Complications of Post Angioplasty Bleeding

Complications of Post Angioplasty Bleeding Introduction This paper is aiming to identified the potential complication of post angioplasty bleeding and abrupt closure of coronary artery base on the case of Elizabeth Green from caseworld and explore the issue in depth and widen horizon. Relevant nursing decisions and recommendations of post angioplasty care will be provided and discussed which is based on clinical guideline of the University of Minnesota Hospital and Clinic(UMHC). This article is structured into three aspects which are indications of the percutaneous coronary angioplasty and Mrs Green’s data, evidence-supported nursing interventions for bleeding prevention and evaluation of the interventions regarding to ANMC competency elements. The determine progress of individual plan and quality improvement of unique care will be presented. Indication of the percutaneous coronary angioplasty and Mrs Green’s case data Apart from a very small percentage of individuals who has difficulties to pass the guide wire or the balloon catheter through the narrow artery, 90%-95% of patients can be effectively relieved from coronary arterial obstruction after the percutaneous coronary angioplasty. Percutaneous coronary angioplasty is a non surgical treatment offered to patient with coronary artery disease, the major aim of this procedure is to increase the arterial lumen size and allow greater blood flow. A ballon tipped catheter is used to split and reshape the atheromatous material, pushing it to the artery wall therefore more blood can be transferred through the particular artery. Abrupt closure of the dilated coronary artery and bleeding are two uncommon but possible complications for Elizabeth Green within the very first few hours post angioplasty. The cause of abrupt closure varies, it can be due to combination of dissection of the inner lining of artery , thrombosis and spasm at the balloon site. As to assist in preventing thrombosis formulation during or post percutaneous coronary intervention, oral anticoagulant medication including aspirin will be administered to avoid platelets from adhering the artery wall and stimulating blood clotting. To further prevent blood clotting, intravenous heparin or synthetic analogues of heparin molecule can be given to the patients. The anticoagulant drugs can help reduce the risk of abrupt closure however can contribute to increasing risk of post angioplasty bleeding. Giving the fact that Mrs Green’s gender, age, past history of unstable angina and episode of heart attacks make her at high risk for bleeding or bruise on the puncture site. The femoral sheath is funnel-shaped and consist of femoral artery, femoral vein and lymphatic, If there is a bleeding in the femoral sheath, it can spread to the abdominal wall follow the wall of the sheath. There will form a continuation of the transversalis fascia and the femoral sheath can directly connect to the anterior abdominal wall. Differ from bleeding to abdominal wall there is another kind of post angioplasty bleeding named rectus sheath hematoma (RSH). The damage or tear to the superior or inferior epigastric arteries can result in bleeding into the rectus sheath. In many case of major bleeding,RSH can also lead to other complication including multiorgan dysfunction and abdominal compartment syndrome Even the fact that RSH has not been detected post a PTA procedure, when patient present episode of acute abdominal pain, RSH can be considered as a differential diagnosis. evidence-supported nursing interventions for bleeding prevention Following Angioplasty After the procedure, pressure is required to apply on the site for about 5-10mintues in order to close off the insertion holes in the arteries. Patient will be positioned to lie on their back with gauze dressing taped to the site for 4-6 hours. 4-6 hour is proper for normal blood clotting seals the hole in the artery. On the other hand, patient need to be assessed for recurring chest pain which indicate the procedure artery is re-closed, bleeding at the groin site and symptoms of dye-induced kidney damage. Guideline for the nursing care of a patient after percutaneous coronary angioplasty The word ‘guideline’ is chosen rather than ‘standard’ is because clarify of term help in avoiding potential legal consequence. Literature has shown that, in a malpractice suit, standards may be used by plaintiff against hospital. Standards could be misconstrued for inappropriate purpose. In real case, if a patient is required a nurse to monitor observation every 15minutes in the first hour post angioplasty, legally the nursing staff can be charged for not implement the standard, even the nurse is considering patients’ urgent priorities. The term guidelines means those strategies are for quality improving and goals promoting for patient care. Nurse can remain independent nursing decision depend on patient’s individual circumstance. Nursing intervention for caring post angioplasty patient 1.Vital signs should be monitored and documented every 15 minutes in the first hour post procedure then every 30 minutes for 2 hours, every hour for 4 hours then 4 hourly observation.Do not use automatic blood pressure cuff. 2. While doing each of vital signs, assess patient femoral site, symptoms of oozing , swelling and increasing pain show signs of hematoma. Especially when patient is coughing, sneezing, vomiting and flexing position on bed etc, there is a high risk of bleeding. 3. If necessary or ordered, exam and monitor patient’s coagulation test result and hemoglobin studies, usually it is done every 4-6 hours. 4 Follow prescribed regimen to perform anticoagulation therapy (goal is to have partial thromboplastin time 50-100) 5 Put a blanket over patient’s extremity and tuck the end under mattress so patient’s groin site can be immobilize however pressure area like ankle and heel should be protected by putting towels under 6 Movement of the patient need to be minimized. Only move the patient bed to bed once. Avoid weighting patient unless ordered by fellow. When patient need to toilet, use bedpan and turn patient away from the procedure site same with lying on the bed always preferred on the side away from procedure site. If the patient need to change position, educate patient to ask for assistance 7 Procedure site need to remain straight at the hips through out the process Educate patient not to extend and bend their limb. 8 Educate patient to cover their groin site when they coughs and sneezes. 9 Check patient medication history if he is on anticoagulant and provide assessment to the fellow for considerations. 10 Do not perform unnecessary venipunctures or intravenous insertions ,intramuscular and subcutaneous injection only if the coagulation value is normal. Instruct the patient on all the above precautions and cares 11 When patient present bleeding, hold pressure on arterial venous puncture site as longer as the bleeding seems to stop usually take 20 minutes or more. Avoid using sandbag or pressure dressing unless ordered by physician. 12 Report and contact intern for any presenting bleeding or potential bleeding. . The PTCA fellow should be notified by the intern 13 Maintain transparent dressing to site at all times. In patient’s discharge planning, health provider need to provide education pack of self-care of angioplasty and long-term care for coronary disease, these contribute in of complication of angioplasty and further cardiac issue. For example in this education pack instruction need to be provided including when they can recovery to normal activity, in the few day post angioplasty, heavy lifting and strong exercise should be avoided hence the femoral site can heal properly and if patient detect early symptoms who should they contact and what do they need to report to the G.P For patients who have been prescribed with aspirin or other antiplatelet medication post angioplasty, they need to be informed what are the medication the patient must take and the purpose.Usually when stent has been implanted, patient will be administered clopedigrol(Plavix) once a day for within 2-4 weeks time. This medication is an potent aspirin-like drug which help reduce the clot formulation around the stent during the first week after the procedure. To avoid life-threatening complication, clopedigrol is a good prevention and patient should bring this medication before they discharged as prescribed. Specially for those patient who had medication history of anticoagulant to treat chest pain caused by the blockage, they can be resistant to the effects of aspirin thus regular blood examination is required to monitor patient’s response to anticoagulant and the doctor can adjust the dosage of aspirin or change the medication. Family support for the patient is essential in the recovery process, specially for elderly client who live alone, family visit help in early detection of complication and maintain of patient’s regular social function. EVALUATION OF QUALITY CARE Firstly if the nursing goal is achieved, clinical outcome directly match to effort, according to ANMC competence it is the nurses responsibility to fulfill duty of care and prevent harm to the patient for example, quickly identify bleeding in the post angioplasty patient. Secondly, practises in accordance with profession framework, understand clinical guideline and perform excellence quality of nursing care, for example, Avoid venipunctures on the post angioplasty patient. Thirdly, demonstrate analytical skills in accessing and and collecting patient’s data. In the case of the post angioplasty patient, this can be like assess patient on their procedure site and vital signs to and make independent nursing judgment to meet quality care. Based on the ANMC competency, nurse need to be able to identify individual and other team member’s responsibilities. Example is the when there occur bleeding, the nurse should contact the intern for bleeding and report relevant assessment and information. What’s more, nurse need to use evidence-based practice and give patient step by step instructions for performing a task, for example with the onset of bleeding from groin site post angioplasty, nurse need to put on gloves and hold pressure on the sheath site for approximately 20 minutes or more. Last but not least set up individual care plan for patient base on their preference and clinical objectives to meet unique demand of the patient. Conclusion Post angioplasty bleeding can be life threatening complication hence it is important for the health provider to monitor and assess early symptoms for internal or external bleeding. To practice within clinical guide benefit in prevention of the complication however individual situation should be considered and nurse need to make independent decision. Clinical guideline is aiming to improvement of quality of care thus evaluation of clinical outcome and feedback from patient play a role in improving practice.

Comparing Brad Manning’s Arm Wrestling With My Father and Itabari Njeri

Comparing Brad Manning’s short story â€Å"Arm Wrestling With My Father,† and Itabari Njeri’s â€Å"When Morpheus Held Him†   Ã‚  Ã‚  Ã‚  Ã‚  The relationship between a father and son stems from an unspoken competition in many countries. Whether it is a physical or mental rivalry the superior role slowly transcends on to the son as he grows into a man. In Brad Manning’s short story â€Å"Arm Wrestling With My Father,† and Itabari Njeri’s â€Å"When Morpheus Held Him,† both contain admiring sons and impassive fathers. Despite both stories similarities in unspoken emotions they differ in the aspect of their physical relationships. This unrequited bond between a father and son in these stories portray various types of love.   Ã‚  Ã‚  Ã‚  Ã‚  Throughout Brad Manning’s anecdote about arm wrestling he refers to his father as â€Å"the arm† or â€Å"the master with clenched fists.† The embodiment of his father in these empowered limbs shows the dominating figure once held over him. â€Å"Daddy,† was the only personal name Itabari Njeri’s father allowed him to say. If Njeri did not settle for â€Å"Daddy,† â€Å"Dr. Moreland† would have to due. There is a sterile and clinical connotation in referring one’s father as Doctor. Manning’s states,† the man would win,† also giving an impersonal and cold feeling to his â€Å"strong father.† But this impersonal name was not forced upon Manning as Njeri’s father had done. Manning’s â€Å"father-son† matches battling â€Å"arm against arm† was their only means of communication. Manning decodes his father’s crude â€Å"ritual,...

Ema Essay

The main reason for this is the radical changes put in place so rapidly with immediate effect. This resulted in lack of structure and consistency throughout the whole chain stores, as you gave each store manager to much autonomy to change the store i. e. decor, food menu etc. , the business culture values as a whole was lost and that was what made the business a success before. I understand some changes had to be made but not so drastically. The loss of business culture and lack of dimension of structure had a lot negative effect in the business especially demographic and sociology factor wise as regular customers dislike the changes and constant change in staff router, the reason for this was staff/managers never has any incentive target to work towards so they would leave after short while which causes extra expenditure cost. Some good ideas drawn from the case study but presented in a quite unstructured way Part b) In Study session 1 we introduced a series a metaphors to describe a business one of them was business as a culture which is a pattern of belief and expectation shared by the organisational members. These beliefs and expectation produces norms that powerfully shape the behaviour of individual and groups within the organisation. As you recruited new staff with no experience and gave managers freedom to change each branch to their liking it took away the business identity and culture. The cause of this is inadequate training giving to new staff and lack of knowing the root/history of the business. A good example is how Disney world recruit and trains their staff, after passing the first phase the second is enrolling at university of Disney land where they undergo forty-hour apprenticeship programme, employee learn about the history and philosophy of Disneyland, and the regulation and procedures that govern work. The way Disney recruits is essential to keep hold of the business ethics and culture. OK but make sure the TMA maintains focus on the set question. Another example by Drennan (1992), who proposed 12 key factor that shape the culture of the business some of these are: The influence of a dominant leader-the vision, management style and personality of the founder or leader in a business often has a significant influence on the value that the business tries to promote The history of the business – how things has always been done The customers of the business who are they and what they expect The reward system and the measurement of performance c) These factor (above) could be useful to you to address your business problems vague and general in the future if put in place other suggestions are: Practices: These are the rites, ritual and ceremonies of the business. These can take many forms, and would include the annual office party, employees and inner site completion (what does this mean? ). (as mentioned before) Physical form: these include location, open plan or individual plan or individual office. Not relevant in a restaurant. Communication: Stories of notable events in the past tend to become part of the culture of the business and can influence behaviour explain how this relates to the case. A common language: jargon is common to many business. It is a convenient short hand form of communication, but is also effect behaviour. Disney employees are â€Å"cast crew† while McDonalds employee are â€Å"crew Members†. You have to be careful to hold on to the facts of the case, and not to go off at a tangent. Part 2 One of topics I found interesting through reading and taking part in discussion (book1 TMA01 Activity 1. 3) through TGF, which was the concept of business culture & whether a business culture can be changed. At first I thought how a culture integrates in a business metaphorically and the more I read and researched the more I understood the big role it plays in a successful business. Many cultural element of a business is not obvious, but there has been attempts in the academic literature to develop definition and identify influencing factors. It is possible to see, or feel, that one business is different from another, and that this involves more than just how it present itself to the outside world.. During our discussion on whether a business culture can be changed, I felt that as human we have to adapt to new cultures to understand each other so for a business is imperative for changes to be put in place to modernise the business culture where needed to evolve the business. Some key factors influencing culture are: Which industry or sector he business is in, and how much and what type of competition it faces The procedures and policies within the business – ever-evolving, but often a good indicator of underlying values. The reward system and the measurement of performance Good summary Where is your references list? Where is your word count? MARKING GRID Part I Maximum Marks Your Marks Question 1 (a) Identify the problems faced by Lodge Bistro that relate to the study session chosen Explicit identification of the study session chosen20 List of problems106 Why these are problems and how these affect Lodge Bistro1814 Total marks Q1(a)30 20

Marketing Design And Innovation Ipod Marketing Strategy

TABLE OF CONTENTS LISTS OF CONTENTS PAGE NO. TASK 02 2 Reflective Essay: Learning and assessment of the module 2 References 5 Title: Marketing Design and Innovation: iPod Marketing Strategy TASK 02 (Re-sit Submission for Partial Fulfillment) Reflective Essay: Learning and assessment of the module An organizations general design and it power of innovation determines the competitive advantage in the local as well as international level (Johansson and Holm, 2006). If a firm can respond immediately to the change then it can get expected benefits. Before adopting any change in the system, it is essential to know its appropriateness in the organizational context. The nature of†¦show more content†¦It is also true that all bodies of the business entity strive to facilitate consumers directly or indirectly. So, while developing and designing system, it is essential to know the needs and expectations of the consumer. Research department must know the pulse from the consumer about satisfaction, dissatisfaction and expectation from the company. It is also essential to know about actual service enjoyed by the customer of the rivals. Depending on that management will identify the required changes in the system. Another important aspect is time consideration. Any change should tar get long term rather than short term consideration. The design and innovation are not the same of product and services providing organization. This is a good lesson for this module and it is will shown from theoretical and applied aspects form different organizations. Some features of business innovations are discussed with their relative importance. Flexibility, cost effectiveness, moving from product to business, innovation in risk management, innovation in different economies, different customers, techniques of using data in the innovation process are important dimensions. One cannot get immediate benefit from innovation. 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