs the patient has at present and will have in the

future.  If assessment is not at an optimum or a robust enough level, then all other

aspects of the nursing process will not be met, moreover, resultant care could be

both unsafe and inappropriate to the care needs of the client.

There are many reasons for reducing/eliminating pain, these incorporate deontology

and ethics. The Code of Professional Conduct: Standards for Conduct, Performance

and Ethics (Nursing and Midwifery Council (NMC), 2004) explain how due to

contracts of employment, the nurse has a Duty of Care for patients. This involves

having to act continuously beneficently and in a non-maleficent manner.  Therefore

as a registered nurse, it is important to acknowledge that you have duty to reduce

pain and prevent deterioration of Andrew’s condition.  The code of conduct notes

that registrants on the NMC Register of Nurses, Midwives and Community Public

Health Nurses (NMC, 2008) are accountable for their actions or omissions in a Court

of Law.  The implications of this accountability extend to any delegated task given to

other workers whom the nurse must know are competent to do the task.

As a result of a Department of Health (DH) report, “Comprehensive critical care: a

review of adult critical care services” (DH), the ALERT (Acute Life-threatening

Events Recognition and Treatment) course was created (Smith 2003).   This course,

based around a manual, was designed to assist acute healthcare professionals to

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recognise early signs that patients may be deteriorating.  It encourages workers to

predict and prevent and treat deterioration whilst communicating their actions to

both patients and others in the multidisciplinary team.  There is an acknowledgement

that workers on non-critical care can find dealing with acute deterioration extremely

stressful.  Furthermore, the DH document called for an early warning scoring system

to be introduced for detecting such deterioration.

One of the major tenets of the ALERT course is the use of the ABCDE mnemonic,

which stands for airway, breathing, circulation, disability and exposure. ABCDE is

used to prioritise the assessment of an individual patient.  Each of these areas needs

to be attended to and any problems noted dealt with prior to proceeding on to the

next letter. The professional would use a look, listen and feel approach, for example

if an individual has an occluded airway it is imperative it is dealt with prior to dealing

with the patient not breathing. Airway is the first area to be addressed. Andrews’s

airway was patent, which was evident by the fact that he was able to talk in

sentences without any impedance as well as corresponding appropriately to

questioning. Had his airway been compromised, this would not have been possible

and the emergency team would need summoning. Smith (2003) identifies how

opening the airway or use of a jaw thrust would be needed in an emergency to

attempt to gain a patent airway.

Once a patent airway has been established, breathing should be assessed. This

should include how the individual appears such as evidence of cyanosis, evidence of

sweating, depth and rate. Listening to breathing will assist in establishing if there are

any problems such as excessive secretions or wheezing/stidor which may be

indicative of partial airway obstruction (Smith 2003). Moore and Woodrow (2004)

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note that respiratory failure is the most common cause of admission to High

Dependency Units.

The assessment of circulation is primarily concerned with the effectiveness of the

cardiovascular system to perform gaseous/nutrient transfer throughout the body.

This is assessed by assessing capillary refill time (Ahern et al, 2002). Cyanosis is

also indicative of cardiovascular impairment as it can mean that Oxygenation of the

tissues is not occurring adequately (Smith 2003). Blood pressure, pulse and Oxygen

saturations are also measures of cardiovascular function. Andrew had had a MI

which meant that some of his cardiac muscle had died. These necrosic areas could

no longer contract/relax in synergy with the rest of his cardiac muscle thus reducing

the effectiveness of his heart’s pumping action. ECGs can also show the rhythm and

rate of the heart as well as indicating any areas of cardiac insufficiency (Kumar

2006).

Within the ABCDE rubric, the presence of disability pertains to the individual’s

neurological state. Smith (2000) advocates the use of AVPU scoring (American

College of Surgeons, 1997). This system is used to assess the alertness of an

individual by classifying her/him as alert, responding to voice or pain or if the

individual is unconscious. It forms part of the MEWS score. It is provides a rapid

assessment of the consciousness of an individual but does not take into account if

an individual is confused which can be indicative of neurological deficit. It is also not

as rigorous as the Glasgow Coma Scale which is widely used for more in depth

neurological assessment (Dougherty and Lister, 2004).

Once all the above steps have been assessed and dealt with, then a fuller

assessment of the patient is undertaken under the exposure label. This is a head to

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toe assessment and is where such areas as temperature blood glucose and pain are

considered.

All aspects of the ABCDE are considered within the modified early warning system

score. Subbe et al (2001) devised a score which encompassed systolic blood

pressure, pulse, respiration and temperature. Stenhouse et al (2000) then included

urine output and normal blood pressure so that deviations in temperature would be

less sensitive. This is the scoring system which is used in the ALERT course (Smith,

2003). In a well argued paper, Johnston et al (2007) suggests that although early

warning scoring can be sensitive to deterioration, their potential is not maximised

and the developmental rigour of both critical care outreach teams and MEWS are

both poor. They call for more research into the physiological trigger factor variables

which elicit the calling of outreach teams. The MEWS score is calculated by

allocating the results of clinical observation a score from 0 to 3. If the total score

exceeds 4, the protocol in Appendix 1 is followed.

Chest pain is one of the leading cause of acute hospital admission in the United

Kingdom, accounting for approximately 20-40% of acute medical admissions

(Capewell and McMurray, 2000). These figures appear to be the only ones available

thus more recent research would provide some valuable information.  Its origin can

be as diverse as from resulting from a myocardial infarction (MI), angina pectoris,

10nfracted10l/gastic origin, to anxiety (Kessenich, 1999). Melzack and Wall (1996)

argue that it pain, generally, is a multi-factoral concept encompassing both

physiological and psychological factors.

Epstein (2003) reports that MI is the major cause of chest pain on admission to

hospital and can present itself with severe, central crushing (sometimes described as

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band-like or severe indigestion) which can persist 15 to 20 minutes, despite rest or

the use of Nitrate preparations. The patient may appear pail and be sweating

perfusely. Hypotension may be present with reduced pulse pressure (difference

between systolic and diastolic readings). This may be due to compromised pumping

potential caused by 11nfracted areas of muscle. The pulse may be irregular with

ectopic beats. He also acknowledges that with elderly patients and individuals with

Diabetes Mellitus symptoms may be present with reduced levels of pain being

reported due to neuropathy.

The cause of chest pain in MI is due to insufficient perfusion to the heart due to an

embolus, travelling blood clot, lodges in one of the coronary arteries.  This is the

mechanism by which the administration of high flow (as near as 100%) Oxygen

works.  Insufficient oxygen is being perfused to the cardiac muscle thus the heart is

less efficient.   This leads to insufficient oxygen perfusion to the rest of the body,

which is detected by chemoreceptors responding to acidosis caused by build up of

Carbon Didoxide in tissue. This, in turn, stimulates tachycardia, thus increasing

strain on the heart.  Increasing inhaled Oxygen percentage results in increased

perfusion and strain thus pain reduction. Respiration rate will increase by this

mechanism also which will be stimulated to reduce in the same way (Clancy and

McVicar, 2002).

The British National Formulary 54 (BNF) (2007) suggests that Oxygen, Diamorphine

and Nitrates are the used in initial support and for pain relief. High flow (up to 60%)

oxygen can be given (Section 3.6) does not cause extreme risk in Pneumonia or

fibrosing alveoli as lower arterial Oxygen levels are associated with normal or lower

levels of arterial Carbon Dioxide. This is not the case in Asthma where positive

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airway pressure may be required to remove excess build up of Carbon Dioxide and

Chronic Obstructive Pulmonary Disease.

Other methods of reducing chest plain include the administration of Glyceryl

Trinitrate (section 2.6.1) which acts as a vasodilator.  The stenosed coronary vessels

dilate thus facilitating blood flow thus increasing oxygenation. This medication can

cause hypotension as the lumen of the vessels increases whilst the volume of blood

remains constant thus pressure exerted by the vessels is less.  For this reason, its

use is contra-indicated in Aortic Stenosis as the reduced lumen of the aorta, the

primary artery of the body, cannot provide adequate blood flow to not only the heart

but the rest of the body.  Glyceryl Dinitrate can be given in intravenous form to

induce vasodilation but regular assessment of blood pressure must be made as

hypotension is a complication.

Diamorphine is another pain killer which is used widely and effectively with

individuals with chest pain. The BNF (section 4.7.2) states that is does not cause

neither as severe hypotension or nausea as morphine. Intravenous administration

provides the fasted route.  If it is only used in emergency situations; the risks of

dependency on the part of the individual are low.  However, if an individual has a

propensity for addiction/dependency upon morphine then this may be a problem.  As

an opioid, it can suppress the respiratory centre in the brain.  Once morphine has

been administered, it is very important that respiratory rate is monitored at regularly. 

Assessment of pain can be complicated due to its subjective nature with many tools

used attempting to measure it. Several visual scales are analysed by Duke

(2006).the visual analogue scale consists of a line with no pain at all at one end and

the worst pain possible at the other. The numerical rating scale is similar that has

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figures 0 to 10 marked on it. The verbal rating scale is similar to the visual analogue

scale that has increasing description of pain degrees from no pain at all to worst

possible pain. These provide some idea of the patient’s own perception of her/his

pain. She cites Turk (1989) as being one of the first writers to argue that pain may

not be linear and maybe more complex and that the unidirectional approach may

cause distortion to the individual’s pain experience. Also, the individual needs to be

able to understand the concepts involved as well as being able to express her/his

self and be understood for these tools to be effective.

Some pain assessment tools use acronyms an aide-memoir to consider the different

dimensions of pain assessment. “OLD CART” (Onset, Location, Duration,

Characteristics, Accompanying symptoms, Radiation and Treatment) (MacAvoy,

2001) and PQRST (provocation and palliation, quality of pain, region and radiation,

severity on a 0-to-10 scale and timing) (Wentz, 2003) are mnemonic pain

assessment tool. The former is specifically designed for cardiac pain. However, both

tools origin is unknown and little is written about them, moreover its rigour, uses and

limitations. More research in this area could provide some light in these areas.

Much research has been carried out into how Nurse’s biases can influence their

assessment of pain in individuals.   This is exemplified by Macfrey et al (2007) who

compare how respondents to 2 vignettes created by Marks and Sachar (1973). 

These vignettes, one describing 2 similar 25 year olds who report eight out of ten

pain scores, one smiling and one grimacing, were presented to individuals attending

pain conferences.  They were asked what pain score they would record on the

patients pain and if they would give more intravenous morphine.  Results showed

that, over time, more nurses reported that they would actually recorded 8/10 pain

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scores for both clients and would also give higher levels of morphine. Although this

may give an insight into the attitude of Nurses, there are several flaws.  The

respondents are dealing with vignettes, not actual patients so ethnographic validity is

an issue.  Also, both patients mentioned are male thus the question of different

responses may have been different if they had been female.  Furthermore, on some

occasions, the vignettes were not in their original form so methodology can be

criticized.

Cardiac chest pain can have serious implications if action is not taken quickly after it

inception.  For this reason timely and effective assessment is essential.  Nurses are

accountable for their actions/inaction and have a duty to respond if individuals

reporting pain, not only for physiological reasons but for humanitarian ones also. 

Pain assessment can be complex.  Not only are there issues of measuring the

intangible but also issues of nurse bias. Several tools can be helpful but these

require the client to be able to show understanding as well as appropriate

expression. There are several chemical pain relievers but these all require skilled

nursing assessment. A Nurse making an assessment of pain must be weary of not

allowing her/his own biases to enter proceedings as this may cloud her/his

judgement when making clinical decisions, thus delivering suboptimal care. Much

has been learned during the writing of this piece. This includes much about the

ALERT course and some of the processes involved. The value of incorporating

ALERT into pre-registration Nursing could be considered. This could have

ramifications for Nursing as a whole as individuals would be more aware of signs

that could be indicative of patient deterioration and the steps to take to summon help

where required. Pain, especial when of cardiac in origin, is a very complex concept

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requiring specialist assessment part of which can be facilitated by understanding the

nature of pain and being aware of the psychological aspects of it.

(2688 Words)

 

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References

American College of Surgeons (ACS) (1997) Advanced Trauma Life Support

Manual. Sixth edition. Chicago, American College of Surgeons. In: Ahern, J. and

Philpot, P (2002) Assessing Critically Ill Patients on General Wards. Nursing

Standard 16(47), pp 47-56

British National Formulary 54 (2007) London. BMJ Publishing

Capewell S, McMurray J (2000) Chest pain-please admit: is there an alternative?. A

rapid cardiological assessment service may prevent unnecessary admissions.

British medical Journal. 8;320(7240):951-2.

Clancy, J. and McVicar, J. (2002) Physiology and Anatomy. London: Arnold

Department of Health (2000). Comprehensive critical care: a review of adult

critical care services. London. Stationery Office

Dougherty, L. and Lister, S. (Eds)(2004) The Royal Marsden Hospital manual of

clinical nursing procedures (6th ed) Oxford: Blackwell publishing

Duke, S. (2006) Pain Management in: Alexander,-M.., Fawcett, J. and Rucciman P.

J. (2006) Nursing practice: Hospital and Home – The Adult. Churchill Livinstone:

London

Epstein, O. (2003) Clinical Examination. 3e London: Mosby.

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Johnstone, CC. Rattray, J. and Myers, L. (2007) Physiological risk factors, early

warning scoring systems and organizational changes. Nursing in Critical Care. 12

(5) pp 219-224,

Kessenich, C R. (1999) Differential Diagnosis of Chest Pain: A Case Report.

Gastroenterology Nursing. 22(1):10-12.

Kumar, D. (2006) Cardiac Monitoring: New Trends and capabilities. Nursing. (34) pp

7-10

MacAvoy, J (2001) Cardiac pain: Discover the unexpected: Staff Development

Special. Nursing Management. 32(2), pp 27-34

Mackway-Jones, K. (2002 ed) Emergency Triage, 9e, Publishing Group, London

Marks, RM. and Sachar EJ. (1973) Undertreatment of medical inpatients with

narcotic analgesics. Annals of International Medicine ;78(2):173–81

McCaffery, M. Pasero, C. Ferrell B R (2007) Nurses' Decisions About Opioid Dose.

American Journal of Nursing. 107(12), December 2007, p 35–39

McCaffery, M. (1968) Nursing Practice Theory Related to Cognition, Bodily Pain, and

Man-Environment Interactions. University of California, Los Angeles in: Dougherty,

L. and Lister, S. (2004 Eds) The Royal Marsden Hospital manual of clinical

nursing procedures (6th ed) Oxford: Blackwell publishing

Melzack R, Wall P D (1996) The Challenge of pain. Marmondsworth, Penguin

Moore, T. and Woodrow, P. (2004) High Dependency Nursing Care: Observation,

Intervention and Support. London: Routledge,

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Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct:

Standards for conduct, performance and Ethics. London: Stationery Office:

Nursing and Midwifery Council [online] (2008) Nursing and Midwifery Register

http://www.nmc-uk.org/aSection.aspx?SectionID=20 (visited 17 January 2008)

Roper N., Logan W.W. & Tierney A.J. (1980). The Elements of Nursing. London,

Churchill Livingstone

Smith, G. (2003) ALERT - a Multi-professional Course in Care of Acutely Ill

Patients. Portsmouth, University of Portsmouth.

Stenhouse, C. Coates, S. Tivey, M. Allsop, P. and Parker, T. (2000) Prospective

evaluation of a modified Early Warning Score to aid earlier detection of patients

developing critical illness on a general surgical ward. British Journal of

Anaesthesia, 84, (5) 663.

Subbe C.P., Kruger M., Gemmel L. (2001) Validation of a modified Early Warning

Score in medical admissions. Quarterly Journal of Medicine; 94; 521-6.

Turk, D. C. (1989) Assessment of Pain: the Elusiveness of Latent Constructs. In

Chapman, C. R. and Loeser, J. D. (eds) Issues in pain measurement. Advances in

pain research and therapy. 12. New York: Raven.

Wentz, J. D (2003) Assessing pain at the end of life. Nursing. 33(8), p 22

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Appendix 1: Example of a Modified Early Warning System Chart after Stenhouse, C.

Coates, S. Tivey, M . Allsop, P. and Parker, T. (2000) Prospective evaluation of a

modified Early Warning Score to aid earlier detection of patients developing critical

illness on a general surgical ward. British Journal of Anaesthesia, 84, (5) 663 .

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