Clinical Case study

Answer

Case Study on Acute Coronary Syndrome

Introduction

Cardiovascular conditions are currently considered among the leading causes of death particularly among the aged patients. These conditions emanate from an array of sources including poor lifestyle. The American Heart Association estimates that cardiovascular conditions result in more than one-third of total deaths in the developed nations (Roffi et al., 2016). To mitigate this condition, although medicinal approaches have been considered effective, non-pharmacological interventions are noted to be equally efficient which entail lifestyle changes such as healthy dieting and regular exercising. Among these conditions are the Acute Coronary Syndrome, a disorder that is an umbrella of various clinical symptoms and signs such as unstable angina, and myocardial ischemia (Overbaugh, 2009). It is therefore critical for nursing staff to evaluate these signs and symptoms to develop an effective management plan. This case study entails a patient, Mrs. Hale, who has ACS and has been noted to have ischemia and angina episodes, a possibility of heart attacks. Some of the aspects involved in this paper include the physiology and anatomy of the condition, nursing care priorities and ethical factors considered in developing the care.

Analysis of the Condition

Acute Coronary Syndrome is a cardiovascular condition that emanates from coronary arterial disease (CAD). ACS is characterized by several signs and symptoms which include reduction of blood flow to the heart (myocardial ischemia) and unstable angina which is described as chest pain and discomfort (Overbaugh, 2009). The anatomy of the condition is centered on the source of the symptoms which entail the interruption of blood flow to the cardiac muscle. This interruption is as a result of plaque or blockage in the arteries. Notably, every artery supplies blood to a specific region and based on the degree and level of the artery blockage, the tissues receiving blood from it are at risk of infarction, injury, and ischemia. For instance, upon blockage of the circumflex artery, the left ventricle lateral walls, left posterior fasciculus and left atrium may become infracted, ischemic and injured. On the other hand, if occlusion of the right coronary artery occurs, the right ventricle and atrium and portion of the left ventricle become injured, infarcted and ischemic.

Considering the pathophysiology of ACS, the condition commences when there is stimulation of the thrombus formation and platelet aggregation as a result of disruption of the coronary artery by atherosclerotic plaque. Previously, research suggested that the thickening of the plaque resulted in narrowing of the coronary artery which led to ischemia as a result of restricted blood flow to the arteries (Buja, 2015). Overbaugh (2009) however, suggests that it is as a result of the unstable rapture, a vulnerable plaque with its affiliated inflammatory dynamism that causes the narrowing of the coronary artery. It is noted that most infarction cases are as a result of occluding thrombus formation on the plaque surface. Notably, the myocardial cells require several aspects to maintain the mechanical and electrical activities in a normal situation that ensure the heart functions normally. Some of these requirements are adenosine triphosphate (ATP) and oxygen. It is through the deprivation of these aspects particularly oxygen that results in the glycogen anaerobic metabolism and less ATP production which results in acidosis. This is the source of the injury, ischemia, and infarction.

The physiology of the condition can be discussed through the overview of the disorder, the affected parts, and consequences. As mentioned above, the condition mainly results from blockage of the coronary artery. Depending on the level of obstruction and location, the condition may result in three different situations of Non-ST elevation myocardial infarction (NSTEMI), non-ST segment elevation acute coronary syndrome (NSTEACS) and unstable angina (Montalescot et al., 2009). Each of these conditions is determined by the levels of the cardiac biomarkers. The causes of ischemia, angina, and infarction can be attributed to the blocked artery supplying blood to a particular tissue. As mentioned in the anatomy of the condition and operation of the heart, the tissue which receives the less blood lacks oxygen and ATP resulting in discomfort. For instance occlusion of the left anterior artery may result in ischemia, injury and infarction of the interventricular septum, left anterior fasciculus and right bundle branch.

Analysis of Changes in Patient’s Condition

The changes in the patient conditions can be described by the different observations at 0800 hours and 30 minutes later. Previously, at 0800 hours, some of the vital signs included a temperature of 37.3 Degrees Celsius, pulse of 74 beats per minute which is regular and an indication of strong volume and a respiratory rate of 14 beats per minute which is also characterized as regular and with a normal depth. The blood pressure is 165/90 mmHg which although high is normal to her. The SpO2 is 98% on room air. The changes in Mrs. Hale’s condition are reflected in the diaphoretic nature, mild pressure sensation which she records as 4 on a scale of 0-10 and pain. She further notes that she has a slight ache in the upper left arm underside part and she nauseated. Other vital symptoms that have changed include a low blood pressure of 105/70 mmHg, pulse of 116 beats per minute which has increased and a shallower respiratory rate of 26 per minute.

The above variations can be described by the pathophysiology of the Acute Coronary Syndrome where the patient is in the third stage of a possible heart attack characterized by ischemia, dyspnea (breath shortness) and angina which is described by pain and pressure sensation on the chest (Amsterdam et al., 2014). Based on the pathophysiology of the condition as presented above, lack of interventions to reduce the infarction upon acidosis occurring results in tissue and cell injury unless there are interventions to reverse the injuries and ischemia. The patient has already entered the ischemic phase where both the anaerobic and aerobic metabolism are exhibited. Further decrease in the myocardial perfusion results in the ceasing of aerobic metabolism and the condition moves into the next phase, the injury stage. More than twenty minutes pass in this situation and the signs and symptoms begin to show where the patient is in a myocardial shock, necrosis is noticed, and the damage becomes irreversible (Overbaugh, 2009). As a result of the impaired myocardial contractility, the scar tissues that replace the damaged ones cause a decrease in the cardiac output. In this situation, there is limiting perfusion to the peripheral tissue and vital organs resulting in the clinical presentations of nausea, clammy skin, hypotension, and tachycardia.

In an attempt for the body to adjust the situation and support the vital functions, the nervous systems take action and respond to the myocardium ischemic changes.  At first both the blood pressure and cardiac output decrease as reflected in Mrs. Hale 165/90 mmHg to 105/70 mmHg. This stimulates the release of norepinephrine and epinephrine hormones which is noted as the body attempts to compensate for the signs and symptoms (Libby, 2013) This, in turn, increases the pulse rate since the oxygen demand is high in an attempt to increase the blood pressure as reflected in Mrs. Hale’s condition where the pulse rate and respiratory rate increase from 74 and 14 to 106 and 26 beats per minute respectively. The chest pain and pressure sensation are attributed to possible NSTEMI and unstable angina. As suggested by Montalescot et al. (2009), for patients with Angina and ACS, dyspnea (breath shortness) and nausea are some of the present vital signs which are as presented in Mrs. Hale situation

Nursing Care Priorities

Based on the presented symptoms, the nursing care priorities are centered on the vital signs. In this case, some of the most critical conditions include chest pain and discomfort, shortness of breath and nausea. It is therefore important to develop nursing care management approaches that address these conditions. Essential to note is that the priorities may entail both the pharmacological and non-pharmaceutical strategies

1. Monitoring the vital signs, administration of medication and addressing discomfort

As noted in the pathophysiology of the condition, it is critical for the nursing care to monitor and observe the vital signs including blood pressure, heart rate, and respiratory rate. This is based on the fact that unobserved condition may result in a severe heart attack causing death. In this regard, possible conditions to monitor are unstable angina and the myocardial infarction which is caused by coronary artery occlusion as a result of thrombus (Weinstock et al., 2015). Notably, these conditions are reflected by the patient’s signs and symptoms of pain that may or may not have arm, neck and neck radiations, breath shortness, nausea, and a decrease in arterial oxygen saturation and abnormalities in rhythm. Important to note is that these conditions have already been presented as Mrs. Hale’s vital signs. The nursing approaches include providing oxygen for maintaining the saturation level of above 90%, and administration of morphine or nitroglycerine to mitigate the pain (Amsterdam et al., 2014). For the non-pharmacological intervention, it involves placing the patient in a resting position and observing other signs and symptoms such as vomiting and nausea.

The rationale behind these interventions is that increase in the vital signs may result in patient’s death from a severe heart attack. Through the monitoring of the presented vital signs, it is possible to prevent a further decrease in the blood pressure or rise in pulse rate. In addition, the ischemia and angina episodes are reversed thus reducing pain experienced by the patient (Overbaugh, 2009). Ensuring oxygen saturation of above 90 is essential in reducing the risks of tissue and cell injury and also decreasing the myocardial workload. Another non-pharmacological intervention is ensuring a quiet and peaceful environment which is important in addressing the patients’ emotional discomfort. To enhance vascular muscle relaxation, the beta blockers such as statins which are provided upon admission can be administered. Possible medication may also include glycoprotein inhibitors. Important to note is that the patient may be frightened and anxious as a result of the condition. It is therefore important to assure them that their condition is stabilized and that they should remain calm.

2. Addressing patient’s knowledge deficiency

This entails enhancing the patient’s knowledge regarding the condition and how it can be managed. This deficiency is as a result of poor exposure, being unfamiliar with the condition and misinterpretation of the information. Some of the important factors to note are that ACS is caused by several aspects among them poor lifestyle such as high cholesterol and sugar intake and smoking (Buja, 2015). Although Mrs. Hale notes that she quit smoking six years ago, it is important to warn her of the risks involved if she goes into a recess. The goal of this priority is to enhance the patient’s participation in the management approach, verbalize the understanding of the complications and process of the condition and to initiate the necessary lifestyle change. For a patient with relatives, including them in the training programs about the condition is important to enhance their knowledge on medication, administration routes and dosage and understand the risks involved upon termination of the treatment without medical advice (Roffi et al., 2016). Lifestyle changes entail altering the eating and exercising habits of the patient which are considered as the sources of aggravating the condition such as intake of foods rich in sugar and fat. The rationale behind enhancing patient’s knowledge regarding ACS is based on the increasing severity of the condition as a result of poor medication adherence and lifestyle such as unhealthy eating habits.

3. Providing referrals and addressing patient’s concerns

For patients with cardiac conditions such as ACS, it is critical to refer them to specialists in various realms such as cardiologists and dieticians for advanced advice. In addition, these patients should be encouraged to attend cardiac rehabilitation programs and in particular for minority populations and the hard-to-access groups such as the aged, various ethnic groups and women. This is also important for patients from low socioeconomic status whose attendance to these programs is less than expected. Another possible referral is a referral to nurse specialist in chest pain who can conduct triage assessment and facilitate access to specialist services and physicians such as cardiologists. According to O’Neill et al. (2014), nurse-led triage is beneficial in facilitating quick intervention. Most importantly in a nurse priority is addressing the patient’s concerns and issues affecting them. With anxiety and depression among other psychological conditions being the source of increase in the vital signs, addressing the patient’s personal issues may assist in averting the clinical episodes. For Mrs. Hale, for instance, she has indicated that she is down from her life’s situation. As a nursing priority, it is important to listen to her and assist in solving her situation.

Psychological Issue

Myocardial ischemic episodes result from various factors among them stress and anxiety. Notably, patients with unrelieved stressing situation face a risk of damaging their arteries and increase in the vital signs adversity (Libby, 2013). The nervous system upon facing a stressing situation increase pulse and respiratory rate and together with the vital signs may result in heart attack and death. For Mrs. Hale situation, she has already expressed that she is under stress and opens that she has been feeling down lately. This can be related to the adjustments in her life which include retiring from her job and living in a rented accommodation. From the presented information, she has one family member, her son who she rarely sees due to distance separation. She is worried about going back home based on her chest pains which have occurred several times especially when she is doing her housework. From the presented situation, it is apparent that Mrs. Hale is stressed and concerned about her welfare. In addition, being in the third stage of ACS where she faces possible heart attacks is a challenge to her psychological welfare in fear of death and her survival. It is therefore important to assure her that her condition is stabilized through medication and that continuing with stress may result in more health complications.

Ethical Issue

Health care is characterized by various guidelines and principles which dictate on the medical provider's approach to their roles and functions. Among these guidelines are ethical, legal issues which the healthcare providers must uphold. These are described as executing one role according to the set principles (Cohen et al., 2014). Confidentiality of patient’s information is considered a vital legal and ethical issue. Medical practitioners are obliged to maintain high-level confidentiality regarding the patient’s condition and information failure to which they are liable for legal actions. In the case of Mrs. Hale, the legal and ethical issue pertains her life and family matters. She has already confided in me about her private information which as a nursing staff I should maintain the confidentiality while developing the management plan. Among the intervention, plans include communicating with the son and developing a strategy of how Mrs. Hale can have company at home, someone who will assist in taking care of her and addressing the various situations such as ischemic, angina and dyspnea episodes. In this case, this information should not be shared with other nursing staff. Also, issues pertaining her accommodation, retirement and her son’s whereabouts should be kept private from others unless under her permission such as upon refereeing her to a cardiologist.

Conclusively, cardiovascular conditions remain among the major threats to human health and have been noted as the sources of more than one-third of the global deaths particularly in the developed nations. As a result, healthcare providers are tasked with developing effective management strategies to avert these conditions while maintaining a healthy population. The above discussion entails a case study of Mrs. Hale, a 56-year-old woman who has Acute Coronary Syndrome. The condition which is related to Arterial Coronary Disease is caused by interference of blood flow resulting in infraction, ischemia, and angina. As presented above in the anatomy and physiological aspects of the condition, the vital signs of ACS include myocardial Ischemia, dyspnea which is characterized by breath shortness and angina which is described by chest pains. For Mrs. Hale, she is in the third stage of the condition which entails a series of heart attacks. Some of the nursing priorities are observing the vital signs and addressing and enhancing her knowledge regarding the condition to enhance her involvement in the management process.