Clinical case study

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Clinical Case Study on Coronary Arterial Disease

Introduction

Healthcare providers are tasked with fostering the primary goal of quality patient outcome in medical facilities. To achieve this, it is critical to understand the underlying factors associated with the condition which includes the present symptoms of the disorder, the causes of aggravating symptoms and the treatment and management plans. In this regard, it is important for the medical practitioners to relate the vital signs to the physiology, pathophysiology, and anatomy of the condition. This assists in the development of effective management strategies. Nursing staff remains central to enhancing the welfare of patients in regards to establishing the priorities of care. Although this is guided by the symptoms of the condition, other factors determining these priorities include the history of the present illness (HPI) and causes of the situation. This paper is an evaluation of Mrs. Hale’s condition, Coronary Artery Disease (CAD) with major aspects covered including the physiology, pathophysiology, and anatomy of the condition, nursing care priorities, psychosocial factors associated with the disorder and ethical and legal issues to consider in the nursing care.

Anatomy, Physiology, and Pathophysiology of CAD

Coronary Artery Disease is among the most common cardiovascular conditions accounting for approximately one-third of all deaths in developed nations (Montalescot, Sechtem, & Achenbach, 2013). The condition entails blood flow being restricted to flow through the artery. Common clinical presentations of the condition include acute coronary syndromes such as myocardial infarction and cardiac death. Considering the anatomy of the condition, it affects the left and right coronary arteries that arise from the left and right coronary sinuses in the aorta’s root which is above the orifice of the aortic valve (Schelbert, 2010). The coronary arteries partition to medium and large-sized arteries located at the surface of the heart. Considering the operation and structure of the heart, the coronary artery commences as the main artery on the left side and immediately divides into circumflex, left anterior descending (LAD) and in other cases the intermediate artery. The LAD artery accompanies the anterior interventricular groove and in some cases over the apex. The LAD artery provides the anterior septum which also includes the conduction system. It also supplies the left ventricle anterior free wall.

The pathophysiology of the CAD can be understood in two major conditions, coronary atherosclerosis and artery spasm. In the first situation, it is identified by the irregular distribution of various vessels although it occurs at the turbulence points such as vessel bifurcations. During the growth of atheromatous plaque, the arterial lumen continuously narrows which results in ischemia (Gyberg et al., 2015). In this situation, the level of stenosis sufficient to cause ischemia differs with demand in oxygen. The coronary artery spasm is distinguished by increase in vascular tone, the lumen narrowing, transient and reduction in the flow of blood. This may result in variant angina (symptomatic ischemia). It is also characterized by marked narrowing which may trigger the formation of the thrombus resulting in life-threating arrhythmia or infraction. Notably, the spasm occurs in the arteries regardless of atheroma presence. In the arteries that have no atheroma, the basal coronary artery tone will probably increase while the artery with atheroma results in endothelial dysfunction causing local hyper-contractility.

The physiology of the condition is characterized by the changes in both the function and structure of the blood vessels. In the atherosclerotic processes, they cause the deposition of lipids in the wall of the vessels abnormally. In addition, these processes cause vascular inflammation, formation of plaque, vessel wall thickening and infiltration of the leukocyte (Schelbert, 2010). The results of the changes include narrowing of the lumen restricting blood flow. Also present are functional and structural changes. Upon restriction of the myocardium blood flow which is referred as ischemia, an imbalance of the oxygen demand and supply arises. In case there is an inadequate supply of oxygen to meet the demand, hypoxic occurs in the myocardium which is affiliated with angina described as chest pain and pressure. In severe blood flow restriction, there is infarction and anoxia of the tissue. In addition, chronic or acute ischemia resulting from CAD could impair the cardiac electrical and mechanical activities that result in arrhythmias and heart failure.

Analysis of Mrs. Hale’s Clinical Presentation

The variations of Mrs. Holmes condition are reflected in the pulse rate, blood pressure, and SpO2. The observations at 0800 hours include a pulse of 74 beats per minute which is regular and has a strong volume. The respiratory rate is 14 per minute characterized by a normal depth that is also regular. The blood pressure is 165/95 mmHg which is normal for her. The SpO2 is 98% on ambient room air. Half an hour later, the vital signs have changed drastically and include a pulse of 116 beats per minute which is regular although the volume is not as strong as earlier. The respiratory rate is 26 beats per minute which is regular although shallow than there before. The blood pressure, on the other hand, is 105/70 which has reduced the systolic pressure particularly. Finally is the SpO2 which is 92% on room air. The condition is further characterized by dyspnea, shortness of breath and the peripheries being little cool to touch.

The changes mentioned above are as a result of various aspects among them the emotional stress which the patient has already expressed. As mentioned above pertaining the physiological presentation of the condition, the main source of the vital signs is the reduction of the oxygen supply/demand ratio. The restriction of blood flow to the myocardium as a result of the CAD condition causes ischemia which is characterized by imbalanced oxygen supply and demand. This is the cause of the first noticed signs of being diaphoretic and nausea as a result of the myocardium becoming hypoxic (De Bruyne et al., 2014). The symptoms associated with the hypoxic nature is angina described as chest pain. In this situation, the patient feels tightness in the chest which usually occurs on the left side. One of the vital signs is dyspnea characterized by reduced breath which can be associated with blood flow restriction resulting in the heart having challenges to pump enough blood that meets the body needs.

Relating the vital signs with pathophysiology of the condition, coronary atherosclerosis can be attributed to the variations. Once the patient gets anxious and stressed, the atheromatous plaque splits or raptures. Although the reasons for this are still unclear, the most common include plaque calcium content and inflammatory process causing softening of the plaque or morphology of plaque (Douglas et al., 2015). It is this split or rapture that exposes the thrombogenic material and collagen activating the plateslates and cascading of the coagulation. This causes acute thrombus that interrupts blood flow in the coronary artery. This causes the imbalanced oxygen demand and supply described as myocardial ischemia (Maddox et al., 2014). Although the consequences of the condition depend on the location and obstruction degree, this is the primary cause of angina and pressure in the chest which Mrs. Hales rates as 4/10 in a scale of 0-10. Upon further questioning, patient notes that there is a slight ache in the underside of the upper left arm and feels a little nauseated. Considering the patient’s condition, it is in the severe stage which is also characterized by a possible heart attack. The aggravated condition emanates from chronic ischemia which is caused by CAD impairing the electrical and mechanical activities.

Priorities of Care

Nursing care for CAD is dependent on the symptoms and associated effects. For Mrs. Hale, some of the symptoms include low blood pressure, pain and chest pressure resulting in discomfort. The pressure and pain are as a result of plaque buildup in the coronary arteries which result in reduced blood flow thus less oxygen supply to the body, classic symptom of CAD are angina, pain caused by loss of nutrients and oxygen as a result of insufficient flow of blood. Among the nursing care plans to address the patient’s condition include reducing pain, enhancing the patient’s knowledge regarding the condition, addressing anxiety and lifestyle change.

First Priority: Managing Acute Pain

For a patient with the condition, acute pain, and emotional experience and unpleasant sensory emanates from potential or actual tissue damage. This is related to either of two conditions, decrease in myocardial blood flow and increase the workload of the heart as compared to oxygen consumption. The condition is evidenced by several factors among them pain that varies in frequency, intensity, and duration. As a result, the patient is restless and has autonomic responses which include changes in pulse rate, blood pressure, and fluctuating respiratory rate (Maddox et al., 2014). The nursing intervention in this regard entails medicinal and therapeutic interventions. Some of the non-pharmacological interventions include instructing the patient to notify nursing staff if pain occurs, identification of location and intensity of the pain, observing the associated symptoms such as nausea and vomiting, place the patient in a complete rest and elevating her head to address dyspnea (breath shortness). It is also important to stay with the patient while providing supplemental oxygen as recommended. The rationale behind these interventions includes avoiding further decrease of heart rate and blood pressure as a result of pain, helping in evaluating possible progression of angina especially if it is unstable, reducing oxygen demand to decrease the risks of tissue injury and reducing myocardial workload. Essential to note is that emotional stress is addressed through maintaining a comfortable and quiet environment. Different medicines can be administered to reduce this pain (Wal et al., 2013). These include beta-blockers such as acebutolol which reduce heart workload thus decreasing angina. Another possible medication calcium channel blockers such as Vascor which is responsible for producing coronary vascular smooth muscle relaxation.

Enhancing Patient Knowledge

This is described as the patient’s deficiency of information pertaining the condition which in this case is CAD. It is related to poor exposure, misinterpretation of information and being unfamiliar with the resources. This deficiency is evidenced by numerous questions from the patient an inaccurate following of the instructions. The goals of the plan include enhancing the patient’s participation in the management process, verbalizing comprehension of the disease process and complications and initiating the required lifestyle changes (Montalescot, Sechtem, & Achenbach, 2013). The care plans to address this situation include discussing the stress condition as a way of preventing the attacks, reviewing the levels of cholesterol, emphasizing the importance of regular measurements, encouragement of ways through which the patient can reduce stress, reviewing the importance of weight control, and educate the patient on the importance of medication adherence (Lingel, Srivastava, & Gupta, 2017). For the pharmacological intervention, it entails lipid-lowering agents such as cholestyramine. Possible medicines also include the HMG-CoA reductase inhibitors such as simvastatin. The rationale behind these interventions include patients with CAD being required to understand angina and the triggers such as stress that results in lifestyle changes of the heart. Considering the cholesterol levels, although the normal LDL is slightly below or above 160 mg/dl, patients with CAD should maintain it below 100 mg/dL. Educating the patient on the importance of avoiding stressing situations is critical as it reduces ischemic episodes. Considering the medical interventions, the rationale behind their administration include reducing the myocardial workload thus controlling the attack risks. While the lipid-lowering agents are administered to reduce serum cholesterol levels, the HMG-CoA reductase inhibitors induce photosensitivity. 

Addressing Decreased Cardiac Output

The situation is characterized by insufficient blood pumped to meet the body’s metabolic demands. Among the risk factors include rate or rhythm alterations, electrical conduction and inotropic changes. The nursing goals include displaying the reduced dyspnea episodes and angina, demonstrating an increase in activity tolerance and participating in activities or behaviors that lower the heart workload (Rosendorff et al., 2015). The nursing interventions in this regard include maintaining bed rest in the comfort position when the acute episodes occur, monitoring the variation in the cardiac rhythm, listening for murmurs and providing adequate resting period. It is also important to assess for symptoms and signs of heart failure. The medicinal approach to addressing the condition is the administration of calcium channel blockers such as diltiazem or beta-blockers such as nadolol. The rationale behind these interventions includes reducing oxygen demand thus decreasing decompensation risks and myocardial workload and addressing the noted signs and cardiac rhythms such as anxiety and pain. The rest periods are meant to conserve energy and reducing the heart workload (Dobesh et al., 2012). Assessing the symptoms and signs of heart failure is aimed at establishing whether the patient suffers myocardial ischemia as a result of angina. The medication approach, on the other hand, is aimed at terminating ischemia as a result of coronary artery spasm while reducing vascular resistance. The beta blockers are administered to decrease cardiac workload by lowering the systolic blood pressure and heart rate.

Psychosocial Issues

The occurrence of the Ischemia episodes is as a result of various factors including stress and anxiety. Unrelieved stressing conditions in the patient’s life may damage the arteries and worsen the risk factors associated with CAD. Psychosocial issues are the source of stress and anxiety (Lingel, Srivastava, & Gupta, 2017). Mrs. Hale has already noted that she has been feeling down of late. This can be attributed to a reduction in her social life which includes retiring from her work where she used to interact with more people. Also, she lives alone and rarely sees her son who lives in Melbourne. She fears going back home as a result of the chest pains especially when she is doing the house chores and the fact that she hates requesting assistance from anyone is an indication of the anxiety and stress triggers. Through these stresses and psychological triggers, it is apparent that the recent ischemic episodes could continue if they are not addressed. Her current life condition is that she faces a series of heart attack risks which may result in death. While tranquilizers and sedatives can be administered to address the condition, effective therapeutic strategies where the patient is made to relax and cope with the condition is imperative. This may include engaging in social activities and making her understand the importance of being assisted.

Legal Issue

Among the requirements of effective nursing care and interventions is upholding ethical and legal issues which are related to the patient’s condition. Healthcare standards and principles oblige nursing staff to consider ethics in the developed management strategies (Montalescot, Sechtem, & Achenback, 2013). For Mrs. Hale, the ethical issue pertains her privacy and life which she has opened to me as the nursing staff. As reflected in her notes, she lives alone in a rented accommodation. Also, she retired recently, and her only source of income is the superannuation pension. Upon further interaction, Mrs. Hale opens up and notes that she is concerned about going home based on her chest pain episodes which have increased especially when doing housework. She also confides in me that she does not like requesting for help. Notably, knowing this information that is private to the patient comes with legal and ethical responsibility. Such include ensuring privacy of her situation. While developing the nursing intervention which may involve enhancing the patient’s psychosocial welfare, it is important to get in touch with her son and establish the best approach to addressing her loneliness and any other challenges such as financial constraints. While doing this, the ethical and legal issue entails ensuring this information is known only to the involved individuals and me.

Conclusively, the effective comprehension of a patient’s condition and development of a profound management plan is considered a critical factor in achieving the primary healthcare goal of quality patient outcome. In this regard, it is important for the healthcare providers to understand the anatomy, pathophysiology and physiology aspects associated with the condition and relate them to the symptoms and signs as portrayed in the patient’s vital signs. The above discussion entails the evaluation and development of nursing care for a patient with Coronary Arterial Disease which as reflected in the history and changes in her vital signs is in the third stage where she is having a series of ischemia episodes characterized by dyspnea and angina. With the priority nursing care involving addressing chest pain and discomfort, educating the patient on how to manage the condition and reducing cardiac workload, it is important to reduce the triggers of the condition which include the psychosocial issues of the patient such as anxiety and stress emanating from her loneliness.