The deterioration of his depression, however upon arrival

The aim of this essay is to discuss the condition of a
patient given in the form of a case study using systematic approaches including
the ABCDE model and to communicate any immediate or critical information using
the SBAR tool. The case study that is the focus is a 68 year old male named
Alan Hamer who has been admitted to the IAPT Team for the deterioration of his
depression, however upon arrival he was also displaying some physical symptoms.
These symptoms include a persistent cough, dyspnoea, a crackling noise when
breathing, oedema in the legs and ankles.

The ABCDE Model is a systematic tool used by healthcare
practitioners to accurately assess a patient whilst minimising the risk of
over-looking any small details that may cause problems for the patient. This
approach divides the assessments into Airway, Breathing, Circulation,
Disability and Exposure (Resuscitation Council, 2014) which allows the nurse to
pinpoint an area of deficit and decide on effective treatment for the situation.
It is often used in emergency situations where it is likely to save time.

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Airway

To assess the airway often the patient will be asked to
speak, a partial blockage in the airway causes breath to be noisy (Janahi et al
2017), this makes it difficult for the patient to reply clearly. Observing the
patient is also a way of assessing the airway as when there is a blockage the
patient is likely to be using the accessory muscles to breathe and therefore
visibly breathing abnormally, there may be difficulties in the expiring air
which can also be observed and the patient may also start to experience cyanosis
which is a blue tint to the face, particularly the lips caused by poor
circulation and oxygenation in the blood (Snider 1990). Alan was able to
respond clearly to the questions asked and did not appear to be struggling to
breathe in this way and therefore it is determined that Alan’s breathing
problems are not related to the airway.

Breathing

Breathing can be assessed by taking physical observations,
issues with breathing can present in a number of ways. Some symptoms are
similar to having problems with the airway such as noises when air is expired
and cyanosis, however they can also present with abnormal observations
including respiration rate and oxygen saturation levels. The normal respiration
rate is said to be at 15-18 per minute when at rest (Waugh and Grant (2014,
p.480).

Alan has a high respiration rate of
24 breaths per minute and it has been noted that there is crackling sound when
he breathes. Fluid in the lungs causing an audible crackling sound can be a
sign of numerous ailments including heart failure (Platz et al, 2015) which he
already has a diagnosis of. A high (>25 per minute) or increasing
respiration rate would indicate a deterioration in health. Abnormal respiration
rates are an early indicator for conditions such as, hypoxia (low oxygen),
hypercapnia (high carbon dioxide) and respiratory or metabolic acidosis (Flenady
et al 2016). Being so close to this marker it would be ideal for Alan’s
respiration rate to be repeated to track any changes to determine the need for
intervention and if needed, the interventions effectiveness (Department of
Health 2013) and if there are no signs of improvement treatment should be
performed. To treat the dyspnoea research suggests that bronchodilators can be
used to improve the respiratory function in patients diagnosed with heart
failure (Minasian et al. 2013).

Circulation

Circulation can again be assessed by looking at the physical
observations of the patient, this would include the blood pressure, pulse and
temperature. Nakamura (2010) listed poor circulation as a reason for
sensitivity to the cold suggesting that temperature, particularly of the limbs,
will be lower in those with poor circulation and therefore would be cold to
touch.

Alan’s blood pressure and pulse measure at 140/100 and 110
respectively. The average adults resting heart rate is generally around 120/80
and resting pulse ranges from around 60-80bpm (Waugh and Grant 2014 p.480)
meaning that Alan is relatively high on both observations. There is a number of
explanations relating to Alan as to why his pulse and blood pressure may be
higher than average.

Firstly his age is likely to put him at risk of higher blood
pressure, Waugh and Grant (2014, p.16) suggest that this is linked with
physiological changes of the body as it ages. Specific changes include
stiffening of the blood vessel walls and a reduction in the cardiac
function/efficiency (Waugh and Grant, 2014). Goyal et al (1996) attempt to link
age to tachycardia by comparing the age of symptom onsets and evaluation of
those with tachycardia. They found that the ages of those with atrioventricular nodal re-entrant tachycardia ranged from 30-66 providing
evidence to support their theory. The issue with this however is that the evidence
is becoming outdated and there have not been any recent studies to confirm nor
disprove this theory and therefore there is no evidence to suggest that Alan’s
age is linked to his tachycardia.

Alan also appears to have a background of smoking, it is
recorded that he has not been smoking for 8 years, however smoking can do long
term damage to the respiratory and circulatory systems; this means that there
may be some abnormalities in his physical observations which could be caused by
this.  Some abnormalities include a
higher resting heart rate (Papathanasiou 2014). Whilst he claims to have quit
for a long period of time, it may be possible that due to recent events of not
taking care of his health, he may have also taken up the habit again.

Finally his diagnosis and suspected deterioration of his
heart failure is likely to be causing these symptoms as he has reported to be
taking his medication inconsistently. For these reasons it would be wise to
discuss with Alan if he had been smoking or exercising recently rather than
making any assumptions around his health. As heart failure is a progressive
condition, not taking medication would increase the speed of progression and
eventually lead to a decrease in oxygen to the brain and a collapse in the
circulatory system (Waugh and Grant 2014 p.119).

When assessing circulation, nurses must be aware of the
symptoms of emergency situations such as cardiogenic shock. The symptoms of
shock are something to be aware of when caring for someone with heart failure
because decompensated heart failure can lead to cardiogenic shock. Van Diepen
et al (2017) summarises the symptoms of cardiogenic include a rapid and weak
pulse, falling blood pressure as well as being clammy in appearance. It is
important for a nurse to be aware of these symptoms and monitor for them
regularly as although at this current time Alan is not presenting with these
symptoms, the onset of cardiogenic shock is rapid and difficult to reverse when
not noticed immediately. Missing these signs could lead Alan to becoming
dependant on services for survival (van Diepen et al, 2017).

It would also be recommended to refer Alan for an ECG and a
chest X-Ray to monitor to assess the current condition of his heart. His concordance
with medication should also be monitored, if he doesn’t begin to take his
medication correctly he risks further damage to his physical health (Wuagh and
Grant, 2014 p119). His physical observations should be completed and repeated
according to the National Early Warning Score (NEWS) observation sheet (Department
of Health, 2013) and if observations do not change, Alan should be seen by a
doctor.    

Disability

In this case, disability refers to any neurological deficits
that may alter Alan’s consciousness and/or orientation. To assess consciousness
generally a nurse would use the assessment tool ‘AVPU’, this means that they
are looking to see if the patient is alert, if not is the patient responsive to
voice (or noise), or if they are responsive to pain, if they are not responsive
to any of these then they are unconscious. This can be used to give an early
warning sign for the patient’s neurological state however it is not a
diagnostic tool (Brunker and Harris, 2015). Alan appears to be alert and able
to respond clearly, therefore it is assumed that he has no disabilities that
require immediate response.

Exposure

When assessing exposure the nurse will observe the body for
any injuries, rashes etc. these could be symptoms leading the nurse to
determine the cause of the patient’s problems or they could also be the cause
of the problem.

When observing Alan it was noticed that he had oedema in his
legs and ankles. This further suggests that Alan is experiencing heart failure
as it a common symptom that is difficult to treat (Pierce and McLeod, 2009)
this is thought to happen because poor circulation causes fluid build-up. Pierce
and McLeod (2009) list several treatments in order to combat this, they
recommended a low-sodium diet to help with fluid retention and NICE (2017)
recommend the prescription of a diuretic. 

SBAR

An SBAR is an effective way of quickly communicate the state
of a patient, this is often in used in emergency situations such as in A&E
but also can be used by nurses or doctors in handover or in a patient’s notes
as they are concise easier to remember particularly in an environment where
there are lot of patients. Resuscitation Council (2014) suggest that it is an
effective way of communicating the patient’s condition after an assessment
using the ABCDE approach.

Situation: Alan Hamer has been presenting with physical
symptoms, including a high respiratory rate, dyspnoea, and swelling to his
feet. Currently he doesn’t seem to need emergency services however due to his
diagnosis of heart failure he is at risk of cardiogenic shock or a heart attack
so his physical observations need to be monitored regularly.

Background: referred to IAPT due to the deterioration of his
depression due to this Alan has been managing day to day activities poorly
including taking his prescribed medication (Prozac and captopril)
inconsistently.

Assessment: Based on Alan’s background, his reason for
admission to the IAPT Team, and his symptoms it is likely that his heart
failure is deteriorating. Shortness of breath, crackling breath and oedema are
some of the typical signs of heart failure and he is currently reported to be
inconsistently taking his medication.

Recommendation: Whilst in our care it is important that his
physical condition be monitored closely, this is because he is at risk of
deteriorating further into cardiogenic shock. If his physical observations
begin to deteriorate further he either needs to be seen by a doctor and
possibly transferred to A&E dependant on the situation. Currently his condition
is not critical. Encourage Alan to take his medication as prescribed as this is
the likely cause of his deteriorating condition and try to relieve oedema by
keeping feet raised. Complete and ECG and refer for a chest X-Ray to assess the
heart condition.   

In conclusion there are a number of things to consider when
evaluating a patient in the care of mental health nurses. I have learnt that
even though people may be admitted to wards for a mental health condition they
may also have physical conditions that need monitoring and attending to. Some
may be as a result of their mental health, for example many people with a
diagnosis of a mental illness have problems with their weight due to medication,
lack of exercise etc, and as a result of this they can have develop heart conditions,
diabetes, etc. (Smith et al 2017). Other people may have physical health
conditions alongside (but not related to) their mental health, as with Alan
Hamer, he had physical health problems as a result of his background showing
that as mental health nurses we have to be aware of all aspects of the service
users health, not just the immediate situation that they were admitted to
hospital with. Another point that I learnt was that Alan’s depression had
significant consequences for his physical health due to not taking his
medication, this can be applied to other aspects of physical health showing how
the two interconnect and highlighting the need that to work in such
environments it is important to have the knowledge in not only mental health
but the physical health. 

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