Nursing Case Study: Coronary Heart Disease

Introduction

In this essay, a patient case study of a long-term condition, Coronary Heart Disease (CHD), is to be developed based on the facts stated regarding the patient in the case study. The pathophysiology of the health issue will be discussed and a justification regarding the choice of the case study will be explained. Further, the nursing assessment framework of Roper-Logan-Tierney (1996), Activities of Daily Living (ADL), will be used for determining the holistic needs of the patient (Roper, 1996). Two key activities of daily living (ADL) will be focussed on for framing patient care: breathing and eating and drinking. The expected outcomes of the nursing intervention for resolving the two identified care needs will be discussed. According to the Nursing and Midwifery Council (NMC) Code of Practice, the personal identity and details of the patient and trust cannot be shared publicly so that confidentiality and privacy of the patient is maintained (NMC, 2018). Thus, Mr. Wise will be used for indicating the patient and the hospital trust will not be identified.

Case Study

Pathophysiology of cardiovascular diseas

Pathophysiology of diseases refers to the disordered physiological processes that are associated with the cause of the disease in patient (Boren et al., 2020). The pathophysiology of CHD informs that cardiovascular disease begins with the process of deposition of plaques within the arteries that causes atherosclerosis (Pothineni et al., 2017). The atherosclerosis is the low-grade inflammatory condition of the intimae of the arteries leading the arterial walls to be narrowed, restricting smooth blood flow to the heart (Sharifi-Rad et al., 2020). High blood pressure creates the increased pressure on the inner lining of the arteries which causes the plaque and cellular debris to be deposited and narrow the arteries resulting in restricted blood flow (Fatmi et al., 2019). In the case of Mr Wise, it is reported that he already has high blood pressure, and this may have contributed to the development of CHD in him as per the stated pathology. The development of atherosclerotic plaque occurs with the increased deposition of cholesterol esters, fats, and inflammatory cells inside the arteries (Eligini et al., 2019). The lipid-rich plaque which are precursors for cardiac event in CHD is determined to be formed under the plaques having fibrous caps which is developed with collagen (Xing et al., 2017). However, the luminal side of the plaque is seen to be covered with the endothelial cells similar to the inner lining of the arteries. The foam cells developed from the monocytes in the blood leads to the development of inflammatory cells. The inflammatory cells are then seen to migrate within the arterial wall which weakens as well as thins the fibrous cap that leads to expose the thrombogenic fluid present in the tear cup culminating in the development of intralumenal coronary thrombus (Williamset al., 2019). The developed thrombus leads to narrow the lumen by either growing spontaneously or remaining intricately incorporated in the artery. This mechanism hinders the transmission of blood flow that occurs toward the heart, in turn, leading to development of CHD symptoms (Ezhov et al., 2019). In Mr Wise’s case, it is seen that he already has high cholesterol and eats high amounts of fast foods that leads to deposition of unsaturated fat in the body. Thus, his eating habits are considered to have contributed to his current CHD condition.

Justification of the choice of the case study

The case study of Mr Wise suffering from CHD which is a long-term condition was chosen because it is one of the major health issues which is leading an increased number of individuals in the UK to suffer and face death (British Heart Foundation (BHF), 2019). This is evident as it is reported that in 2019 there were nearly 63,000 deaths as a result of CHD in the UK which is an average of 170 people each day and 1 death each 8 minutes (BHF, 2019). CHD affects more men than women, effecting 1 in 8 men and 1 in 13 women in the UK which causes them to die (BHF, 2019). Thus, the case study will develop understanding regarding the intervention along with care based on the complications which may develop so that better quality life of the patients suffering from CHD can be attained and mortality can be reduced. In relation to the NHS, it is seen that CHD alone causes NHS England to bear the cost of £7.4 billion each year along with annual costs in the wider economy to be suffered estimated to be £15.8 billion per year (publichealthmatters.blog.gov.uk, 2019). This indicates that CHD is creating an increased financial burden on the NHS. Therefore, discussion regarding its complications in patients and a way to resolve them at the earliest is needed to reduce some financial burden on the NHS.

Nursing Assessment Framework

The advantage of using Roper-Logan-Tierney model is that helps in maintaining consistent and continuous care to be provided to the patients along with avoid creating conflicts in care between nurses working as team (Roper, 1996). However, the disadvantage of using the model is that the activities of living mentioned are misunderstood that led to error in assessing the health needs of patients (Roper, 1996). The Robert-Logan-Tierney model is better than Orem Self-care model because following care through Orem’s model is time consuming and does not allows to effectively identify the key needs of everyday life to be supported for the patient (Vieira et al., 2021). Thus, the nursing assessment model to be used for detecting the holistic needs of patients is the Roper-Logan-Tierney (Roper, 1996). The specific model is to be used because it provided ability to the nurses to holistically assess physical and mental health condition of the patient to determine his holistic care needs to be fulfilled (Roper, 1996). The 12 activities of living in this model to detect patients’ holistic needs are communication, eating and drinking, safe environment, elimination, temperature control, breathing, mobilisation, expressing sexuality, working, sleeping and death and dying, washing and dressing (Roper, 1996). In CHD, it is seen that due to narrowed arteries enough oxygenated blood is unable to reach the heart which creates chest pain and shortness of breath. This is because narrowed arteries cause blood to be backed up and develop increased pressure in the veins of the lungs. It leads the fluids to be pushed into the air sacs and it causes the liquid to build-up in the sacs making people experience hardship in breathing (Albrecht et al., 2018). In the case of Mr Wise, he reported increased chest pain but moderate breathing issues. In this context, his breathing level per minute during rest is measured which indicates 27 breaths per minute. The normal respiration rate of an adult is 12-20 breath per minute (Hopkinson and Baxter, 2017). This indicates that Mr Wise needs effective intervention in improving his breathing rate and lowering chest pain. The safe environment according to Roper-Logan-Tierney model is maintaining a safe situation for the patients (Williams, 2017). In the case of Mr Wise, it is seen that a safe environment is already maintained within the hospital as adequate clinical support to improve his condition was arranged by the nurses. The eating and drinking aspect regarding Mr Wise show he can manage his own eating and drinking without assistance. However, Mr Wise eats fast food and drinks alcohol which indicates his eating and drinking habits need to be changed. This is because eating increased amounts of fast foods and drinking alcohol both raise cholesterol and triglycerides levels in the blood which acts as major risk for development of CHD (Sasakabe et al., 2018). In respect to elimination along with washing and dressing, Mr Wise expresses no issues and reports no requirement of support in these cases of ADLs. In respect to body temperature, it is seen that Mr Wise has normal body temperature that is 37℃. This is evident as normal body temperature fluctuates between 36.1-37.2℃ based on the activity of the body (Diamond et al., 2021). Moreover, he expresses no issues with mobility, working or playing and sexuality expression. Thus, Mr Wise requires mainly assistance and health interventions regarding two key activities of daily living (ADL) that are breathing enhancement and managing his eating and drinking habits. The care plan in meeting the two specified ADLs for Mr Wise and any patients suffering from any long-term condition is mainly followed by taking a patient-centred care (PCC) approach. This is because the PCC approach leads nurses to personally interact with patients in understanding their care needs and demands (Santana et al., 2019). Moreover, it allows discussion to be developed with the patient by the nurses and information regarding care intervention to be shared with the patients so that they can analyse their care choice and provide critical decisions regarding the clinical support to be provided to them by the nurses (Marchand et al., 2018). It leads the nurses to act towards the patient in respectful and responsive ways to meet their individual care preferences and needs (Fix et al., 2018). This approach makes patients feel valued and receive quality care with satisfaction as in the process the patients are regarded as key decision-makers for the clinical support to be provided by the nurses towards them (Marchand et al., 2018). As a person-centred approach, Mr Wise is to be guided through diet chart regarding the way specific diet to be followed and education regarding the way alcohol addiction is to be managed to help him develop better eating and drinking habit. In respect to breathing, the person-centred care to be provided to Mr Wise is by providing him personal training regarding pursed lip breathing. The health monitoring for Mr Wise is to be established to follow the outcomes of the nursing intervention and the impact of the care plan provided to him. This is because monitoring of the patient allows the nurses to continuously examine and re-assess the vital health status of the patient to determine if they are showing progress or deterioration in health. It in turn helps the nurses determine which specific changes in care are to be made on the basis of health evidence of the patient to ensure better quality health and well-being (Wardoku et al., 2019). If nurses become concerned as the physical and mental needs of Mr. Wise change, this needs to be assessed and documented. This is to determine the cause of the raised concern and appropriate actions can be taken to change care strategies to ensure better well-being of the patient (Wardoku et al., 2019). The social and psychological needs of the patient are to be assessed as part of following their care to determine if they require additional assistance at home after discharge from the hospital to ensure effective care management (Fang et al., 2017).

Care Plan

The two ADLs identified to be focussed on for the care plan of Mr Wise are breathing and eating and drinking. In this context, the care plan for Mr Wise is required to focus on the medication to be prescribed to him for improving his breathing condition. According to NICE (2016), ACE inhibitors are to be prescribed to patients suffering from coronary artery disease. This is because it causes vasodilatation of the arteries that inhibit the angiotensin II formation which narrows the blood vessels and results individual to experience reduced heartbeat along with difficulty in breathing (NICE, 2016). In addition, the NICE (2016) guidelines state that aspirin with dose of 75 mg is to be provided to patients suffering from CHD. This is because narrowing of the arteries in CHD patients leads to create affinity of formation of blood clot due to hindrance in free movement of the blood through the vessels and aspirin acts to avoid blood clot formation by diluting the blood (Hu et al., 2018). Thus, the two medication that are aspirin and ACE inhibitors are to be provided to Mr Wise and ensured by the nurses that it is taken regularly by the patient so that he does not develop chest pain and high blood pressure which eventually leads him to experience breathlessness. The monitoring of medication intake of Mr Wise is to be executed by nurses as he was recommended ACE inhibitor for blood pressure control but did not take it regularly. In case of Mr W, it is stated in the case study that he already has two blocked arteries due to the CHD. Therefore, angioplasty is to be involved in the care plan for Mr W to improve his CHD condition that is responsible for chest pain and raising shortness of breath. The benefit of executing angioplasty is that it helps in reducing damage to the heart muscles and creates immediate effect to restore blood flow to the heart that avoids stroke (Völz et al.,2020). However, there are a few risks with angioplasty that may be faced by Mr Wise, such as allergic reaction to the stent inserted, bleeding of the blood vessel and others (Darvishpour et al.,2017). The nurses do not have any role in performing angioplasty apart from supporting surgeon in the process, but they have duty to control side-effects or risk after the surgery. In this aspect, the nurses have the role to monitoring the health of patients after angioplasty and record data to be reviewed by the physicians to ensure their health progress. Moreover, they are responsible in making the patient lay flat to avoid serious bleeding after the surgery and implement catherization process to let the patient stay still (Cost et al., 2020). Thus, the nurse role for Mr Wise is to protect him from any risk or side-effects after angioplasty to improve his health. The breathing efficiency of Mr Wise is to be monitored as a part of the care plan after the surgery and delivery of medication. This is to determine if the surgery was successful to enhance the heart rate and breathing efficiency of the patient which was the target of care (Abdelbaky et al., 2020). It is to be achieved by performing electrocardiogram (ECG) and counting rate of breathing per minute of the patient by the nurses. This is because ECG provides information regarding the way the heart is functioning by presenting a record of how fast it beats (Bigler et al., 2021). The breathing per minute informs the rate at which the patient breaths to determine if they are breathing normally (Babu et al., 2017). In the case of CHD, the patient is required to limit unhealthy fat intake along with avoiding sugary products and alcohol consumption to develop enhanced health. This is because fatty foods and alcohol are seen to worsen the condition of CHD (NICE, 2016). It is argued that patients with CHD should eat whole grains, low-fat proteins and low-fat dairy products to enhance their health (Temple, 2018). Thus, Mr Wise should follow the required diet accordingly to allow healthy eating and drinking habit development that would support better control of his CHD that ensures his health and well-being. A detailed monitoring health record is to be kept and managed by the nurses for Mr Wise as a part of the care plan to follow the impact of care provided to him. This report is to be shared with the multi-disciplinary team of cardiologists and dieticians to help them examine Mr Wise’s progress and if any changes in the care plan are required to ensure his better health improvement.

Outcome of Nursing Intervention

The nursing intervention to be mainly performed for Mr Wise is alcohol abuse control as per the care plan. This is because it is seen that Mr Wise is involved in taking too much alcohol as reported by his wife (Whitman et al., 2017). The alcohol abuse control can be established by the nurses for Mr W by collaborating with the de-addiction centre for alcohol abuse and referring him to attend therapy to overcome alcohol addiction in the centre. This multi-agency collaboration with de-addiction centre is effective for Mr Wise as it would help the nurses to access additional support and expert assistance in overcoming alcohol addiction among patients (Wang et al., 2017). The nursing intervention of developing compliance with diet is to be provided to Mr Wise. This is because enhanced compliance with diet would lead patients with CHD to develop healthy eating habit that is essential for avoiding fat deposition and lowering cholesterol level in the body that are risk factors for worsening the disease (Satija et al., 2017). In order to make Mr Wise comply with the diet and medication process for CHD management, he is to be educated through evidence regarding the benefits and risk of abiding and not abiding by the care. This is because health education regarding care helps patients to understand the importance and its benefits towards their health (Fincham, 2020). Moreover, to make Mr Wise comply with care he is to be engaged in active communication where all his concerns regarding healthcare is resolved. This is because resolving care concerns lead patients to avoid fear of receiving the care and show compliance in accepting it (Schulz, 2020). The other nursing intervention for Mr Wise improving his medication adherence. This is because without effective medicine adherence, the CHD condition for Mr Wise cannot be controlled in a stabilised way as the blood clot formation and dilation of the arteries cannot be achieved without intaking proper dose of medication (Ferdinand et al., 2017). Mr W’s wife was healthy and may be made responsible in manging care of his health. This is to be achieved through consultation and negotiation between him and his wife with the nurses to determine Mr Wise and is wife are both willing to support and execute the action. Thus, the nursing intervention to be taken in this case is that Mr W’s wife is to be asked if she is willing to participate in care and guide her to develop skills in appropriately caring for Mr W after release from the hospital to maintain his steady health.

Conclusion

The above discussion informs that Mr W who is 78 years old is an alcoholic and is suffering from CHD (CHD). He is reported to have been detected with high blood pressure 10 years ago but did not followed medication regime or healthy lifestyle in controlling it. The pathophysiology of CHD indicates that increased alcohol intake, fast food, presence of high blood pressure and others are related to cause risk of CHD and all of them are present in case of Mr W. The care needs identified for Mr W is improving his CHD to resolve his chest pain and shortness of breath along with enhancing his dietary habits. The patient-centred care approach, health monitoring and other action are to be taken in following the care plan and outcome of nursing intervention for Mr W. The use of medication and angioplasty are effective care intervention to improve Mr W’s health condition regarding CHD. In addition, the nursing intervention of alcohol abuse control, creating compliance with diet and medication are to be implemented for Mr W to improve his health and well-being.

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