Case Study of a Patient with Coronary Heart Disease
Coronary heart disease is an umbrella term for a group of diseases characterized by the pathological limitation of blood supply to the heart caused by the build-up of plaques along the coronary arteries. When the build-up increases, blood supply to the heart may be totally cut-off resulting in a heart attack. Coronary heart disease (CHD) cannot be fully cured, but when diagnosed early can be easily managed with proper diet, medications and mechanical intervention. ( NHS 2007) If the heart has been damaged by the lack of oxygen, a heart transplant will be required. For the past eight decades, coronary heart disease has remained the leading cause of death in the United Kingdom as well as in the United States, and is the leading driver of health care costs to the both governments. (CDC 2005) In England alone, somewhere over 100,000 people die of CHD. The British government is committed to reducing mortality rates from CHD by at least 40% by 2010. (UK Department of Health 2000)
What makes CHD even more tragic is the fact that most cases of CHD could have been prevented with a healthy lifestyle. While those with a family history of coronary heart disease are more prone to get the illness, CHD often occurs with a lifestyle of excessive consumption of fatty foods, smoking, and drinking, and lack of exercise, choices that depend on the person alone. Thus, the loss of so many lives to CHD is unnecessary. Given the high number of incidences of coronary heart disease and its high mortality rates, it is important for nurses and community health care professionals to be able to properly assess patients for risk factors given their specific circumstances and medical history. This allows nurses to properly refer suspected patients to the proper department and receive early intervention. Further, nurses who understand the causes of coronary heart disease are in a better position to design programs that will promote a healthier heart for the public.
Presentation of Case
The subject is a 47-year old white male with a history of hypertension. He came in complaining of tightness in his chest severe and persistent enough to merit medical attention. When interviewed, it was revealed that he had smoked for all his life, particularly during his younger years. He is also a frequent drinker. Family history points to an occurrence of diabetes and heart disease, both risk factors for coronary heart disease. (US Surgeon General, 2004) The patient’s vital signs were all within normal parameters, except for his blood pressure, which at 120/100 is elevated.
A further interview reveal that the patient has had incidences of angina attacks over the past four months. He also reports with sporadic episodes of shortness of breath on physical exertion, palpitations, and a few cases of light-headedness. During the interview, the subject said that these symptoms did not happen regularly or often. He recalls five to six cases in the past four months, with exacerbations clustered during high level of physical activities, all consistent with coronary heart disease. The client has no other health complaints except for the ones involving his angina and shortness of breath. His symptoms may be due to many underlying illnesses. However, given his age and history of smoking and diabetes, the patient may have coronary heart disease which prevents adequate supply of blood to the heart.
At first glance, you can tell that the patient is overweight. He lives a sedentary lifestyle, without any job or family. The patient’s face appears puffy and his lips and extremities are bluish, another sign of some underlying circulatory problem.
Head to Toe
The client was admitted for observation and further tests. Vital signs have been stable for two consecutive days. The patient’s vital signs are within normal range, which is a good given his hypertension. Monitoring of temperature is particularly important because the elevation of temperature may indicate possible infection. (Gulanick, 2002, p. 110) Hypertension may signify reduced urinary function, and calls for careful monitoring as well. The client does not seem to show any discomfort and when asked, he does not complain of any significant pain.
As far as neurological assessment is concerned, the patient is awake, alert, and responsive. He can understand and follow commands and instructions and is very cooperative. His arms and legs show normal range of motion, without any pain or rigidity. The patient’s cardiovascular examination shows some problems with circulation. His skin is a bit pale and ashen, although is warm to the touch. All peripheral pulses are present and his heart rate is within normal range. He no longer complains of any chest pain or tightness which led him to seek admission in the first place. The patient is on NPO for further observation, until a differential diagnosis has been made.
IPPA
It seems clear that the patient has an underlying circulatory problem. Observation reveals that the patient is slightly uncomfortable, but is trying his best to appear calm and collected. His chest does not show any abnormal appearance. Breathing appears normal, with no abnormal patterns of respiration, except for a slightly elevated rate in breathing. Palpation indicates the thorax is within normal position, there is no presence of crepitus, and no pain upon palpation. The same goes for auscultation, an indication that the patient’s respiratory functions are strong.
Physiological integrity – From the onset, it is very evident that the subject is not healthy and has some major health problems. The constant smoking and drinking of alcohol predisposes him to a number of life-threatening illnesses, not the least of which is the risk of acquiring heart and lung problems. His swarthy complexion is testament to an inadequate supply of oxygen due to some circulatory and/or respiratory problem.
Care environment – The subject lives alone, but his house is near brothers and sisters who also live in the neighbourhood. As such, he has people to take care of him should he need medical attention or support.
Psychosocial integrity – When interviewed, the subject is aware that smoking and drinking alcohol are responsible for all his health problems. However, he is unable to stop the habit because the circumstances of his life make drinking and smoking his only escape. He seems no longer interested in fighting for life, passively accepting his lot, waiting for his body to give up on him.
Differential Diagnosis
While in emergency, the patient’s symptoms subsided and he was kept for observation given his high risk for coronary heart disease. He was given an ECG and blood was drawn to test for blood cholesterol levels. While waiting for the results, the patient was also referred to a specialist for proper diagnosis. The patient was given a coronary angiogram, the most common test for coronary heart disease. The patient tested positive for the illness. Luckily, the blockage is relatively small and can be managed with lifestyle changes and medication. (UK Department of Health 2007) So far the patient is not in need of any surgical intervention. He was prescribed a blood thinner, a statin, as well as referral to a nutritionist for a low-fat, low-cholesterol diet. Blood thinners, such as Warfarin, facilitate the flow of blood by reducing its viscosity, while statins reduce the cholesterol levels in the blood which create plaque build-up. (UK Department of Health 2004) The patient was asked to come back in a week, or as soon as chest pains and shortness of breath occur again. It is expected that the patient will have regular check-ups with the doctor to check for changes in condition and perhaps change in management plan.
Management under Primary Care
Those with mild coronary heart disease are the ones that can benefit most from primary care and management because, whilst they do not have any acute medical condition that requires emergency or hospital care, they nevertheless have medical conditions that require constant management and provision of care (Evans et al 2005, p. 345). These people require social and health services to help them live as independently and autonomously as possible. Because hospital or emergency care costs more than primary care or health management at home, primary and preventive care for patients with mild coronary heart disease becomes a priority (Evans 2005, p. 344). The British government is seeing the value of improving the delivery of primary health care and management to people with such an illness, including the design of standard models of care and increase in community-based support for the patients (Dunleavy et al 2003).
Caregivers play a crucial role in ensuring the health and safety of people with coronary heart disease and their effectiveness in their roles helps ease the burden on the NHS and health care costs by delaying the need for formal care. Community intervention and management, including the provision of primary care, has been proven to reduce health care costs because patients are able to function better without the need for added health services such as hospital care. (NHS 2007) To such ends, nurses work with and within a multi-disciplinary team, including input from the patient and their family, to design activities that are meaningful to the patient. These includes the use of the patient’s own interests and activities to create a holistic therapy programme that improves physical strength, dexterity, coordination, and movement, to include and improve the patient’s cognitive and emotional domains as well. The main goal is to achieve as much independence as possible, with emphasis on the safety and dignity of patients. (UK Department of Health 2008)
Expected Outcomes
There must also be a thorough assessment and appreciation of the patient’s knowledge as far as his smoking and eating habits are concerned. Growing awareness in the patient’s knowledge in so far as his health is concerned may be the impetus that will compel and inspire the patient to take a more active and empowered role in managing his medical condition. It is also important to encourage the verbalization of fears and doubts, as well as feelings of failure and loneliness. In common with those suffering any other addiction, heavy smokers often indicate an underlying emotional or psychological problem. Being able to vent these frustrations may help the patient deal with his condition in a more positive way. It is hoped that when the patient acknowledges his problems, he may be able to stop his self-destructive habits.
Some weight management is also recommended because excessive weight heightens the risk of blockage and heart attack. In this particular case, the main focus is on teaching how to live a healthier lifestyle and minimize the risk factors associated with coronary heart disease. Lifestyle changes needed include giving up smoking, eating a healthier diet, and compliance with taking prescribed medications.
Any intervention program should have realistic expectations. Easily achievable goals give the subject a sense of success early on and will encourage him to stick with the health intervention plan. In this case, the intervention plan should perhaps deal with one addiction at a time.
With an adequate health intervention plan, the subject is expected to:
- Be able to come to terms with his smoking and understand that smoking heightens the risk for coronary heart disease and exacerbates an existing condition.
- Patient will express willingness to quit smoking in two weeks as a requirement for the management of his coronary heart disease.
- Patient will be able to manage his illness by himself through dietary changes, compliance with medications, and involvement in mild physical exercise.
- Patient will be able to recognize and avoid risk factors, recognize impending signs of an attack, and be able to properly apply intervention measures while waiting for medical attention.
- Patient will show significant improvement in his circulatory condition and be able to manage the illness with very little effect on his independence and quality of life.
Provide initial information about smoking in a non-judgmental way.
RATIONALE: How a health care worker approaches a patient determines the early success of an intervention plan. If the patient feels that he is being judged, that may lead to a defensive attitude and uncooperative behaviour.
Identify people who will support the patient in his efforts to quit smoking.
RATIONALE: A strong support system is crucial in this intervention plan. An enlightened friend or relative will be able to provide deeper understanding of what the patient is going through.
In order to design an effective health promotion campaign, health professionals should not limit themselves to addressing physiological problems; rather, they should be responsive to, and understanding of, the emotional and social problems that aggravate the illness. Nursing interventions go beyond clinic or hospitals and involve lifestyle and emotional counselling, health teaching and education, among other things. In this case, it is important that community health workers show empathy because researches have been consistent in showing that empathy benefits both the health care provider and the patient. Empathy is empowering because it establishes trust and rapport, two elements that are crucial for a successful health intervention plan.
Plan for small, steady improvements.
RATIONALE: Planning for small improvements make the plan achievable. The small, steady successes that the patient will experience will encourage him and give him the resolve to keep at it and never give up.
References
CDC 2005 Prevalence of Heart Disease – United States, 2005, Retrieved on March 23, 2009 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5606a2.htm
Dunleavy, P et al 2003, Developments in British Politics 7, Palgrave Macmillan.
Evans, C et al 2005, Practice nurses and older people: a case management approach to care, Journal of Advanced Nursing, Vol. 51 Issue 4, pp. 343-352, Retrieved on April 22, 2008 from http://web.ebscohost.com/ehost/viewarticle?data=dGJyMPPp44rp2%2fdV0%2bnjisfk5Ie46bRJsqy3UbKk63nn5Kx95uXxjL6prUq2pbBIrq6eSa6wsEi4qbc4zsOkjPDX7Ivf2fKB7eTnfLujtUmxq7BRsa%2byPurX7H%2b72%2bw%2b4ti7ee7epIzf3btZzJzfhruntU%2byqLdItZzkh%2fDj34y75uJ%2bxOvqhNLb9owA&hid=22.
Gulanick, M 2002, Nursing Care Plans: Nursing Diagnosis and Intervention, 5th ed. Mosby Inc.
NHS 2007, Coronary heart disease, Retrieved on March 21, 2009 from http://www.nhs.uk/conditions/Coronary-heart- disease/Pages/Introduction.aspx?url=Pages/What-is-it.aspx
Surgeon General 2004, Surgeon General’s Report—The Health Consequences of Smoking. Smoking Among Adults in the United States: Coronary Heart Disease and Stroke. Retrieved on March 23, 2009 from http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/highlights/3.htm
UK Department of Health 2000, Coronary heart disease: national service framework for coronary heart disease – modern standards and service models. Retrieved on March 23, 2009 from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_4094275?IdcService=GET_FILE&dID=8771&Rendition=Web
UK Department of Health 2004, Heart drug available without a prescription, Retrieved on March 23, 2009 http://www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4082004
UK Department of Health 2005, Coronary heart disease: More on risk factors and initiatives to promote a healthier lifestyle, Retrieved on March 21, 2009 from http://www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks/Coronaryheartdiseas e/DH_4097269
UK Department of Health 2007, More on statins. Retrieved on March 19, 2009 from http://www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4082004
UK Department of Health 2008. The Coronary Heart Disease National Service Framework: Building on excellence, maintaining progress – Progress report for 2008. Retrieved on March 21, 2009 from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_096555?IdcService=GET_FILE&dID=188474&Rendition=Web.