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In this assignment, the case study of M who is an elderly patient suffering from coronary heart disease because of damaged arteries in cardiovascular system is to be discussed. In this purpose, the pathophysiology of the health issue for the elderly is to be discussed along with the way psychological and social factors influence the presence of the disease in the elderly is to be mentioned. The influence of homeostasis in causing CHD is to be disused along with the therapeutic intervention to be used in managing the health issue for the elderly. The pharmacological intervention for the patient is also to be synthesised and reflected.
Homeostasis is the capability of the body to maintain a stable internal state despite the changes in the external world (Mallah et al., 2018). The cardiovascular system has the key role in maintaining homeostasis in the body by promoting continuous as well as controlled blood flow through the arteries and veins to enable the reach of nutrient and oxygen to each part of the body (Wu et al., 2019). In this system, the function of coronary artery sends oxygenated blood to the heart muscles so that they can lead the blood to be further transported to other arteries connecting different parts of the body (Mallah et al., 2018). The presence of smooth internal lumen is essential in the coronary arteries to send effective amount of blood to the heart for supporting its functioning and maintaining homeostasis in the body (Mallah et al., 2018). However, in case of people with CHD such as M, it is seen that his homeostasis condition has been disrupted due to the complication created by CHD.
The study by Ottosson et al. (2018) argued that in patients with CHD the optimal functioning of the coronary artery is not achieved. This is because their inner peripheral diameter is narrowed with the deposition of plaque in the lumen leading to create increased pressure on the blood to flow through arteries and facing difficulty in adequate blood supply to the heart for its effective functioning. The reduced blood flow due to atherosclerosis which is build-up plaque in the arteries in CHD leads individuals to face disrupted body homeostasis making them experience chest pain or angina (Ottosson et al., 2018). Thus, the disruption in homeostasis by impact of CHD that created inadequate blood supply to the heart of M made him to experience increased chest pain and the relation of atherosclerosis is to be discussed.
Ageing is referred to the process of growing older in which the cells within the body develop cellular senescence leading the individual fail to heal damaged cells due to lack of effective cell division and growth for healthy living (Pal and Tyler, 2016). As a result, during ageing failure of various parts of the body and organ occurs making the elderly develop chronic condition. One of the common affected system in the body due to aging as seen in case of M is damaged cardiovascular system due to which elderly face hindrance with effective functioning of heart. The pathophysiological mechanism for coronary heart disease (CHD) initiates with build-up of atherosclerosis that develops and progress for many days until the indication of the signs and events of CHD. The Atherosclerosis is referred as low-grade inflammatory stage of the inner lining of the arteries known as intima which has been accelerated by the presence of risk factors such as high blood pressure, increased cholesterol, smoking and others among the elderly (Noble, 2017). This is evident as chemical such as nicotine present in the tobacco smoke causes release of catecholamines which is responsible in increases blood pressure and heart rate. The adverse hemodynamic effects cause progression of atherosclerosis because high blood pressure damages the internal lining of the arteries overtime to make them narrowed by supporting building up of plaque (Xu et al., 2018). In case of M, it is seen that both his blood pressure and cholesterol levels are high along with he is an active smoker which indicates that all the risk factors are present in M for causing CHD. Moreover, his ageing has led to deterioration of the heart functioning supported by the presence of these risk factors leading the individual to experience CHD.
In the study by Ambrose and Singh (2015), it is mentioned that atherosclerotic plaque is developed of cellular debris, inflammatory cells and increased amount of cholesterol esters and crystals. The cholesterol level of M is 240 mg/dL in which the LDL is 81 mg/dL indicates he has increased presence of cholesterol esters and crystal in the body. The lipid core in atherosclerosis develops under the plaques with fibrous cap is made of collagen. On the luminal side, the cap is covered by single layer of endothelial cells like the inner layer of the arteries. The increased amount of the inflammatory cells developed from the foam cells in the monocytes circulating in the blood is seen to migrate in the arterial wall that weakens and thins the fibrous cap leading to exposure of thrombogenic fluid our of tear in the cup leading to development of intralumenal coronary thrombus (Williams et al., 2019). In case of M, the intralumenal coronary thrombus which is mainly obstruction in the coronary artery has been responsible in narrowing his artery lumen which hindered flow of blood to the heart through the coronary arteries for effective body functioning (Williams et al., 2019). This is responsible in slow progression of atherosclerosis causing CHD in M. This is because he informed that for 2 year he is only been experiencing mild pain in the chest which has suddenly increased in the only in the last three days.
In case of M, if the plaque haemorrhage process is responsible in sudden worsening of his CHD condition, it can be determined that rapid thickening of the intima of his artery occurred. The mechanism which led to such condition is that blood supply or vasa vasorum mainly grow to the outer layer of the artery initiating from the adventitia and nutrients required for the process are absorbed from the blood. The process causes the coronary arteries to become thin-walled and the endothelial integrity of the arteries remain hindered as a result of the process causing rupture of the vessels leading to presence of increased plaque formation (Selwaness et al., 2016). The cell membrane is high in lipid, thus presence of plaque haemorrhage leads to inflame the plaque. The slow progression along with inter-mixed cycle of rapid progression causes plaque growth in the arteries. The initiation of plaque grow does not initially narrow the lumen of the artery until the volume reaches to 40% which is known as Glagovian responsible for acute presence of coronary heart disease (CHD) (Ambrose and Singh, 2015).
The individuals with ageing are predicted to be related with decline in psychological ability to adapt to stressful situations in life as a result of hypertension and anxiety on thinking of the stressful challenges to be faced in life (Ouanes and Popp, 2019). In the study by Veltman et al. (2018), it is informed that increased emotional turmoil and stress leads to create enhanced risk among elderly in facing coronary heart disease (CHD). This is because stressful situation leads the emotional threshold of the elderly to be lowered, which in turn, socially affects them to be unable to cope with emotional conditions with ease and develop stress on the blood vessels carrying blood to the heart leading to perform function in hindered manner and develop CHD (Fioranelli et al., 2018). Thus, in case of M, due to ageing and being alone after the loss of his wife, he may have developed psychological stress regarding the way to manage his health condition and livelihood without support causing his psychological condition to influence increased risk and presence of CHD.
In case of M, the condition of living alone without any communication or support from his only son may have led him to become emotionally depressed of living his life. This is evident as people often out of depression and stress are seen to involve in smoking to cope with the emotional condition (Wilcox et al., 2016). In the study by Zhang et al. (2018), it is asserted that elderly patients with increase emotional depression are seen to show high platelet reactivity along with decreased heart variability and enhanced promotion of proinflammatory factors like C-reactive proteins and others that are risk factors for CHD. Thus, M’s psychological condition of being depressed out of being alone may have created increased risk for him to develop CHD.
In case of M, it is seen that he hardly socialises and interact with others in turn trying to live alone. This social condition of living without lack of effective support from family members and friends may have led M to remain socially depressed. The presence of depression leads elderly individuals to gain increased blood pressure which results in weakened immune system, improper heart rhythms and atrial damage creating risk of stroke and increased chest pain with CHD (Fotokian et al., 2020). Thus, the social condition of M may have led him to be at risk and gradually develop CHD. The social behaviour of individuals to be involved in smoking for long time leads them to develop risk of coronary hearty diseases (CHD). This is because harmful substances in the smoke causes the blood to become thickened and develop clots in the arteries and veins. This leads to increases in the plaque formation in the blood vessels leading the arteries to be narrowed and make the individual develop CHD (Iwanicka et al., 2017). In case of M, it is seen that he has been socially smoking cigarette for quite long which has been doubled after the loss of his wife while living alone. Thus, this increased smoking for long time may have led M to contribute in thickening of his blood and form plaque to face CHD.
The effective management of coronary heart disease (CHD) in M is required as with delayed care in CHD, the individual develop chances of facing stroke which is fatal. In respect to pharmacological response for M, according to the NHS the use of blood-thinning medication are to be used along with statin and nitrates (NHS, 2019). The NHS mentions that use of blood-thinning medication such as clopidogrel and/or rivaroxaban helps in diluting the thickened blood to allow it to easily flow through the arteries without creating much pressure on the plaque developed wall of the artery. This in turn helps the heart to receive enhanced amount of blood to retain normal functioning (NHS, 2019). On administration of clopidogrel in the body of M, it acts by getting metabolised with the help of CYP450 enzyme to develop as active metabolite which would inhibit aggregation of platelet in the blood vessels. The active metabolite of clopidogrel include binding of the thiol group with the free cystine on the P2RY12 G1-protein coupled receptor that trigger cascade of intracellular events (Thotakura et al., 2018). This results to reduce phosphorylation of protein kinase (PKA) of vasodilator-stimulated phosphoprotein (VASP) along with activates glycoprotein (GP) IIb/IIIa receptor, platelet aggregation, release of granule and stabilisation of aggregated platelets. The irreversibly bound P2Y12 receptor to clop-AM leads to inactivate the GP IIb/IIIa receptor and causes destabilisation of thrombus that was blocking the blood flow, in turn, supporting increase of diameter of the artery to support enhanced blood flow to the heart (Jiang et al. 2015).
In comparison, the nitrates as medication can be used be used for M as pharmacological intervention for CHD because it acts as vasodilators which increase the lumen of the arteries to create space in supporting enhanced flow of blood to the heart for its normal functioning (Bock et al., 2018). Moreover, nitrates act to relax the veins which helps to lower workload on the heart during return of the blood from the arms and legs in the body. The mechanism through which the nitrates works involve two way based on their types. One of the nitrate medications directly releases nitric oxide (NO) and other type that is organic nitrates which are converted into NO through an enzymatic process including intracellular sulfohydryl groups (Pang et al., 2017). The NO produced from either of the two types of nitrate medication activates the soluble guanylyl cyclase (GC) in smooth muscle cells to produce cGMP (cycling guanosine monophosphate). The cGMP present intracellularly inhibits the entry of calcium in the cell, in turn, lowering intracellular calcium level and relaxing smooth muscle cells. The NO is also involved in activating potassium ions which contributes also to relaxation of muscles and hyperpolarisation leading to widen the arteries and ease blood flow (Pang et al., 2017).
In case of M, he is to be provided nitrates so that immediately his narrowed arteries due to atherosclerosis is widened to allow enhanced flow of blood to the heart to promote his condition regarding CHD. The use of ACE inhibitors (Angiotensin-converting enzyme) is to be provided as medication to M to normalise his raised blood pressure. This is because the ACE inhibitors act to block angiotensin-2 that is responsible in causing the arteries to be narrowed in the CHD (Ramchand et al., 2018). In contrast, the use of statin is mentioned to be useful in CHD as it helps to block formation of cholesterol in the body and enhances increased low-density lipoprotein in the liver that assist to remove LDL cholesterol from the blood. It creates lower chances of development of plaque in the arteries and protect individual from CHD (NHS, 2019).
M is to be involved in talk therapies and smoking cessation programs to motivate him to stop smoking which is harmful for this health condition and worsening of the CHD. This is because in talk therapies, individuals trying to quit smoking like M are informed regarding the way they are to reframe their self-defeating and negative thoughts which are influencing them to smoke (Richards et al., 2017). It is evident as nicotine cravings from smoking are developed as a result of overcoming any negative emotion by individuals (Richards et al., 2017). Thus, helping M to overcome negative feelings which are instigating hm to smoke would help him to be successful in cessation of smoking activity that is harmful for his CHD condition.
According to NICE, statins are effective in reducing cholesterol in the blood (NICE, 2016). The statins are the class of medication which ha the primary mode of action to inhibit the formation of HMG-CoA (hydroxymethylglutaryl-coenzyme A) reductase. The reductase is the rate limiting enzyme for cholesterol production (Elshazly et al., 2020). In case of M, he already has increased level of cholesterol that is going to worsen his condition with CHD as cholesterol is one of the key risk factors to worsen the build-up of plaque. Thus, use of statin that is effective for his health is to be determined by the physician so that the LDL cholesterol level can be reduced to allow M to more effectively cope CHD. In case M’s health condition related to CHD do not improve with the use of medication, the coronary angioplasty is to be performed as surgical procedure. In coronary angioplasty, insertion of a small balloon is done in the arteries so that the fatty tissues and plaques are pushed outwards, and the normal diameter of the arteries are regained to promote enhanced amount of blood to the heart (NHS, 2019).
The above discussion informs that coronary heart disease (CHD) is one of the issues in the cardiovascular system faced by elderly which leads them to experience chest pain, dizziness and others. In case of M, who is suffering from CHD, it is determined that his hindered psychological condition of being depressed and stressed in living life along with social isolation and increase smoking as social actions are responsible in creating risk for the CHD. The development of atherosclerosis ha led M to develop CHD. The use of medication such as nitrates, statin, ACE inhibitors and others are effective to help him cope with the health condition.
The patchwork led me to develop understanding regarding the way a patient is to be physical, psychologically and socially analysed to determine their needs in framing an effective care plan. The patchwork led me to determine that I have strength of providing compassionate and empathetic care as well as I have the strength to remain calm and patient in emergency situation. This is because when M was admitted in hospital he was experiencing extreme pain and I was able effectively manage the situation without panicking on seeing his condition. However, my weakness is that I doubt my confidence in deciding care for the patient due to which I always ned assistance from others in delivering complex care.
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An elderly named M who was 80-years-old was admitted to the hospital for health support on report of acute chest tightness along with light headedness, cold sweats and nausea for the past 3 days. According to NMC, the personal detail of the patient is to remain confidential and not to be shared without their permission (NMC, 2018). Thus, the anonym M was used to indicate the patient so that confidentiality of the patient’s identity can be ensured. M was found to be living alone in his own house and is admitted to the hospital through the emergency services on report from the neighbours. During initial health assessment of Mr M by identifying the symptoms, the physician reported the person may be suffering from coronary heart disease and referred for further diagnosis. The blood test was executed for Mr M to detect his cholesterol level which indicated that the person’s total cholesterol level is 250 mg/dL in which the LDL is nearly 81 mg/dL. In case of elderly, the total cholesterol level above 240 mg/dL and LDL level above 70 mg/dL is considered to indicate high risks for coronary heart disease (Ahmed et al., 2016). The Angiogram is used for coronary heart disease (CHD) diagnosis that includes use of x-rays to detect of the arteries are narrowed or blocked ensuring presence of CHD (Collet et al., 2018). The angiogram of Mr M showed the person has extremely narrowed arteries and requires immediate support for the CHD condition. The blood pressure of M indicated to be 170/100 mmHg which indicates that the patient ha quite high blood pressure as 120/90 mmHg is the normal blood pressure level (Gosmanova et al., 2016). Mr M's wife has died 10 years ago and has only son who is living outside the country and has no communication with his father. M has reported his father has history of cardiovascular complication and he has been smoking 10 cigarettes a day for last 40 years which has increased to 20 after loss of his wife. He also expressed minimum socialisation and the neighbours reported that he hardly interacts with them. On consideration of the health condition and family history of Mr M, effective actions are taken to understand the cause of the CHD and provide him with effective health support.
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