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My Clinical Experience

As an advanced practice nurse student, there are various clinical experiences that I have gained during this week. Some of the most crucial areas that have required much experience are the ones involving my performance and comprehensive assessments while managing patients with various chronic health problems. Additionally, I will say this experience also involves utilizing knowledge and coming with plans to reduce illness among patients in general and their health needs. As an NP student, I have learned that it is important to ensure collaboration in care management, promoting a comprehensive primary care provision. I didn’t face any challenges specifically in this first week, I most likely felt that I needed to gasp as much info as I could to become successful in this specific area. Getting to know each one of the main problems affecting these patient populations can be of great advantage at the time of finding a solution overall. The understanding of many clinical conditions can vary depending also on approaches related to cultural and religious beliefs that can become a barrier while implementing treatment in many patients.

Patients Assessment

The assessment involves a 67-year-old man patient that has been suffering chronic cough for more than 3 years. During this assessment, the examination is carried to identify areas that have been abnormal in his health history and vital signs.

Chief Complaint: Dizziness.

HPI:

A 75-year-old man is brought by his granddaughter to the office with an episode of dizziness. He still feels unwell when he is seen 30 min after the onset. He has been well for the last 6 months, he had some falls in the past irregularly. On some occasions, he lost consciousness and was unsure how long he was unconscious. On a few occasions he has fallen, grazing his knees, and on other occasions, he has felt dizzy where he had to sit down but has not lost consciousness. These episodes usually happened on exertion, but once or twice they have occurred while sitting down. He recovers over a time period of 10–15 min after each episode.

He lives alone and most of the episodes have not been witnessed. Once his granddaughter was with him when he blacked out. Worried, she called an ambulance. He looked so pale and stiff that she thought that he had died. He was taken to the hospital, where he recovered completely and was discharged and told that he had a normal electrocardiogram (ECG) and chest X-ray.

There is no history of chest pain or palpitations. He has had gout and some urinary frequency. A diagnosis of benign prostatic hypertrophy has been made, therefore no treatment is in place for it. He takes ibuprofen occasionally for gout and stopped smoking 5 years ago. He drinks 5–10 units of alcohol weekly. The dizziness and blackouts have not been associated with alcohol consumption. There is no relevant family history. He used to work as an electrician back in the day.

Health Assessment:

He is pale with a blood pressure of 96/64 mmHg. The pulse rate is 33/min, regular. There are no heart murmurs. The jugular venous pressure is raised 3 cm with occasional rises. There is no leg edema; the peripheral pulses are palpable except for the left dorsalis pedis. The respiratory system is normal and the rest of the exam is unremarkable.

Diagnosis:

• Atrioventricular block, complete I44. 2: There is complete dissociation of the atrial rate and the ventricular rate which is 33/min. The episodes of loss of consciousness are called Stokes–Adams attacks and are caused by self-limited rapid tachy- arrhythmias at the onset of heart block or transient asystole. Although these have been intermittent in the past, he is now unstable complete heart block and, if this continues, the slow ventricular rate will be associated with reduced cardiac output which may cause fatigue, dizziness on exertion, or heart failure. Intermittent failure of the escape rhythm may cause syncope.

Differential Diagnosis:

• Transient cerebral ischemic attack TIA, unspecified G45. 9: A TIA may last only minutes, and symptoms often resolve before the patient presents to a clinician. Thus, historical questions should be addressed not just to the patient but also to family members, witnesses, and emergency medical services (EMS) personnel regarding changes in any of the following, behavior, speech, gait, memory, movement (Nentwich, 2020).
• G45.0 vertebrobasilar insufficiency (VBI): Vertebrobasilar TIAs typically have a shorter duration than attacks involving the carotid territory, lasting 8 minutes on average compared with 14 minutes for carotid TIAs. Classic symptoms of posterior region ischemia include the following, vertigo, diplopia, hemianopia, auditory phenomena (sudden sensorineural hearing loss), facial numbness or paresthesia, dysphagia, dysarthria, hoarseness, syncope (drop attacks), hemisensory extremity symptoms (e.g., contralateral to facial component). Vertigo is the hallmark symptom of patients experiencing ischemia in the vertebrobasilar distribution. Many patients describe their vertigo as nonviolent or more of swimming or swaying sensation. The exact incidence of vertigo is unknown, yet as many as one-third of patients with VBI may experience vertigo as the sole manifestation of their illness (Neto et al., 2020).
• Orthostatic hypotension I95. 1: Orthostatic hypotension is defined as a drop in systolic blood pressure (BP) of at least 20 mmHg or of diastolic BP of at least 10 mmHg within 3 min of standing. It is uncommon in the healthy elderly. However, it occurs in 30–50% of elderly persons with known risk factors and is another example of multifactorial geriatric syndrome-like falls and delirium. Most patients with orthostatic hypotension either have no symptoms or atypical symptoms and therefore, screening BPs should be taken in all patients with risk factors (Kadioglu & Celik, 2020).

Plan:

Laboratory Studies:

• Complete blood count with differential.
• The erythrocyte sedimentation rate.
• EKG
• Head CT or Brain MRI.
• Referral to ER was arranged.

The blackouts do not seem to have any relationship to posture. They have been a mixture of dizziness and loss of consciousness. The one witnessed episode seems to have been associated with loss of color (Aguiar Rosa et al., 2017). This suggests a loss of cardiac output usually associated with an arrhythmia. This may be the case despite the absence of any other cardiac symptoms. There may be obvious flushing of the skin as cardiac output and blood flow return. The normal ECG and chest X-ray when he attended the hospital after his episode did not rule out an intermittent conduction problem. On this occasion, the symptoms have remained in a more minor form.

The treatment should be the insertion of a pacemaker, the reason why the patient was immediately transported to the ER in order to assess and treat the condition properly as soon as possible. If the rhythm incomplete heart block is stable, then a permanent pacemaker should be inserted as soon as can be arranged. This should be a dual-chamber system pacing the atria than the ventricles (DDD, dual-sensing and pacing, triggered by atrial sensing, inhibited by ventricular sensing) or possibly a ventricular pacing system (VVI, pacing the ventricle, inhibited by ventricular sensing) (Aguiar Rosa et al., 2017). If there is any doubt about the ventricular escape rhythm, then a temporary pacemaker should be inserted immediately.

Lessons Learned

There are various lessons that I have learned in the clinical experience that are beneficial to my practice and to my development as a Nurse Practitioner. First, as an advanced nurse practitioner, it is important to ensure that there is the incorporation of the family’s beliefs during the provision of treatment. Additionally, ensuring that patients’ education is handled correctly while managing their condition is important to ensure that they take proper care, hence always promoting their wellbeing (Darch et al., 2017). It is also relevant to consider patients’ beliefs and other spiritual aspects that go hand in hand with treatment during care provision. Care coordination is also essential for advanced nurses since they can deal with different professionals than can contribute with their knowledge towards the improvement of patient health. Competent advanced nurse practitioners can ensure that they coordinate their patients’ activities and ensure that they receive proper treatment (McDonald et al., 2018).

Additionally, nurse practitioners also have the responsibility to advocate for their patient’s needs and ensure that the provision of evidence-based practice needed is meet. Importantly, I have learned the fact of ensuring the use of proper plans during care provision for different patients. These plans should also promote the patients’ health and wellness, hence reducing the rate of risks and infections that can come along while treating a patient.

References

Aguiar Rosa, S., Timóteo, A. T., Ferreira, L., Carvalho, R., Oliveira, M., Cunha, P., Viveiros Monteiro, A., Portugal, G., Almeida Morais, L., Daniel, P., & Cruz Ferreira, R. (2017). Complete atrioventricular block in acute coronary syndrome: Prevalence, characterization, and implication on outcome. European Heart Journal: Acute Cardiovascular Care, 7(3), 218-223.

https://doi.org/10.1177/2048872617716387

Darch, J., Baillie, L., & Gillison, F. (2017). Nurses as role models in health promotion: a concept analysis. British Journal of Nursing, 26(17), 982-988.

Kadioglu, S. B., & Celik, T. (2020). Orthostatic hypotension and drugs: Drug-induced orthostatic hypotension. Orthostatic Hypotension in Older Adults, 45-59.

https://doi.org/10.1007/978-3-030-62493-4_6

McDonald, E. W., Boulton, J. L., & Davis, J. L. (2018). E-learning and nursing assessment skills and knowledge–An integrative review. Nurse education today, 66, 166-174.

Nentwich, L. M. (2020). Acute ischemic stroke and transient ischemic attack. DeckerMed Family Medicine.

https://doi.org/10.2310/fm.4027

Neto, A. C., Bor-Seng-Shu, E., Oliveira, M. D., Macedo-Soares, A., Topciu, F. R., & Bittar, R. S. (2020). Magnetic resonance angiography and transcranial Doppler ultrasound findings in patients with a clinical diagnosis of vertebrobasilar insufficiency. Clinics, 75.

https://doi.org/10.6061/clinics/2020/e1212

Takaoka, H., Funabashi, N., Ozawa, K., Uehara, M., Ueda, M., Horikoshi, T., Uno, T., & Kobayashi, Y. (2017). Computed tomography is important in appropriately diagnosing patients with third-degree atrioventricular block and second-degree atrioventricular block but not Wenckebach type. International Journal of Cardiology, 228, 700-706.

https://doi.org/10.1016/j.ijcard.2016.11.187