QUESTION
This assessment task allows students to demonstrate theoretical knowledge around pathophysiological changes in disease, pharmacological management of disease, planning nursin gcare and evaluating care. Students are required to answer the case scenario questions provided.
Students should attempt all questions in the case study:
…You are just starting your shift as a graduate nurse and you are about to review your first patient, Jon Edwards. Jon is a 64 year old man who has been admitted to the medical ward with cellulitis to his left lower leg. During admission, it is documented that Jon has a past history of hypertension, hypercholesterolaemia, and Angina for the last 3 years. He is prescribed Metoprolol, Aspirin, Pravastatin and Glyceryl Trinitrate Spray as needed and is prescribed Cefazolin 2g TDS IV for his cellulitis. His social history reveals he is married to Gabby, he smoked 20 cigarettes per day for 25 years but recently stopped. Drinks 4 glasses of red wine per day and eats “fairly healthily”. Jon walks his dog daily, but doesn’t partake in any other additional exercise. Jon’s father died at age 48 years of a heart attack.
1.1 Describe the pathophysiology (cause, progression and outcome) of Angina. Include in your answer risk factors for Angina and the treatment options for Angina. Demonstrate links to Jon’s case (ie. What has been commenced for Jon in terms of preventative pharmacology and what preventative strategies would be appropriate in his case?). When you arrive at Jon’s bedside, he tells you he is experiencing severe chest pain after having his shower. You take an initial set of vital signs: Temp 35.8, Pulse irregular 110 bpm, BP 110/90, RR 24, SaO2 93% room air.
1.2 Discuss THREE types of physical nursing assessments that would be appropriate for Jon’s complaint (excluding vital signs) you would initiate for Jon and provide a description of each of these in the context of Jon’s complaint with rationale as to why these would be your
priority.
1.3 Discuss THREE nursing interventions (excluding pharmacological) you would initiate and provide rationale as to how these would improve physiological outcomes of Jon’s chest pain.. Nursing interventions would include nursing activities or actions that the nurse
could initiate in response to nursing assessment findings.
1.4 Discuss the administration (including administration, benefits, risks and contraindications) of sublingual Glyceryl Trinitrate for Jon’s pain. Include in your explanation what education you need to provide to Jon on its administration. You have undertaken an ECG for Jon and the rhythm strip looks like this:
1.5 Report the major abnormal finding and apply your findings to Jon’s case. Explain why this
finding would need to be reported immediately to the Doctor.
ANSWER
1.1. Ans. Angina is said to be a type of chest pain which is caused due to reduction in blood flow to the heart. It is not a disease itself, however, it is a strong indicator of a person having a type of heart disease. It is a symptom of coronary artery disease, and it can be present in various forms such as an angina attack, discomfort or pain in the chest lasting between 1 to 15 minutes. Some of its symptoms include tightness in the body, squeezing in the chest, heaviness, burning or aching in the chest, or difficulty in breathing. The pain can further spread to other parts of the body such as neck, jaw, arms, throat, back, etc.
Angina is caused mostly due to lack of oxygen supply to the heart. There is a mismatch or imbalance between myocardial blood flow (supply of the oxygen) and the oxygen demand by the body. This imbalance is called as myocardial is chaemia. The restriction of the blood flow supply results in atherosclerotic narrowing of a coronary artery. Heart rate has been found as one of the major determinants of myocardial ischaemia.
Unhealthy cholesterol levels, high blood pressure, tobacco smoking, overweight, being 60+, and having some family history of heart disease are some of the risk factors for Angina. In the case of Jon, he has been a regular chain smoker for the last 25 years, his father died from a heart disease, he also eats fairly healthy, while not performing enough exercise for the body. These prolonged habits and conditions have made him a victim of Angina, and he has not been able to fight with it. Moreover, when he was measure, his pulse found to be irregular and other similar symptoms.
The preventative treatment options of Angina also depend upon certain factors, such as medication is helpful in some cases while changing lifestyle habits could be beneficial in some cases. In the case of Jon, the preventative strategy should be more related to changing the lifestyle habits rather than taking only medication. He needs to exercise daily apart from the usual dog walk, and he should stop smoking cigarettes and eating regular healthy diet. In pharmacology, he should try to perform lipid and diabetes management, and consult for pharmacotherapy and control his blood pressure.
1.2 Ans. Rapid physical nursing assessment is one of the key ways to successfully handle cardiac emergencies. In the case of Jon’s complaint, assessment is compulsory apart from the identification of the vital signs.
The three most important types of physical nursing assessment to be performed for Jon would be –
- Providing supplemental oxygen before performing any other check-ups – Providing supplemental oxygen to Jon should be the first task for the nurses. This would help in increasing the haemoglobin saturation and improving tissue oxygenation. The dose would included nasal cannula, partial rebreather, simple face mask in the appropriate amount, along with an artificial airway for breathing. They should continue other checks but meanwhile, providing supplemental oxygen in case of any emergency, unconsciousness, breathing or circulation problem. While applying the supplemental oxygen, the nurse would ask and talk to the patient about their brief history and living habits to assess Jon’s past medical record and his lifestyle, on the basis of which further assessment would be continued.
- Instant ECG Monitoring and Physical Assessment – This assessment should be done to check the correlation of any physical exercise or activity with the magnitude of pain. A depression or downfall of the ST segment in the graph or the inversion of the T wave would give a clear indication of ischemia, which is the major cause for Angina. The nurse would also ask about Jon’s legs, arms, and his skin to identify any sign of edema, clubbing, or lesions. It would be done for the whole duration of the day irrespective of whether Jon is suffering from chest pain or not. Another indication for ischemia could be an ST depression without any pain in the chest, or the significant Q waves. Brachial and radial pulses would also be checked for finding any epitrochlear lymph node. Moreover, it would also tell us about the duration and impact of any physical activity performed by Jon.
- General Cardiovascular Assessment – This is one of the important assessment steps in the procedure of Angina assessment (Jarvis, 2012). The calves would be measured at the widest point, any palpation of the legs for determining temperature changes, measurement of posterior tibial arteries for grading the existing blood flow in Jon. They can also use a Doppler Ultrasonic Stethoscope for finding out any weak peripheral veins and calculating ankle brachial index. Foot neuropathy and sensation related diagnosis also need to be performed for checking out Jon’s foot and legs condition.
1.3. Ans. There are many nursing interventions, which the nurses could initiate to improve physiological outcomes of Jon’s chest pain. The three most useful of those are described below: –
- Reducing the anxiety of Jon – Many times it happens that the patient gets worried or stressed out due to identification of any disease in him. Angina is a case of low oxygen supply to the heart, and any anxiety, stress, fear, or negative feeling would further worsen the condition of Jon. While diagnosing him and performing physical assessments, the nurse also has to prevent its further progression in the body. He/she would have to smartly express the illness and its treatment to Jon in a light-hearted manner so that he doesn’t come under any psychological stress. Depressive symptoms and psychological distress are very important factors for Angina progression
- Physical Activity treatment for pain relief – Understanding the physical activities, exercises, daily habits come under one of the most important physical assessment for nurses in case of Angina. Jon has been a chain smoker for years, with bad eating habits and past family record with heart disease. This leads to further care for him in terms of physiological outcomes so that his pain reduces marginally by improving his physical activities. One of the most common techniques to treat this would be to instruct Jon to stop all activities and sit in his bed in a semi-Fowler’s position whenever he feels that he is going to experience Angina, and the nurse would also administer nitroglycerin sublingually.
- Revascularization and decreasing the oxygen demand – Angina occurs due to mismatch between the oxygen supply and demand in the heart. If the nurse would ask Jon to stop physical activities at the moment and go for balancing activity and rest, it would result in a reduced demand of oxygen for his body. Revascularization could help in reducing his coronary flow and physically storing it resulting in a reduced recovery time. Jon’s activities would be first noted down to analyse the behaviour and they will be planned accordingly to reduce the pain and provide a balanced oxygen supply.
1.4. Ans. Glyceryl Trinitrate, also known as Nitroglycerin, has been famous for relieving anginal chest pain and managing blood pressure through vasodilation. Jon has been suffering with a similar Anginal chest pain, and a dose of Nitroglycerin would be provided to him for his pain reduction and relief. It can be administered in his body in a number of ways, such as sublingual (under the tongue) tablet consumption, sublingual powder usage, rectal ointment, sublingual spray, transdermal paste which could be applied through skin, extended release oral tablets for consumption, etc.
These consumptions require particular amount of doses to be beneficial. For example, the Nitroglycerin sublingual tablets could be provided in the form of a 0.3 mg, 0.4 mg, or 0.6 mg dosage. The Nitroglycerin sublingual spray could be sprayed from a distance of 1 meter with an approximate weight of 1 mg. The transdermal paste could be applied with a measuring paper, which could be 7.5 to 8 mg per half inch.
Nitroglycerin has a very strong effect on vascular smooth muscle, which is generally found in peripheral veins. It is metabolized by liver enzymes, and it results in the formation of Nitric oxide which would cause smooth muscles to relax and hence, Jon would feel relief and rest. The probable vasodilation of Jon’s body would reduce his myocardial preload and afterload, along with a decreased blood pressure.
Generally, Nitroglycerin is not taken for a patient who is under the effect of intoxication, alcohol ingestion, or any kind of smoking. In the case of Jon, he has been smoking for years, which is somehow currently stopped, but he stills consumes 4 glasses of red wine per day, and he would have to stop his consumption of wine till the time this medication will be continued. He should also try to reduce his anxiety or stress level, as this medicine is not suited for ones who are hypertensive.
Some of the side effects of this medication are headache, hypotension, dizziness, nausea, etc. The storage of this medicine is very important, and it should not be chewed or swallowed. Jon would have to wear gloves while applying the paste. Excessive of this medicine could result in prevention of oxygen release from red blood cells to tissues, which could be a problem for Jon.
1.5. Ans. The below given is an ECG report of Jon, which is to be studied and further examined.
The three most important intervals to examine in this case will be PR interval, QRS duration, and QT interval. In this ECG report of Jon, we can see that there is no such real problem with the PR interval as it lies in the allowed range of 3 to 5 small squares of the given ECG paper. The QRS duration is comparatively quite lesser as it covers only 1-2 squares of the paper, which highlights the obesity and chronic heart disease symptom factor. Another important factor to consider is that we can observe a wide QT interval, which highlights a heart rhythm disorder for Jon and can be seen as the reason for his erratic pulse and blood pressure. This ECG report needs to be shown to a doctor as the irregularity and downward trend of the QRS and QT interval could result in a cardiac attack for Jon.
1. Jane Reid, 2013 Sep 05, Psychological Interventions for Patients with Coronary Heart Disease and Their Partners: A Systematic Review, NCBI US
2. Roberto Ferrari and Philipo Crea, 2017 Sep 07, A ‘diamond’ approach to personalized treatment of angina, Nature Research Journal
3. Sheila Melander, 2013 June 19, Evaluating Symptoms to Improve Quality of Life in Patients with Chronic Stable Angina, Hindawi Nursing Research and Practice Journal
4. Rom Duckworth, 2018 Jan 03, Nitroglycerin: Major actions and misconceptions, EMS Topics
5. Jamshid Alaeddini, 2018 Jul 19, Angina Pectoris Practice, Medscape Organization
6. Suzanne Albrecht, 2013 Feb 20, The Pathophysiology and Treatment of Stable Angina Pectoris, US Pharmacist
7. Peter Crosta, 2017 Dec 11, Everything you need to know about angina, Medical News Today
8. David Tilton, 2018 Apr 23, Cardiac Emergencies: Assessment, Angina, and MI, CEUfast Nursing
9. Elizabeth Cotter, 2013 Jun 21, Health Assessment of Patient with Angina – Nursing Assessment, Academia.edu
10. Marianne Belleza, 2017 Sep 24, Angina Pectoris – Pathophysiology and description, Nurselabs.com
11. Michelle McGillion, 2014 Feb 01, Impact of self-management interventions on stable angina symptoms and health-related quality of life: a meta-analysis, US National Library of Medicine Journal
12. David E. Winchester, 2015 Dec 16, Angina treatments and prevention of cardiac events: an appraisal of the evidence, European Heart Journal Supplements
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