Holistic Care Plan For A Patient With Unstable Angina - Case Scenario Analysis

Mr. Frank Jura is a 54 year old male, currently admitted to the cardiac unit in response to an exacerbation of his unstable angina.  Mr. Jura also presents with uncontrolled Type II diabetes, hypertension, and is currently obese.

As a pregraduate PN student on the unit, you are assigned to Mr. Jura’s care for the duration of your shift.  You have negotiated the plan of care with your RN preceptor (who is also assigned to Mr. Jura), and divided the responsibilities of his care for the remainder of the 12-hour shift.  

After completing your AM vitals, you notice that Mr. Jura’s blood pressure has been hovering just above high-normal range (around 145/90) as long as he has been admitted.  Curious at this trend, you examine his medication administration record and note that he is currently prescribed the following cardiac related medications/treatments:

• Ramipril 2.5mg PO OD
• Metoprolol 100 mg PO BID
• Hydrochlorothiazide 20 mg PO OD
• Transderm nitropatch 0.2 (0.2 mg/hour) – apply patch at 0800 and remove at 2000
• Nitrospray,1 spray (0.3-0.6mg) SL q5 mins up to 3 times; use at first sign of angina

You inform your preceptor of your findings regarding his elevated blood pressure.  In response, your preceptor states:

 “Ah well, the poor guy is probably nervous….you know, being in the hospital and all.  I’ll just pop a PRN Ativan into his AM meds and that should help with his elevated blood pressure.”

Select one case study from the above listing, and complete the assignment focusing upon the following:

1. Deconstruct the case narrative, exploring the scenario from both the nursing, health and psychosocial perspectives.

2. Generate relevant and timely actions and recommendations to assist the patient (and their family) in the situation to obtain the highest level of wellness possible. 

3. Discuss your process of finding, retrieving, and analyzing best practice information to develop care plan for the patient and their family in the given case narrative.

4. Include discussion of at least one College of Nurses of Ontario Practice Standard or Guideline (http://www.cno.org/learn-about-standards-guidelines/publications-list/standards-and- guidelines/), and how the Standard or Guideline is relevant to the case scenario.

Interpretation of initial case information

In nursing profession, professionals are liable for a holistic well being of the care user. While ensuring the holistic well being of the patient, nurse should understand the patient’s current needs and should prioritize these needs based on the urgency. In this context, diagnosing patient’s each symptom and vital signs are crucial for improving the overall health issues of the patient (Carpenito, 2012). The nurse is liable to act as a communication bridge between the patient and the doctor, she needs to communicate thoroughly with the patient for identifying patient’s health needs and convey it to the multidisciplinary care team for the patient, for developing suitable care plan for the patient, which maximizes the positive health outcomes of the patient (Hamm et al., 2011). In this assignment, a particular patient’s case would be demonstrated and analyzed for identifying his care needs and providing recommendation for his well being through a systematic manner.

In this case scenario, the key focus is a 54 years old male, named Mr. Frank Jura, who have been admitted to the cardiac unit, upon experiencing an exacerbation of an unstable angina. In addition, by reviewing his previous health history, it has been revealed that he is also experiencing with uncontrolled type II diabetes, hypertension and obesity. In addition, through his admission in the health care centre, it has been revealed that his blood pressure was slightly high from the normal range, i.e. 145/90 mmHg. Thus, he needs continuous monitoring for his condition (Hamm et al., 2011). Although the practice nurse has suggested that the high blood pressure might be due to anxiety and stress in the hospital environment.

Therefore, analyzing Mr. Jura’s case, it has been revealed that the patient has several issues, which are needed to be prioritized in an urgent basis. On the other hand, it has also been revealed that each of his symptoms and previous health history has a strong association. For instance, Mr. Jura’s history of Type II diabetes, hypertension and obesity are the key risk factors for elevating the risk of cardiovascular complications, including short or long term angina, stroke and myocardial infarction (Lilley et al., 2011). Moreover, in response to his constant high blood pressure, the practice nurse depicted that he may be anxious and stress in the hospital environment; however stress and depression are also consequences of type II diabetes, hypertension and obesity. Therefore, to ensure Mr. Jura’s holistic well being, it is important to mitigate his health issues from the root, prioritizing his previous health history, i.e. type II diabetes, obesity and hypertension.

Mr. Jura’s medication chart includes Ramipril, metropolol and Hydrochlorothiazide which are used for treating his high blood pressure; Transderm nitropatch and Nitrospray, which are administered for controlling angina or chest pain. Therefore, it has been revealed that Mr. Jure has been administered with medications for treating his continuous high blood pressure, but it has been also revealed that no medication or therapies are provided to Mr. Jura for controlling his high blood sugar, type II diabetes as well as obesity (Potter & Perry, 2014). Therefore, these would be the key focus in Mr. Jura’s holistic care plan, along with the current symptoms. In addition to that, his alleviated blood pressure is also indicating stress and anxiety, which also increases the risk of chronic depressive symptoms to be developed soon. In this context, psychological and emotional interventions should also be included in the holistic care plan for Mr. Jura (Barr et al., 2011).

Development of therapeutic goals

According to the case scenario, the following goals have been developed to meet Mr. Jura’s current health care needs:

• To establish a positive therapeutic relationship
• To promote his healthy lifestyle to control obesity
• To monitor and control high blood pressure
• To reduce the risk of cardiovascular issue
• To reduce the risk of developing depressive symptoms

To achieve these goals, co-operation of patient, patient’s family and the members of multidisciplinary team is crucial and it is the initial step in the procedure (Sattelmair et al., 2011). In addition, while implementing the goals in the therapeutic plan, each goal should be assessed on the basis of SMART criteria, i.e. whether the goal is specific, measurable, attainable, realistic and time-specific or not. Development of potential goals helps to meet the expected therapeutic outcomes through a systematic way (Hamm et al., 2011).

According to the pre-existing literatures and evidence based processes, the following resources can be recommended for Mr. Jura’s well being:

• To establish a positive therapeutic relationship-It is most important step in ensuring patient’s well being. For this the nurse need to show respect, dignity, positive regards, genuineness and positive communication skills, to promote his understanding that his opinion is being valued in the health care context (Lunney, 2013). It would also develop a trust of the patient towards the patient and the health care system. The practice nurse depicted that Mr. Jura’s blood pressure is constantly high, due to the discomfort in the hospital environment, which would be reduced through a positive therapeutic relationship building with the nurse.
• To promote his healthy lifestyle to control obesity-Obesity is a chronic disorder that also enhance the risk of other diseases, as in Mr. Jura’s case, it is significantly related with his high BP and angina. For this, a health promotion would be arranged for Mr. Jura and his family members, where they would be provided with information regarding the importance of leading a healthy lifestyle (Wilkinson, 2011). In addition, the dietician would make a diet chart for him. For instance, the dietician would suggest him to avoid junk food, include more vegetables in diet. On the other hand, physical therapist would prepare an exercise schedule for him including aerobic exercise for reducing his weight. Weight management is crucial also for controlling progress of type II diabetes.
• To monitor and control high blood pressure-The nurse would continuously monitor his blood pressure level after a scheduled interval and would administer PRN Ativan for controlling BP. As it has been revealed that it may be resulted from stress, continuous emotional and mental support would be provided for making him familiar with the environment (Blais, 2015). In addition, nurse would give him relaxing massage; include several relaxing techniques like the acupuncture, meditation, yoga and music therapies for reducing his stress.
• To reduce the risk of cardiovascular issue- Continuous monitoring of Mr. Jure’s vital signs, signs of chest pain, high blood pressure are needed. For helping him with this, reviewing his previous health history, appropriate physical activities would be recommended, which would help him to keep his heart healthy, along with the healthy diet (Medlineplus.gov, 2017). High blood sugar level significantly enhances the risk of thrombosis in blood vessel, enhancing the cardiovascular risk, thus, Mr. Jura should be administered with appropriate medication or controlling blood sugar level; for instance, extracellular intravenous insulin, if required.
• To reduce the risk of developing depressive symptoms- To reduce the risk of psychological issue development, counseling is one of the key therapies. According to the principle of person-centered approach, his family members would also involved, which would help Mr. Jura to have a homely environment, thereby motivating him to achieve the therapeutic goals (Tabloski, 2013).

According to the “College of Nurses of Ontario Practice Standard or Guideline” establishing nurse-patient relationship is crucial for ensuring patient’s well being and a nurse should demonstrate the standard by establishing a positive nurse-patient relationship, which is related to Mr. Jura’s case scenario (College of Nurses of Ontario, 2015).

Conclusion and Reflection

In conclusion, demonstrating and analyzing Mr. Jura’s case, it has been revealed that nurses’ responsibility is to maintain standards in practice, while promoting the maximum well being of the patient. In addition, the case study assignment helped to understand the importance of holistic diagnosis and assessment for identifying the key causes of illness (Hamm et al., 2011). I would use the acquired knowledge in further practical cases, for improving the relationship with the patient, by identifying the patient’s needs in logical and empathic way. From Mr. Jura’s case, it has also been revealed that dealing with CVD patients, it is important to monitor patient’s vital signs thoroughly, as these can fluctuate significantly, thus, nurse should be aware of any kinds of patient’s altered symptoms. In addition, CVD patients also need mental and emotional support to cope with the chronic disorder, which should be promoted by the nurse (Barr et al., 2013).  

Reference List

Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., ... & Coursin, D. B. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical care medicine, 41(1), 263-306.

Blais, K. (2015). Professional nursing practice: Concepts and perspectives. Pearson. Medlineplus.gov, U. (2017). Unstable angina: MedlinePlus Medical Encyclopedia. Medlineplus.gov. Retrieved 4 June 2017, from https://medlineplus.gov/ency/article/000201.htm

Carpenito, L. J. (2012). Handbook of Nursing Diagnosis (14 ed.). New York: Wolters Kluwer Health. 

College of Nurses of Ontario. (2015). Practice Standards: Medication. Retrieved from https://www.cno.org/en/learn-about-standards-guidelines/standards-and-guidelines/

Hamm, C. W., Bassand, J. P., Agewall, S., Bax, J., Boersma, E., Bueno, H., ... & Ohman, M. (2011). ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European heart journal, 32(23), 2999-3054.

Lilley, L., Harrington, S., Snyder, J., Swart, B., & Savoca, D. (2011). Pharmacology for Canadian Health Care Practice. Toronto: Mosby Elsevier. 

Lunney, M. (Ed.). (2013). Critical thinking to achieve positive health outcomes: Nursing case studies and analyses. John Wiley & Sons.

Potter, P., & Perry, A. (2014). Canadian Fundamentals of Nursing (5 ed.). Toronto: Elsevier Canada.

Sattelmair, J., Pertman, J., Ding, E. L., Kohl, H. W., Haskell, W., & Lee, I. M. (2011). Dose response between physical activity and risk of coronary heart disease. Circulation, CIRCULATIONAHA-110.

Tabloski, P. A. (2013). Gerontological nursing. Pearson Higher Ed.

Wilkinson, J. M. (2011). Nursing process and critical thinking. Pearson Higher Ed.