Nursing care of a patient with a chronic condition requires a nurse to apply critical thinking and clinical decision-making skills competently. The care has to be approached in a holistic manner and all the aspects surrounding the patient considered. These are the physical, psychological, and social factors. While managing a client with a chronic condition, the nurse needs to understand that the patient will not only be managed in the hospital setting but also the community. This is because the patient has to live and cope up with the long-term condition while symptoms are being prevented or managed. This essay will discuss the plan of care for managing the health condition in the chosen case scenario in the acute sector and in the community. Moreover, the importance of the registered nurse having knowledge in the primary and tertiary care will be highlighted.
Carl Paxton-Giles is a 54-year-old male who presented with complaints of sudden central chest pains, nausea and profuse sweating. He was home sleeping when he was awoken with a sudden onset of chest pain. Carl is obese with 115kgs and a body mass index of 33.6kgs, and he is diabetic on DM medication. His ECG shows anterior St elevation, and his angiography shows 95% occlusion to the right coronary artery and 90%occlusion to the left anterior descending coronary artery, 70% occlusion to the circumflex with the distal disease.
Coronary heart disease is caused by impaired blood flow to the myocardium (ischaemic pathology) due to the accumulation of atherosclerotic plaque in the coronary arteries causing narrowing thus limiting blood flow to the heart (Buja, 2015). The plaque is made up of fat, cholesterol, calcium and other substances found in the blood. When coronary arteries are narrowed, oxygen-rich blood cannot reach the heart muscle. Coronary heart disease may be asymptomatic or may lead to chest pains (angina pectoral) to a heart attack (Khoujah, & Mattu, 2015). A person may also have indigestion or nausea, lightheadedness or sweating, fast heart rate or shortness of breath.
This patient has pain related to decreased myocardial blood flow. Pain is an unpleasant sensory and emotional experience arising from tissue damage (Gorczyca, Filip, & Walczak, 2013). This is evidenced by the patient reports of pain and the presence of autonomic responses such as diaphoresis, BP and pulse rate changes, pupillary dilatation and increased or decreased respiratory rate. The goal of care for this patient is to relieve pain. In order to achieve this goal, first of all, assess the level of pain using a scale of 0-10. Administer pain medications as ordered, for example, morphine to interrupt the flow of vasoconstricting catecholamines. Place the patient on complete bed rest to reduce myocardial oxygen demand to minimize the risk of tissue injury (Saleh, & Ambrose, 2018). Administer antianginal meds such as Nitroglycerin. Monitor his vital signs as ordered and ensure that he is on a continuous cardiac monitor to note changes in heart rate and rhythm since patients with unstable angina have an increased risk of acute life-threatening dysthymias occurring in response to ischaemic changes. The nurse should also maintain a quiet and comfortable environment to prevent emotional stress increasing myocardial workload (Krinsky, Murillo, & Johnson, 2014). Also, administer supplementary oxygen as indicated to increase the oxygen supply for myocardial uptake and reversal of ischaemia, thus decrease in pain.
The patient is fasting, taking nothing per oral because he might be scheduled for theatre after the ECG results are out. He is also post- angiogram as well as a diabetic patient. He is put on ward diet, salt and fat-free diet because of his cardiac condition. Both salt and fat are restricted to this patient because salt causes the body to retain too much water thus worsening the fluid buildup and may lead to heart failure (Pellicori, Kaur, & Clark, 2015). Fat will increase the already high cholesterol levels. This patient, therefore, has altered nutrition less than body requirements related to oral intake restriction. Adequate nutrition is essential to meet the body’s metabolic demands. He is also at risk of hypoglycemia. The goal is to ensure that the patient meets metabolic needs and that he does not go hypoglycemic. To achieve these goals, give IV fluids to act as feeds as indicated to prevent dehydration, monitor his blood glucose level 4 times a day or as needed. Refer the patient to a dietitian and a diabetic educator tor for complete nutritional assessment.
This patient has never had this condition before and therefore has knowledge deficit related to lack of exposure to the condition. He may also be anxious due to the pending results and have concerns about the outcome of the disease. Patients with angina need to be educated to learn why it occurs and what they need to do to control it (Brown et al. 2013). The goal of care here is to help him learn about his condition and his ability to initiate necessary lifestyle changes. To achieve this goal, teach him on the pathophysiology of coronary heart disease, signs and symptoms, treatment and management. Encourage him to avoid situations that may precipitate angina episodes such as stress and much physical exposure in order to reduce the incidence of ischaemic episodes. Also, teach him the importance of weight control and regular exercise. Teach him to avoid exhaustion to prevent triggering attacks due to increased myocardial strength.
Carl is also at risk for decreased cardiac output, inadequate blood pumped by the heart to meet the body’s metabolic demands. The goal of care is to help the patient display decreased episodes of dyspnea, angina and demonstration of increased activity tolerance. This will be achieved by maintaining him on bed rest position to reduce myocardial workload. Assess for tachycardia because of pain, anxiety, hypoxemia and reduced cardiac output. Perform neurovascular checks for peripheral circulation is reduced when cardiac output falls thus, changes in skin color and diminished peripheral pulses (Aboyans et al. 2018). Also, monitor SPO2 as indicated to determine oxygen therapy. Doing this will aid in early interventions and additional evaluations.
Carl management in the community
Carl should be taken care of in the community once he has been discharged. This is to ensure that he remains stable and live a quality life. Coronary heart disease is a leading cause of disease burden worldwide (Santulli, 2013). Patients with this condition need to be referred to cardiac rehabilitation in order to reduce mortality rates as well as improve their functional capacity and quality of life. Cardiac rehabilitation provides a cost-effective therapy that aims to accelerate recovery following an acute event and reduce the risk of recurrent events through structured exercise prescription, education and risk factor modification. It is therefore recommended for all patients with coronary heart disease.
In this case of Carl, continuity of care is vital to eliminate division and maintain positive patient outcomes. The discharge plan for Carl will include managing his risk factors. This is by helping him to make lifestyle changes as needed to help prevent worsening of coronary artery disease. The risk factors may include obesity. We see that he has a weight of 115kgs and a high BMI. So, he needs to work on his weight and avoid sedentary lifestyles.
With the assistance of dietician and diabetic educator, give him information on dietary changes as recommended. These changes may be eating less fat and less sodium diet to prevent risk for high blood pressure. He needs to limit sweat, greasy and fried foods. If he is a cigarette smoker or chews, tobacco should stop and limit alcohol consumption if he is an alcoholic in order to prevent aggregating the disease. Advise him to enrol in a stop-smoking program to improve his chances of success or also join a support group.
The patient will also be recommended to get more involved in physical activity since he has been inactive with his office work. The physical activity should be moderate, for example, hiking, jogging, dancing and riding a bike. He should do these with the advice of a physiotherapist or a health care provider. This will help him lower his body mass index to normal. Since his job has been highly stressful, he should learn ways to manage stress to help him deal with it. His health will depend on his mental status and focus. The patient will, therefore, will encourage to do other activities that relax the mind and hence overcoming stress.
Moreover, the family members like his wife should be involved in the care at home. This is to help in care activities such as reminding him to comply on his medications by ensuring that he does not skip them, taking the right doses and in case of unwanted side effects from meds they should be able to report to HCP immediately. The patient and family should also be advised to keep records of episodes of chest pains and to present them to the health care provider during follow up visit.
In addition, follow up care should be done after discharge from hospital for health assessments, medication management reviews, and chronic disease management plans to optimize care (Health Quality Ontario, 2013). The community health nurse should actively do this to ensure that the patient is stable at home and ensure prompt response in case of an emergency. The quality of life should be the key. Hence the patient should be assisted to cope up with the condition and live a very comfortable life and be able to continue with his usual activities of daily living easier.
Importance of nurses understanding on primary and tertiary health
Primary health care focuses on general care before the onset of the disease (Greenhalgh, 2013). It focuses on prevention strategies such as education and wellness of an individual while tertiary care involves hospitalization of a patient and treatment of conditions that require specialized knowledge and more intensive knowledge and health monitoring.
Nurses play an important role in the primary and tertiary health care of patients in line with coronary heart disease (Porter, Pabo, & Lee, 2013). In primary health care, nurses help people to manage their health within their own communities. Here nurses are responsible for health promotion through education and prevention of illness. The nurse plays a major role through immunization, treatment of minor illnesses, providing food and proper nutrition, assessing the health status of individuals and mobilizing community involvement by doing all theses there will be a reduction in morbidity and mortality rates.
In tertiary care, it is important that nurses understand this since the patient will be involved in procedures such as coronary artery by-pass surgery and the more the nurse is knowledgeable, the more the competency in the care of the patient thus quality care and good patient outcome. The nurse has a role in functional restoration for patients who have failed to respond to treatment such as surgical care. Rehabilitation is done to help the patient return to activities of daily living.
In conclusion, the management of a chronic condition aims at improving the quality of life of a patient. The nurses should, therefore, have adequate knowledge about the condition and how they can effectively manage the condition. The plan of care should be done in a patient-centred manner. This is so that all the aspect of the patient is considered and the care is individualized to meet the needs of the patient. The patient has to be taken as unique rather than just generalizing the care. Before discharge, the care of the patient in the community should also be looked into and proper preparation made to ensure that the patient is well cared for while in the community.
Aboyans, V., Ricco, J.B., Bartelink, M.L.E., Björck, M., Brodmann, M., Cohnert, T., Collet, J.P., Czerny, M., De Carlo, M., Debus, S. and Espinola-Klein, C., 2018. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS) Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular …. European heart journal, 39(9), pp.763-816.
Brown, J. P., Clark, A. M., Dalal, H., Welch, K., & Taylor, R. S. (2013). Effect of patient education in the management of coronary heart disease: a systematic review and meta-analysis of randomized controlled trials. European journal of preventive cardiology, 20(4), 701-714.
Buja, L. M. (2015). Coronary artery disease: pathological anatomy and pathogenesis. In Coronary artery disease (pp. 1-20). Springer, London.
Gorczyca, R., Filip, R., & Walczak, E. (2013). Psychological aspects of pain. Ann Agric Environ Med, 1, 23-7.
Greenhalgh, T. (2013). Primary health care: theory and practice. John Wiley & Sons.
Health Quality Ontario. (2013). In-home care for optimizing chronic disease management in the community: an evidence-based analysis. Ontario Health Technology Assessment Series, 13(5), 1.
Khoujah, D., & Mattu, A. (2015). ISCHEMIC HEART DISEASE. Emergency Medicine Secrets E-Book, 200.
Krinsky, R., Murillo, I., & Johnson, J. (2014). A practical application of Katharine Kolcaba’s comfort theory to cardiac patients. Applied Nursing Research, 27(2), 147-150.
Pellicori, P., Kaur, K., & Clark, A. L. (2015). Fluid management in patients with chronic heart failure. Cardiac Failure Review, 1(2), 90.
Porter, M. E., Pabo, E. A., & Lee, T. H. (2013). Redesigning primary care: a strategic vision to improve value by organizing around patients’ needs. Health Affairs, 32(3), 516-525.
Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7.
Santulli, G. (2013). Epidemiology of cardiovascular disease in the 21st century: updated numbers and updated facts. J Cardiovasc Dis, 1(1), 1-2.