Reflective Journal #2

Name: David Villa Date: July 10th, 2017

Noticing

Subjective and Objective data

o My patient reported severe chest pain, difficulty in breathing, shortness of breath,
fatigue, and palpitations. He was admitted to St. Anthonys Hospital to see a
cardiologist. The patient underwent a cardiac catheterization and was diagnosed
with multiple vessel disease. The patient was transferred to the Cardiovascular
Intensive Care Unit (CVICU) at Bayfront Medical Center to schedule a Coronary
Artery Bypass Graft (CABG) on July 7th, 2017. After the open heart surgery, the
patient was stabilized for the first few hours post operation. Around 1730, the
patient became extremely hypotensive, tachycardic, tachypneic, with a decreased
level in consciousness, and diaphoretic. Upon auscultation, there was evidence of
muffled heart sounds. Based on the subjective and objective data, it was clear that
the patient had cardiac tamponade.

How did you know there was a problem? Abnormal patient presentation or your
gut feeling?
o I knew there was a problem because my patient had an abnormal presentation. For
this particular case, the patient was very hypotensive, had a heart rate in the 120s,
had a respiratory rate of 45, and was non-responsive. Based on these findings, the
nurse and I suspected cardiac tamponade. I have never seen this before in a
clinical setting so it was an amazing experience to see this.

Interpreting
What other information do I need to make a decision? Is there anyone else I need to
involve or notify? What could be happening and how critical is this situation?
o Based on the information we gathered, and patient presentation, there was no
other information that was needed to make a decision. We knew the patient
needed to go back to the operating room. During the situation, my nurse and I
notified the cardio-thoracic surgeon to get the patient back into the OR. My nurse
and I involved the rest of the nursing staff to help assist in carrying physician
orders. The patient has a confirmed cardiac tamponade and this situation is very
critical.

Responding

Should I do something now or wait and watch? How will I know if I am making the
best decision? What interventions can I delegate to other members of the healthcare
team? Include evidence-based practice (peer reviewed) here to justify why you
 might make one decision over another
o According to what was going on with my patient, it was critical that the CT
surgeon gets the patient back to the OR. My nurse and I prepared the patient to go
back to surgery. We needed to do this immediately because the condition was life-
threatening. I know we made the best decision because we were able to catch this
and report it to the surgeon. Orders were given to infuse 500 mLs of Albumin
rapidly, give 10 units of packed red blood cells, 4 units of fresh frozen plasma,
and 4 units of cryoprecipitate. I delegated my nursing staff to assist in
administering these products while we prepared the patient for surgery. According
to NK Khan et al. (2017), any complication that impedes the circulation of a
patient after an open heart surgery requires a surgical intervention by the surgeon
immediately (NK Khan et al., 2017). I knew that cardiac tamponade is a serious
complication from my patients surgery and it required a surgical intervention
immediately and because of this, I knew I made the right decision.

Reflecting

Did I make the right decision? Did I achieve the desired outcome? What did I do
really well? What could I have done better?
o I believe that we made the right decision for my patient. After getting the patient
back to surgery and stabilizing him, we achieved the desired outcome. I believe
that I was able to identify my patients presentation and figure out what was going
on very well. I believe I am getting really good at patient assessments and
learning how to catch complications from surgery. I think I am getting better at
hemodynamics!

References

Khan, N. K., Jrvel, K. M., Loisa, E. L., Sutinen, J. A., Laurikka, J. O., & Khan, J. A. (2017).

Incidence, presentation and risk factors of late postoperative pericardial effusions

requiring invasive treatment after cardiac surgery. Interactive Cardiovascular and

Thoracic Surgery, 24(6).