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This assessment task allows students to demonstrate theoretical knowledge around pathophysiological changes in disease, pharmacological management of disease, planning nursing care 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?).

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. 

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.
 

Angina: Definition and Overview

Angina is chest discomfort or pain caused by reduced blood flow to the heart muscle, usually associated with coronary heart disease. Treatment primarily involves symptom relief through rest and use of angina medications, as well as lifestyle changes to improve overall heart health. It can be caused by underlying coronary artery disorder. When the cholesterol aggregates are there on the walls of the artery and result in plaques form, ultimately it results in contraction of the artery (Kones, 2010). The progressive frequency or the prolongation of angina episodes, reduces exercise thresholds, a requirement for augmented nitro-glycerine dosing, and lengthier recovery period all the symptoms for the physician to diagnose further. Uncontrolled angina may results in severe chest pain, squeezing, nausea, sweating, dizziness, shortness for breathing, and anxiety. In more severe cases it can also lead to death (Norton, Georgiopoulou, Kalogeropoulos, & Butler, 2011). Risk factors associated with angina include unhealthy cholesterol levels, tobacco smoking, high blood pressure, diabetes, being overweight, sedentary lifestyle, being over 45 years old, lack of physical activity, stress and anxiety, sleep deprivation, and family history (Kones, 2010).

Treatment

In mild cases, lifestyles changes can be helpful to control angina. Some of the lifestyle changes are; stop smoking, losing weight, healthy diet, exercise, avoiding stress events and limiting the alcohol consumptions (Samim, Nugent, Mehta, Shufelt, & Merz, 2010).

The physician may prescribe medicines that control the progression of these health conditions. Medicines like nitrates, aspirin, clot-preventing drugs like clopidogrel, beta blockers, statins, calcium channel blockers, blood pressure lowering medications, and ranolazine can be used in issues associated with angina (Tarkin, & Kaski, 2013).

Lifestyle changes and medicine are often applied to address stable angina. If both the above treatment does not work, in case, the medical processes like stenting, angiography, and coronary artery bypass operation can be used to deal with angina issues (The, 2015). Jon has been prescribed with metoprolol, pravastatin, aspirin, and glyceryl trinitrate spray. He is also provided with cefazolin 2g TDS IV for cellulitis issues.

Some of the preventive strategies can be implemented in the case of Jon are quitting smoking, treating the known issues like hypertension, hypercholesterolemia and cellulitis, avoiding the known triggers of angina such as overeating, regular exercise, maintain a favourable or healthy weight, managing blood sugar level and learning about how to manage the mental stress that may leads to angina disorder. As mentioned in the case study Jon has been facing a lot of additional health issues, therefore his regular vital assessment should be done. 

Symptoms of Angina

The patient has been complaining about the severe pain issues, he is experiencing after the taking shower. The viral sign of Jon’s indicated that his body temperature is normal, and irregular pulse of 110 bpm, the pressure was 110/90, respiration rate reported 24 and oxygen saturation rate was 93 Per cent at room environment. His temperature was 37.9 degree Celsius. The chest pain during the treatment period of angina might make nurses nervous as it can enhance chances of cardiac arrest and other cardiovascular issues. But it is also possible that the pain occurs due to indigestion, any innocuous issues, or muscle strain.

First assessment

First of all the nurse should asses the position of the pain and try to find out the answer of some queries like where is the pain, can patient point it, what cause the pain more worse, what can be done, and is pain reduces or  increases with repositioning (Zetta, Smith, Jones, Allcoat& Sullivan, 2011). Sometime the positioning might cause chest pain it may be indicated that the pain is associated with the musculoskeletal, pericarditis I in which the pain is reduced by taking rest by setting and leaning forward), or pleuritic (Rodrigues, Moraes, Sauer, Kalil, & de Souza, 2011). As Jon discussed that the pain occurs after taking shower, therefore it might be possible that he is facing the problems due to changed position.

Second assessment

The severity of the pain should also be assessed by using the pain assessment rating scale. Accompanying the symptoms of angina might also include vomiting and nausea. The diseased person may also face dizziness, hypotension and also reduced heart rate and feeling scared. If the pain is recognized to be very severe, the patient should be referred to the emergency department as it might be possible that he will be experience cardiac attack (Nezamzadeh, Khademolhosseini, Mokhtari Nori, & Ebadi, 2012). Mr Jon is an old male, so it is possible that severe pain might be life threatening for him.

Third assessment

The time of pain should also be examined by assessing how long the pain remains and is the pain is intermittent, means is the pain starts and stops at regular intervals or it continues. This because the angina attacks typically occur for 2 to 5 minutes and sometimes occurs for up to thirty minutes (Oriolo, & Albarran, 2010).   

First intervention

Chest pain is the major symptom in angina and it might be low or extreme. The severe might also be associated with the occurrence of cardiovascular diseases. First of all the patient should be asked to lay down in forwarding leaning positions comfortably. Angina pain does not last for long and it is reduced with time (Veeram, Reddy, Harinder, Singh, & Reddy, 2010). It is generally triggered by the exertion, it commonly subsides within a few time as the patient rest. If the pain resists for more than two minutes It can leads to heart attack, in this case, the nurses should call for emergency services and report to the physician for further recommendations. The chest muscles should relax and hot baths might also be helpful by adding 2 cups of the Epsom.

Causes of Angina

Second intervention

Patient education is another approach that can be used as the nursing intervention for the pain associated with angina. After the immediate nursing physical assistance, the nurse should instruct Mr Jon to report the pain instantly. They should maintain a quiet environment, calm practices, and comforts measures. This will ultimately reduce the external inducements, which might increase the anxiety and the cardiac strain, and also limits the coping capabilities and adjustment to the present situation (Brown, Clark, Dalal, Welch, & Taylor, 2011). The nurse should also educate the patient to perform relaxations techniques such as deep and relaxed breathing, interruption behaviours, imaginations, guided imagery. This will help Mr Jon to distract himself from the severe pain. As the patient might feel stressed and anxiety these distraction activities might reduce the occurrence of heart-related issues. This may also be helpful in reducing the perception and reaction to the pain. Provide the patient with a sense of control on the conditions, and enhance the positive or favourable attitude (Tobin, 2010). 

Third intervention

After providing the emergency interventions some of the exercises can be applied in the daily life of Mr Jon. Yoga might be a beneficial activity in reducing the pain associated with angina. Chest pain or chest tightness sometimes happens because of the gastrointestinal issues, in which yoga might be a gold standard approach as it helps in decreasing the chest tightness through opening the, stretching and expanding the chest. It addresses problems like poor gestures, a strain of muscles unfavorable positions. Yoga improves the range of motion and helps in stretching the pectoral muscles and enhances the patient’s flexibility which ultimately eradicates the chest pain (Cramer, Lauche, Haller, Dobos, & Michalsen, 2015).

The excess blanked has been taken off, and skin condition has been checked. He is also provided with the face washer, and administered with intravenous ABX and gave nurses initiated 1g Paracetamol orally.

At the initial indication of chest pain, the patient should sit down and place a single tablet below the tongue or between the cheek and gum letting it liquefy. The medicine is generally absorbed instantly through the coating of the mouth.  The patient should not chew or engulf the pill and should not eat, drink or smoke while the medicine is in the mouth. The effects of this drug commonly start appearing in one to three minutes. If after five minutes the patient does not feel the relief of pain, another tablet should be administered (Oliver, Kerr, & Webb, 2009).

Treatment of Angina

GTN works in two different ways; it extends the blood vessels in the body by causing them to broaden and this decrease the pressure on the heart, allowing it to pump the blood easily around the body, which ultimately increases the blood flow to the heart muscle. These effects of GTN also fulfill the oxygen requirements of the heart (Fan, Mitchell, & Cooke, 2009). 


Side effects associated with sublingual Glyceryl Trinitrate include trouble in breathing, headaches, change in heart rate, seizers, extreme sweating, blurred vision, pale and clammy skin, dizziness and fainting, nausea and vomiting, and flushing (Fan, Mitchell, & Cooke, 2009).

The contradiction of this particular drug includes hypersensitivity to the active constituent, to other nitro complexes, Patients treating with phosphodiesterase type five inhibitors such as sildenafil, vardenafil, and tadalafil.  Angina occurs due to the hypertrophic obtrusive cardiomyopathy as it might overstress outflow hindrance, the individual with possible enhanced intracranial stress such as cerebral hemorrhage or head trauma, marked anemia, closed angle glaucoma (Lamey, & Lewis, 2013).

Sublingual Glyceryl Trinitrate is the effective drug that can provide relief in angina instantly, therefore patients should be asked to keep this medicine with them all the time. The pain associated with the angina is not reduced even after taking sublingual Glyceryl Trinitrate; they should call for the ambulance immediately. A patient needs to keep the tablets beneath the tongue and should not engulf it instantly (Fan, Mitchell, & Cooke, 2009).

This particular test notes the electrical indications of the heart and diagnoses any abnormality of the heart like arrhythmias or display ischemia. The ECG results are mostly normal between the attacks, throughout the attack, there might be a transient (Cademartiri, et al., 2009). The ECG interpretations of Mr Jon indicate that the new horizontal or the descending ST depression is equal to or higher than 0.05 mV and the T inversion is higher or more than 0.1 mV in in the two different contiguous leads with the pro-eminent R wave or the R/S ratio is less than one. The ST section and the initial half of the T-wave are principally regular. At its highest the T-wave creates a sharp >90° turn, and its fatal portion is negative.  ECG (monitor strip, lead II): existence of a big ST segment raise with a positive T wave. ECG tracing in the one lead exposed a great elevation of ST segment. Evocative of acute myocardial infarction is detected in the ECG findings. The interpretations should be recorded in the patient’s record sheet and the unstable and abnormality of QRS complex and other waves must be reported to the physician. While recording the interpretations the help of ECG technician should be taken. The discussion should be done between the nurses and other the health care team assigned to Mr Jon and treatment should be fowled accordingly 

Lifestyle Changes to Manage Angina

References

Brown, J. P., Clark, A. M., Dalal, H., Welch, K., & Taylor, R. S. (2011). Patient education in the management of coronary heart disease. Cochrane Database of Systematic Reviews, (12).

Cademartiri, F., La Grutta, L., Palumbo, A., Maffei, E., Martini, C., Seitun, S., ... & Mollet, N. (2009). Computed tomography coronary angiography vs. stress ECG in patients with stable angina. La radiologia medica, 114(4), 513-523.

Cramer, H., Lauche, R., Haller, H., Dobos, G., & Michalsen, A. (2015). A systematic review of yoga for heart disease. European journal of preventive cardiology, 22(3), 284-295.

Fan, M. I., Mitchell, M., & Cooke, M. (2009). Cardiac patients' knowledge and use of sublingual glyceryl trinitrate (SLGTN). Australian Journal of Advanced Nursing, The, 26(3), 32.

Kones, R. (2010). Recent advances in the management of chronic stable angina I: approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities. Vascular health and risk management, 6, 635.

Lamey, P. J., & Lewis, M. A. O. (2013). Buccal and sublingual delivery of. Routes of Drug Administration: Topics in Pharmacy, 2, 30.

Nezamzadeh, M., Khademolhosseini, S. M., Mokhtari Nori, J., & Ebadi, A. (2012). Design of guidelines evidence-based nursing care in patients with angina pectoris. Iran J Crit Care Nurs, 4(4), 69-76.

Norton, C., Georgiopoulou, V., Kalogeropoulos, A., & Butler, J. (2011). Chronic stable angina: pathophysiology and innovations in treatment. Journal of Cardiovascular Medicine, 12(3), 218-219.

Oliver, J. J., Kerr, D. M., & Webb, D. J. (2009). Time?dependent interactions of the hypotensive effects of sildenafil citrate and sublingual glyceryl trinitrate. British journal of clinical pharmacology, 67(4), 403-412.

Oriolo, V., & Albarran, J. W. (2010). Assessment of acute chest pain. British Journal of Cardiac Nursing, 5(12), 587-593.

Rodrigues, C. G., Moraes, M. A., Sauer, J. M., Kalil, R. A. K., & de Souza, E. N. (2011). Nursing diagnosis of activity intolerance: clinical validation in patients with refractory angina. International Journal of Nursing Terminologies and Classifications, 22(3), 117-122.

Samim, A., Nugent, L., Mehta, P. K., Shufelt, C., & Merz, C. N. B. (2010). Treatment of angina and microvascular coronary dysfunction. Current treatment options in cardiovascular medicine, 12(4), 355-364.

Tarkin, J. M., & Kaski, J. C. (2013). Pharmacological treatment of chronic stable angina pectoris. Clinical medicine, 13(1), 63-70.

The, S. C. O. T. (2015). CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. The Lancet, 385(9985), 2383-2391.

Tobin, K. J. (2010). Stable angina pectoris: what does the current clinical evidence tell us?. Journal of the American Osteopathic Association, 110(7), 364.

Veeram, S. R., Reddy, M. D., Harinder, R., Singh, M. D., & Reddy, V. (2010). Chest pain in children and adolescents. Pediatrics in review, 31(1), e1-e9.

Zetta, S., Smith, K., Jones, M., Allcoat, P., & Sullivan, F. (2011). Evaluating the angina plan in patients admitted to hospital with angina: a randomized controlled trial. Cardiovascular Therapeutics, 29(2), 112-124.

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