Question:
Discuss about the History of Hypertension.
Mr Jones was a 46-year-old male patient admitted to the Coronary Care Unit of the healthcare setting at 7:30 pm. He came into the Emergency Room at around 4 pm. The patient had the chief complaint of left-sided chest pain that persisted for two hours before presenting to the hospital. Mr Jones was slim built and tall and weighed 76 kg with a height of 181 cm. He had been admitted to the hospital for a stroke two and a half years ago. He had a history of hypertension and had been attending the medical clinic for the same. His family history included hypertensive parents. Mr Jones was a professor by profession and denied alcohol intake. He, however, had a history of smoking and smoked five cigarettes a day. He stayed with his wife and two children and led a sedentary lifestyle.
The crushing pain in the left side of the chest was the main patient concern. The patient reported that he was having a crushing pain along with shortness of breath, sweating and sense of impending doom. His vital signs were BP 140/95 mmHg; temperature 36 degrees Celsius; pulse rate 63 bpm; RR 22 bpm.
Coronary artery disease in patients is the result of atherosclerosis which is the progression of building up of fatty tissues in the arterial walls, commonly known as plaque (Bellchambers et al., 2017). The formation of plaque in one or more than one places causes narrowing of the arteries that in turn slows the flow of blood into the heart. Since the blood flow is restricted or stopped, the patient experiences chest pain and shortness of breath, a condition medically known as Myocardial Infarction (MI). Myocardial Infarction results from the thrombotic occlusion of the coronary artery. Necrosis and irreversible cell injury are the ultimate outcomes (O’Gara et al., 2013). Another significant cause of reduced blood supply is artery spams. At times, an artery of the coronary system might momentarily undergo contraction, leading to spasm. This occurs when the artery is narrowed, and blood flow is restricted. A spasm is likely to happen in normal-appearing blood vessels as well as those that are blocked by atherosclerosis. Myocardial Infarction is caused due to a severe spasm (Montalescot et al., 2014). The major risk factors for MI are hypercholesterolemia, hypertension, smoking and diabetes. The three criteria for the diagnosis of MI as outlined by the World Health Organization are patient symptoms of prolonged and severe chest pain, serial enzymes and electrocardiography changes.
During the initial phase of MI, the patient had suffered chest pain, profuse sweating and shortness of breath. The sense of impending doom was also an effect of such condition. The chest pain can be considered as the hallmark of acute MI (Nkhomaet al., 2016). The pain that Mr Jones had experienthe patient suffered from initially was owing to blockage of a coronary artery. The injury caused to the heart muscle deprives it from an adequate supply of oxygen and blood, leading to sensations of chest pressure and chest pain (Levine et al., 2015). Shortness of breath is due to the left ventricle being affected by the infarction and reduction of cardiac output. The sense of impending doom is a result of the release of adrenaline and other catecholemines which acts as a component of the compensation mechanism. Sympathetic activation leads to profuse sweating (Johnson & Craft, 2017).
An Electrocardiograph (ECG) revealed that changes were distinctive ST elevations in leads I, aVL, V2, V3, V4, V5 and V6. Laboratory investigations have indicated a blood count, normal levels of creatinine, urea, chloride, sodium, potassium, liver enzymes. The triglyceride and cholesterol levels were elevated significantly. He was alert and had a suitable orientation to place, prime and people. Lung fields were clear and there was no difficulty in swallowing. Air entry was normal bilaterally and there was no abnormality in breath sounds. No visible pulsation, heaves or thrills were detected. No cyanosis or edema was seen. The abdomen was non-tender and soft, and no mass was felt. Normal muscle mass and gait were observed. As a result of the stroke suffered two years ago, power on the left side was 5/5 and on the right side was 3/5.
The condition of Mr Jones required immediate nursing intervention. The patient was given Glyceryl Trinitrate (GTN) sublingually with the aim of easing the pain. GTN is a widely used as a vasoactive agent administered for reduction of myocardial oxygen consumption, subsequently leading to decrease of ischemia and relief from pain (Kaplow, 2015). In addition, the patient was also administered Aspirin tablet 300mg through the oral route. This medication is an antiplatelet, thereby reducing the platelet aggregation and preventing the formation of thrombus. The risk of MI is reduced as a result of this (Moorhead, 2014).
The patient was placed in a semi-Fowler’s position, and oxygen was given at the rate of four litres per minute to aid the patient in breathing. The patient was brought into a stable condition in the emergency room before shifting him to the Coronary Care Unit. After the diagnosis was confirmed the main objective was to address the blockage in the artery and restore the flow of blood. This process is known as reperfusion (Wood, 2010). On the basis of the assessment done regarding patient condition and clinical manifestation, it was indicated that the patient was a probable candidate for Streptokinase infusion. However, the previous history of stroke with residual effects contraindicated the use of the same (Morton et al., 2017). Streptokinase leads to symptomatic intracranial haemorrhage in those individuals who have had a history of stroke.
Once the patient was oriented to the coronary care unit, he was assessed for the present set of problems. He reported of having chest pain due to ischemic myocardial tissue. In addition, he was having feelings of fear and anxiety due to changes in his health status. This mainly related to decreased cardiac output owing to altered cardiac rhythm and rate. The expected outcome of the nursing intervention and medical care was relief from pain. The other nursing goals were a reduction of fear and anxiety and maintenance of sufficient cardiac output.
The planning and implementation of pharmacological and no-pharmacological treatment included injection of morphine 2.5mg through the intravenous route. The rationale was to relieve pain since tab Glyceryle trinitrate was unsuccessful in relieving the chest pain. Mr Jones was assisted to report the chest pain to understand the severity of the condition. The prime point of pain and the direction of movement of the pain were to be assessed. He was thus encouraged and assisted to verbalize his concerns and fear. It was a crucial step to attach the cardiac monitor for monitoring the rhythm and rate of the heart. Vital signs of the patient were recorded every two hours initially for six hours to identify any changes in patient condition. Consequently, the recording was done every four hours. Monitoring signs of reperfusion were also elementary, such as heart block, bradychardia and PVCs (Karch & Karch, 2016).
The patient was advised complete bed rest for the initial three days after he hwas admitted. Visotors were not allowed frequently. The underlying principle was to allow the patient have maximum rest and permit adequate healing of the injury to the heart. According to Willerson and Holmes (2015), complete bed rest allows reduction of workload to the heart. The patient’s diet was also a key concern. His dietary intake consisted of low fat and low sodium food along with those that are low in cholesterol content. As opined by Adrogué and Madias (2014) excess amount of sodium in the body is the cause of increased blood pressure and increased workload of the heart. Since the patient was a hypertensive individual, it was advisable for him to consume food with low salt content. Since saturated fat increases blood cholesterol, Mr Jones was given a fat-free diet.
The daily medication for Mr Jones included Tab Glyceryl trinitrate, Tablet Aspirin 150mg once daily, tablet Simvastatin 20mg note daily, tablet Enalpril 5mg daily, Tablet Isorsobide dinitrate 10mg thrice daily. Isorsobide dinitrite acts as a coronary and peripheral vasodilator that increases blood flow and improves collateral circulation. This, in turn, reduces preload and afterload and decreases myocardial oxygen consumption along with the increase of cardiac output (Karch & Karch, 2016). Simvastatin is a drug belonging to the group HMG CoA reductase inhibitor. The mode of action is through reduction of cholesterol level in the body, more precisely the low-density lipoprotein, or LDL. It is also responsible for reducing the levels of triglyceride and increasing the level of high-density lipoprotein, or HDL.
On the second day, the patient reported a significant reduction in chest pain and relief from profuse sweating, and thus did not require any intervention. Oxygen was administered, and monitoring for vital signs and cardiac output continued. Consumed meals and administered medications did not lead to any complications. Assessment carriedout on the third day indicated that oxygen administration was not required. The patient was reported to be out of danger. On the fourth day, he was mobilized out of bed. A dietician counseled him regarding his future dietary intake. A physiotherapist advised him of having a more active lifestyle through regular physical exercise. After being transferred to the general ward on the fifth day, he was counseled and motivated to quit smoking. He continued receiving collaborative care for upholding rehabilitation after MI. As pointed out by Nieswiadomy and Bailey (2017) Cardiac rehabilitation improves the ability of the heart to function, lowers the heart rate, and reduces the chances of developing difficulties from heart disease.
Mr Jones was released from the hospital on the sixth day, and he follow up included reporting to the clinic after one month. His medications outlined at the time of discharge included tab Enalpril 5mg daily, tab Asprin 150mg daily, Tablet Isorsobide dinitrite 10mg thrice daily, tablet Simvastatin 20mg nocte and Tablet Glyceryl trinitrite. He was recommended to pursue medical help in case of any emergency.
For achieving desirable patient outcomes, it is inevitable to provide an environment that fosters the treatment process undertaken to address the needs of the patient (Nieswiadomy & Bailey, 2017). For achieving suitable early reperfusion, Mr Jones was provided with a restful and comfortable environment before commencing on the treatment. The family members of Mr Jones were emotionally instable and anxious. They were required to be given support and empathy throughout the process. They were educated about the importance of the undergoing treatment and intervention and were provided with all information pertaining to progress in patient condition (Morton et al., 2017).
The care provided to the patient was in accordance to the Acute Coronary Syndromes Clinical Care Standard, Australian Commission on Safety and Quality in Health. The standards are a set of quality statements describing the clinical care to be offered to a patient suffering from specific clinical condition (Murphy et al., 2016). It complements present exertions supportive of the delivery of appropriate care, such as initiatives led by the National Heart Foundation. Ethical issues pertaining to the case study was need of patient education on the presenting symptoms and recovery process (Kaplow, 2015). The patient communication was made effective through clear and sympathetic verbal and nonverbal communication methods.
Conclusion
From the present case study analysis, it can be concluded that cardiac nurses need to have a comprehensive understanding of the multifactorial field of cardiac care technology, including diagnosis, pathophysiology and treatment. A nurse needs to demonstrate skills of multitasking and critical thinking ability to achieve optimal patient outcomes. For resolving patient problems, it is essential to undertake a roper evaluation of the cardiac symptoms. Knowledge of cardiac health rehabilitation and ability to communicate effectively with the family members of the patient are crucial factors for nursing practice. Compliance to legal and ethical considerations are required.
The cardiac care provided to Mr Jones was successful as the patient outcomes were in alignment with the nursing diagnosis and priority of care. As a nurse, I developed a sense of satisfaction and pride in delivering optimal quality care. Fulfillment of all the significant cardiac nursing care attributes ensured exceptional cardiac care nursing. I was able to demonstrate competency in addressing the patient complications and providing patient-centred care. In future, my practice would be guided by research on current evidence for better cardiac nursing care.
References
Adrogué, H. J., & Madias, N. E. (2014). Sodium surfeit and potassium deficit: keys to the pathogenesis of hypertension. Journal of the American Society of Hypertension, 8(3), 203-213.
Bellchambers, J., Neves, E., & Pottle, A. (2017). Inherited cardiac conditions: examining two patient cases. British Journal of Cardiac Nursing, 12(8), 387-396.
Johnson, M. D., & Craft, M. D. (2017). Acute Mitral Regurgitation Following Myocardial Infarction. In The Medicine Forum (Vol. 18, No. 1, p. 19).
Kaplow, R. (2015). Cardiac surgery essentials for critical care nursing. Jones & Bartlett Publishers.
Karch, A. M., & Karch. (2016). Focus on nursing pharmacology. Lippincott Williams & Wilkins.
Levine, G. N., Bates, E. R., Blankenship, J. C., Bailey, S. R., Bittl, J. A., Cercek, B., … & Khot, U. N. (2015). 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Circulation, CIR-0000000000000336.
Montalescot, G., Van’t Hof, A. W., Lapostolle, F., Silvain, J., Lassen, J. F., Bolognese, L., … & Hammett, C. J. (2014). Prehospital ticagrelor in ST-segment elevation myocardial infarction. New England Journal of Medicine, 371(11), 1016-1027.
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.
Morton, P. G., Fontaine, D., Hudak, C. M., & Gallo, B. M. (2017). Critical care nursing: a holistic approach. Lippincott Williams & Wilkins.
Murphy, B. M., O’Higgins, R., Shand, L., Vincent-Smith, M., & Jackson, A. C. (2016). Managing the cardiac blues in practice: a survey of Australian practitioners. British Journal of Cardiac Nursing, 11(5), 222-228.
Nieswiadomy, R. M., & Bailey, C. (2017). Foundations of nursing research. Pearson.
Nkhoma, E., Ptaszynska, A., & Gomez, A. (2016). Characterizing the Incidence of Heart Failure Following Hospitalizations for Acute Myocardial Infarction.
O’Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., De Lemos, J. A., … & Granger, C. B. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), 485-510.
Willerson, J. T., & Holmes Jr, D. R. (Eds.). (2015). Coronary artery disease. Springer.
Woods, S. L. (Ed.). (2010). Cardiac nursing. Lippincott Williams & Wilkins.
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