4.4.1: FRAME 1- Recognize Cues

The telemetry nurse has just received notice they would be admitting a transfer patient from the cardiac-surgical intensive care unit (CSICU). The secretary notifies the telemetry nurse that the CSICU nurse is on the phone to give report. The following phone report is given:

“The patient you will be receiving is Jacklyn Smuth. Jacklyn is a 46-year-old female who was brought to the hospital five days ago with chest pain. She was immediately referred for a cardiac catheterization. She had a positive nuclear stress test that showed reduced blood flow to the left ventricle with a high suspicion for coronary artery disease. Jacklyn underwent a cardiac catheterization through the radial artery. Unfortunately, revascularization could not be achieved to the left ventricle with a coronary stent. You may have cared for her, because after the cardiac catheterization, she was sent to your floor for 3 days prior to her surgery.

On 7/21, Jacklyn underwent “off-pump” cardiac surgery where the heart lung bypass machine was not used in efforts to minimize total blood loss during surgery. I forgot to mention this earlier, but Jacklyn is a Jehovah’s Witness. The 4-hour surgery went ok. They took the saphenous vein from her left leg and used it as the vessel to bypass the obstructed vessel to the left ventricle. Some blood loss was noted during the surgery and post-operatively. Her hemoglobin level prior to surgery was 12.3 and this morning it was 10. She was extubated 1.5 hours after surgery and is on 3 L NC.

Her labs looked good this morning, she has an IV in her left hand that is patent and works well. She had a central line in her right internal jugular vein, but that was taken out at 0645 this morning. The site is covered, dressing is clean/dry/intact. She has one JP that is at the bottom of her midsternal incision with minimal drainage. Midsternal incision and left leg incisions are glued with no swelling or drainage noted. Ventricular pacing wires are secured, and no rhythm issues have been noted since surgery. She ate breakfast this morning and got up and walked about 25 feet down the hallway.”

Recognize Cues

QUESTION: Drop-Down Cloze

Scoring Rule: 0/1

The telemetry nurse reviews notes taken from the phone report and reviews the client’s history. Choose the most likely options for the information missing in the statements below by selecting from the list of options/cues provided.

The nurse recognizes the client’s can impact healthcare approaches. The nurse will closely monitor the client’s , , and while on the telemetry floor during post-operative recovery and in preparation for discharge.

Dropdown 1 Options	Dropdown 2 Options	Dropdown 3 Options	Dropdown 4 Options
Recent surgery	Hemoglobin	JP drain	Pulses
Cultural and religious beliefs	Oxygenation	Midsternal incision	Alcohol withdrawal
Social determinants of health	Heart rate	Mental capacity	Left leg incision
Medical history	Blood pressure	Lab values	Motivation

Putting It All Together

DEBRIEF

It is important for the nurse to recognize cultural and religious beliefs of a client due to the possible impact on healthcare approaches. The basic principle of Jehovah's Witnesses' belief is the refusal of both blood transfusions and blood products. This includes whole blood and primary blood components (platelets, white blood cells, plasma, or packed red blood cells). It is essential to discuss blood alternatives with such clients to assess their position, including their right to refuse treatment, especially in situations that would result in loss of life or limb. In emergency situations, most Jehovah's Witnesses carry a durable power of attorney (DPA) card expressing their wishes in emergencies. If no such card is present, and the client's religious belief is known, every effort should be made to avoid the use of blood and blood products (Chambault et al., 2020).

The nurse must also recognize that the surgical approach for this client was chosen in effort to reduce the amount of blood loss during surgery and avoid pulling blood from the body and putting it back into the body through the cardio-pulmonary bypass machine used in traditional open-heart surgery. Additionally, low hemoglobin levels will result in low energy, tiredness, decreased SpO2, and prolonged recovery due to the body's inability to circulate oxygen to cells, tissues, and organs. Finally, the nurse must recognize the fear, guilt, and lifestyle modifications that may come with major surgery and the impact on the client. Therefore, Jacklyn's history of depression should also be addressed and monitored.

RECOGNIZING SOCIAL DETERMINANTS OF HEALTH (SDOH)

This case study focuses on the cultural/religious beliefs and mental stability of clients undergoing major surgery and addresses three of the five social determinants of health: Health Care Access and Quality, Social and Community Context, and Economic Stability. SDOH has a significant impact on cardiovascular disease (CVD) risk and outcomes, particularly among marginalized communities. The domain, Health Care Access and Quality include related objectives such as increasing the proportion of adults whose health care providers involve them in decisions (HC/HIT-03), decreasing the proportion of adults who report poor communication with their health care provider (HC/HIT-02), and increasing the number of community organizations that provide prevention services (ECBP-D07).

Jacklyn is committed to her religious beliefs and values and should be involved in decisions regarding her health care. The provider should accommodate her wishes, even if these wishes are not consistent with their own beliefs and values. Furthermore, the members of Jacklyn’s Kingdom Hall could possibly assist with her recovery and prevention services, such as meal planning, exercise groups, walking, and emotionally supportive home visits.

What Do You Think About?

1. What approaches should healthcare personnel take to ensure cultural and religious beliefs of clients are being met?
2. How might a client’s past mental health history impact their current hospitalization?
3. When reflecting on this client, what biases might impact the care that is provided?