MN556 Discussion Response Post

Reply to each discussion with 150 words using 2 references within 5 years in APA Format

When encountering patients for psychiatric evaluation in the ED it is important to build rapport from the very beginning (Bickley et al., 2020). Upon this patient’s arrival, he was demanding to leave, therefore, I would take the time to discuss why he wants to leave and attend to any unmet needs. He may need to use the restroom, he may need a snack, or he may just need a few minutes alone. After attending to the patient’s needs, it is important to complete an assessment to determine if this patient is at risk of harming himself or others. Given the report of threatening to shoot his girlfriend, this patient would require a psychiatric evaluation in the ED. In a situation such as this, it will be important to know and understand the state law in which I am practicing determining how long this patient can be detained without his permission (Vermeesch et al., 2023).

This patient has requested his mother and psychiatrist not be provided with the knowledge of his threats and did not want documentation of the same. While there is a legal and ethical obligation to maintain confidentiality, it is important to note this patient is a minor and this patient made a threat against another person’s life. Exceptions can be made to breech confidentiality to protect potential victims from violent behavior (National Conference of State Legislatures, 2022). While the victim has already been made aware of the threat, I still see it fit to speak with the patient’s mother and psychiatrist regarding the threat as potential threats could be made in the future toward them.

To begin with, I would approach this dilemma in a calm, nonjudgmental fashion. It is important to be aware that aggressive behavior occurs frequently and serious problem in acute psychiatric settings which is similar to the emergency department (Celofiga et al., 2022). De-escalation should be the first approach with this patient (Celofiga et al., 2022). Communication must be empathetic and neutral, speaking to the patient at eye level, that is clear and simple language (Gerson et al., 2019). There needs to be limits set that are firmly stated of the unacceptable behavior and praise given for adhering (Gerson et al., 2019). The patient should be reassured that they are in a safe space, where they are valued and respected and that no harm will be done to them (Patel et al., 2018). I would tell the patient that it is good for him to be here so that we can help him as he needs to be aware that his threat to shoot his girlfriend is serious. Since the patient exhibited homicidal ideation, this allows the hospital to provide an emergency hold which is involuntary for the patient who refuses care but is in danger of harming themselves or others (Maniaci et al., 2019). I will be truthful to the patient and tell him that this will have to go into his medical record and that his psychiatrist should be aware of this situation to help him with his medications. Several core values of medical ethics such as non-maleficence, truth-telling, decisional capacity, and beneficence can be mentioned (Bickley et al., 2023). The patient was told that there would be no harm done (Bickley et al., 2023).  The information provided was truthful, and I want to help with the patient's well-being by helping the patient with their mental health illness and helping the patient reach a decisional capacity (Bickley et al., 2023). It is important to find out if the patient has a psychiatric advance directive and if not to help the patient know that this is important to obtain (Substance Abuse and Mental Health Services Administration, 2020). The psychiatric advance directive is a representative that the patient trusts and is legally able to make healthcare decisions such as medications and treatment preferences and facilities (Substance Abuse and Mental Health Services Administration, 2020). The patient does need to be referred to his psychiatrist to discuss further the situation and medications. The patient will need to take his medications to prevent psychosis and stabilize. The patient should discuss why they stopped taking their medications and find out if they had run out and need a refill. The patient should be advised places to seek counseling and therapy to find healthy coping mechanisms and find help for their mental health as well.

Chest pain is one of the most common chief complaints that patients will present within the primary care or emergency room setting. The provider must gather all pertinent data to establish a diagnosis, as there are many differential diagnoses that could cause chest pain. Medical history, physical examination, and obtaining an ECG within 10 minutes of arrival are all crucial when a patient presents with acute chest pain as the patient did in this scenario.

When a patient presents with acute chest pain, the first thing that comes to mind is that I need to rule out a cardiac event. What I would have done differently is order a cardiac panel which includes CBC, blood sugar, serum lipids, troponin, creatinine kinase, CK-MB, and myoglobin. It is important to utilize both the ECG and blood work to identify signs of cardiac concern. I would have also ordered a STAT chest x-ray to identify any potential pulmonary concerns such as a pulmonary embolism (PE). I would also consider an aortic dissection as the presentation could resemble heart problems and could manifest as this patient’s presentation. I would have also considered an MRI for this patient to rule out aortic dissection as it would identify the widening of the aorta (Feri FF, 2021). This would have been a consideration if the other results were negative.

When a patient presents to a provider with symptoms, we must identify any potential differential diagnosis to effectively treat the patient. In this scenario, I would consider the following differential diagnosis; PE, aortic dissection, pleuritis, pericarditis, pericardial tamponade, acute coronary syndrome, just to name a few (Johnson and Ghassemzadeh, 2020). One should not assume that the patient could not suffer from a serious life-threatening event just because the patient is young and otherwise healthy. When addressing acute chest pain, the provider should always rule out worst case scenario in every situation. Considering the list of differential diagnosis could have been life saving for this patient.

A major portion of diagnostic accuracy is the list of differentials. Although as nursing professionals, we can feel confident in our leading diagnosis, it is important to utilize clinical reasoning to be accurate in our diagnosis and the best way to do this is to consider the possibilities. According to Cleveland Clinic, a differential diagnosis is a list of possible conditions that share the same symptoms described by the patient. It is a “systematic process that is used to identify the proper diagnosis from a set of competing diagnoses” (Cook & Decary, 2020). 

In this case, the individual was a previously healthy 35-year-old. However, presents with sudden, sharp chest pain that started just 2 hours prior to coming into the clinic. Chest pain should never be taken lightly. Although the patient is previously healthy it is important to consider the likelihood of a serious diagnosis. There are so many differentials that could have been added to this patient’s list of differentials. The provider should have considered several differentials and followed a protocol for chest pain evaluation. 

If I were the Nurse Practitioner evaluating this patient I would have first initiated the protocol for chest pain. The American Heart Association (AHA) has clear guidelines to evaluate and diagnose chest pain. I would refer to national standardized guidelines prior to creating a differential list. Had the provider done so here, the provider would have found that the patient’s symptoms (acute onset, sharp, constantly present but worse with inspiration and movement, and radiation of the pain to the base of the neck) would be indicative of acute aortic syndromes or possibly pericarditis. Gulati, et. al (2021) reports “sharp chest pain that increased with inspiration and lying supine is unlikely related to ischemic heart disease” and usually occurs with acute pericarditis (Table 3). Gulati, et. al (2021) also reports “ripping chest pain, especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of acute aortic syndrome” such as aortic dissection (Table 3). Additionally, Gulati, et. al (2021) reports “sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome. (Table 3).” These guidelines alone should indicate a differential for acute aortic syndromes. 

However, given the patient’s presentation of chest pain and previously healthy adult status, the provider should have considered cardiac disease and followed the guidelines for chest pain. The provider should have gathered a comprehensive history to include family histories, specifically any premature cardiac deaths in first-degree relatives. Family history of premature cardiac deaths is consistently associated with a risk of early cardiovascular disease with a 95% confidence interval in patients with at least 1 first-degree relative that died of premature cardiac deaths (Ranthe, et. al, 2012). Therefore, I would have also not let the patient’s age and healthy adult status rule out the possibility of cardiac disease. I would have gathered a good family medical history. 

Lastly, I would have followed the AHA guidelines for evaluating and diagnosing chest pain. The first step is to gather a history and physical exam and perform an echocardiogram (ECG). After a normal ECG, consider if there is a potential cardiac cause. In this case, the differential should include cardiac causes based on patient symptoms. In Figure 7 of the guideline the recommendation is to consider acute coronary syndrome (non-STEMI), acute aortic syndrome, pulmonary embolism, acute myopericarditis, and valvular heart disease (Gulati, et. al, 2021). 

Next I would begin to rule in and out the potential differentials. I would order a chest x-ray, lab work to include CBC, CMP, and especially a troponin which is a protein that is highly specific to the heart muscle. The chest x-ray is useful in the diagnosis of PE and pericarditis and could help to rule it in or out. If troponin levels are normal, acute myocardial infarction can be ruled out. Therefore leaving acute aortic syndrome or acute coronary syndrome. Given the patient’s prior health history, this patient is at low risk for developing or having acute coronary syndrome. Therefore, acute coronary syndrome is unlikely at this time. Therefore, acute aortic syndrome should be explored. The gold standard for diagnosis is magnetic resonance imaging (MRI). 

The potentiality of a serious diagnosis is what should be considered and thus why it is important to develop a list of differential diagnoses. This patient’s outcome could have been much different as the mortality rate for this patient could have been significantly decreased with proper diagnosis and treatment. After the onset of symptoms, if untreated, acute aortic dissection (AAD) has mortality rates of 0.5% per hour in the first 48 hours (Harris, Nienaber, & Peterson, 2022). However, the mortality rate for those receiving surgery or going to receive surgery significantly decreased to 0.09% per hour. (Harris, Nienaber, & Peterson, 2022). 

MN556 Response Post Sample

Reply One

I agree with the general approach outlined in the text. It is essential to build rapport with patients presenting for psychiatric evaluation in the ED, including taking the time to discuss their needs and concerns. In this case, addressing the patient's desire to leave would be essential before the evaluation. Once the patient's needs have been addressed, it is critical to assess their risk of harm to themselves or others (Rappolo et al., 2020). Given the patient's history of threatening to shoot his girlfriend, a psychiatric evaluation is warranted.

           The text emphasizes the importance of confidentiality but acknowledges exceptions when patient safety is at risk. I also agree with the decision to inform the patient's mother and psychiatrist about the threats, even though the patient requested otherwise. Informing the patient's mother and psychiatrist about the threats, despite the patient's request, is justified due to the potential for harm to others. Empathy, patient safety, and appropriate care are prioritized through rapport-building, addressing immediate needs, risk assessment, and informing relevant parties.

Reply Two

I agree with the approach outlined in the text. It is vital to handle aggressive behavior in a calm and nonjudgmental manner, especially in acute psychiatric settings like the emergency department. De-escalation should be the priority, using empathetic and neutral communication, speaking clearly and simply, and setting firm limits while praising adherence to those limits. Reassuring the patient of their safety and value is crucial, as is acknowledging the seriousness of their threat and explaining the need for an involuntary hold if necessary. I also agree with the emphasis on medical ethics, particularly non-maleficence, truth-telling, decisional capacity, and beneficence. Ensuring the patient's safety is paramount, and providing truthful information is essential for informed decision-making (El Abdellati et al., 2020). Helping the patient reach a decisional capacity and discussing the importance of a psychiatric advance directive are essential steps in promoting patient autonomy and ensuring their well-being.

           The text emphasizes the importance of medication adherence in managing psychosis, recommending a referral to a psychiatrist, and addressing medication noncompliance. It advocates for understanding the patient's reasons for stopping the medication and providing resources for counseling and therapy to promote healthy coping mechanisms and ongoing mental health support.

Reply Three

I agree with the provided statement that chest pain is one of the most common chief complaints in primary care and emergency room settings. The provider should gather all relevant information to establish a diagnosis, as many differential diagnoses are associated with chest pain. Medical history, physical examination, and an ECG within 10 minutes of arrival are crucial when a patient presents with acute chest pain. The provider's actions to order a cardiac panel, STAT chest X-ray, and consider an MRI to rule out aortic dissection are appropriate steps to identify potential cardiac and pulmonary concerns.

           Additionally, considering the list of differential diagnoses, including PE, aortic dissection, pleuritis, pericarditis, pericardial tamponade, and acute coronary syndrome, it is essential to treat the patient effectively. Ruling out life-threatening events, even in young and healthy individuals, is crucial when addressing acute chest pain. The provider should always consider the worst-case scenario and order appropriate tests to ensure the patient's well-being.

Reply Four

I agree with the paper’s emphasis on generating a comprehensive differential diagnosis when evaluating a patient presenting with chest pain. The article highlights the significance of not being swayed by a patient's age and presumed good health and considering the potential for severe underlying conditions. The article's suggested approach to evaluating the patient aligns with established guidelines and demonstrates a thorough understanding of the clinical presentation of various chest pain causes. Initiating the chest pain protocol and consulting nationally standardized guidelines are crucial steps in ensuring a comprehensive assessment.

           The article provides a comprehensive approach to evaluating chest pain, including identifying potential diagnoses based on symptoms, considering family history, and following established guidelines. This systematic approach ensures accurate assessment and timely intervention of severe conditions. The article emphasizes the importance of prompt diagnosis and treatment for acute aortic syndrome (AAS), highlighting the significantly reduced mortality with early intervention. The author's approach to patient evaluation and adherence to established guidelines reflect a commitment to high-quality care. 

References

El Abdellati, K., De Picker, L., & Morrens, M. (2020). Antipsychotic treatment failure: a systematic review on risk factors and interventions for treatment adherence in psychosis. Frontiers in neuroscience, 14, 531763. 

Roppolo, L. P., Morris, D. W., Khan, F., Downs, R., Metzger, J., Carder, T., ... & Wilson, M. P. (2020). Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). Journal of the American College of Emergency Physicians Open, 1(5), 898-907. 

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