Pathophysiology Case Study: Chest Pain

Assignment essay

Mr George Orwell is a 68-year-old male residing in rural South Australia.  His deceased wife, Heather had terminal breast cancer. Mr. Orwell arrived at, and was admitted to, the Farquharson Memorial Hospital with chest pain. His admission assessment verified he was alert and orientated with unremarkable vital signs. Pre- admission conditions include pitting oedema in both legs prior with an associated diminished pedal pulse, he suffers breathlessness on exertion and has uses an angina relieving spray on average about 4 times a day.  Evidentially, the purpose of the case report is provide information about the pathophysiology of his condition, two nursing problems and required interventions to assist successful management in his respite period as well as the plan for discharge.

The cardiovascular system responsible for the transport of blood throughout the body, consists of the heart, blood and vessels which including arteries, capillaries and veins (Williams & Bradford, 2015).  The coronary arteries are vital to the hearts function as they deliver a constant supply of blood to heart muscle (Williams & Bradford, 2015).  Coronary circulation provides oxygenated blood throughout the myocardium and returns deoxygenated blood to the right atrium via the coronary sinus (Williams & Bradford, 2015). The two main coronary arteries are the first branches of the ascending aorta, just outside the left ventricle. The left coronary artery divided into the anterior descending and the circumflex arteries providing blood for the left atrium and the left. The right coronary artery supplies the ventricle and part of the posterior wall of the left ventricle as well as the atrioventricular node of the cardiac conduction system (deWit, 2013).  The thin walled small diameter of the coronary arteries makes them vulnerable to the accumulation of fatty plaque build-up that can significantly restrict blood flow through the arteries leading to rupture of the fragile walls a process known as arteriosclerosis, involving clotting causing obstruction of a coronary artery (deWit, 2013).

Stable angina, a chest pain or discomfort due to coronary heart disease heart muscle, occurs when the heart muscle lacks oxygenated blood (Cassar el at, 2009). Likely sensations include pressure or squeezing in the chest. This can also manifest in the shoulders, arms, jaws or back. Angina pectoris occurs when one or more of the heart arteries are narrowed or blocked a condition called ischemia (Cassar el at 2009).  Unstable angina caused by acute coronary syndrome, produces unexpected chest pain, normally commencing during rest, (Fladseth el at, 2018).  This arises due to ischemia.

Hypervolemia is condition of having too much water in your body. The fluid can damage your health. The signs of hypervolemia can be swelling, discomfort in the body, swelling can be edema and usual in the feet, ankles, wrists and face. High blood pressure caused excess fluid in the bloodstream (Kreimeier, 2000). Shortness of breath caused by extra fluid entering your lungs and reducing your ability to breathe normally.

There are many nursing issues that are associated with this disease such as anxiety, pain management, education of patients and their families and falling risk.  A major problem with nursing a patient with coronary artery disease could be the onset of a myocardial infarction event (MI), commonly known as a ‘heart attack’.  This a major life-threatening event that can lead to cardiac arrest and must be addressed by efficient and thorough nursing intervention.  With respect to the context of the case study patient of concern, George, the admission report shows that currently the vital signs show no significant irregularities and hence the patient may be at a stage of partial coronary blood flow restriction rather than arteriosclerosis onset as determined by further examination (Maryati & Dioso 2017).  However, if fatty plague is an issue then arteriosclerosis leading to an MI event could occur at any time.  One of the first major nursing interventions is to assess the vital signs of the patient as the signs of a MI incident can occur with clear irregularities in particular signs. Palpitations and irregularity of heart beat as symptoms of a MI will show up in pulse readings, and associated conditions such as dangerously low blood pressure or hypertension can occur in blood pressure reading, shortness of breath and other breathing irregularities can occur in respiration rate readings (Maryati & Dioso 2017).  Low oxygen saturation due to failing heart function in a MI could occur in O₂ saturation readings. This is required on an hourly basis as the event could occur at any time after initial presentation (Williams & Bradford, 2015).  Often the patient is placed on a cardiac monitor to determine if life-threatening dysrhythmias have occurred during an MI.   Heart failure, causing low cardiac output, has an adverse affect on vital signs with specific affects on the different measurements. Therefore, the nurse ought to monitor the vital signs, note the changes-likely subnormal, record, adjust the nursing care plan and report the abnormality to the physician (Park et al 2017).  The pulse rate is likely to be high, as a compensatory mechanism to low cardiac output and hypoxia. The volume, (pressure of the pulse) is likely to be shallow, a clear consequence of low cardiac output. Furthermore, the patient presents with arrhythmia, indicating uncoordinated cardiac output by poor performing heart. The blood pressure is likely to be subnormal (Park et al 2017). While the systolic pressure is designated to be lower than normal, the diastolic pressure may be disproportionately elevated , thus signifying circulatory congestion due to poor venous return by the weakened heart. The patient’s saturation may be lower than normal, i.e. less than 90%, following low cardiac output with low oxygen distribution and pulmonary congestion. The respiration may be fast to compensate for hypoxia, yet conversely shallow due to lack of bodily energy (Williams & Bradford, 2015).

 One possible likely intervention could be a diet that reduces the sodium (salt) level retained in the patient’s system.  The reason for this is that high salt levels can increase the risk of cardiac events such as MI.  It has been known for quite some time that high salt intake leads to high blood pressure that in turn is a major direct cause of coronary heart disease, (Strazullo, D’Elia, Kandale & Cappuccio, 2009).   Recent studies have indicated that high salt intake contributes to the development of left ventricular hypotrophy (LVH) , a thickening of the muscle wall of the heart’s left ventricle, independently of blood pressure ( Du Calair, Ribstein & Mimran, 2002 ;cited in Strazulla et al, 2009).  In turn LVH can contribute to coronary heart disease and its events, including MI.  George Orwell has a medical history of hypertension and obesity and hence may have had diety high in salt intake in past.  Though his admission blood pressure may be normal it could have resulted from a hypertensive state and a possible serious heart condition to yet be diagnosed. It is likely that a low salt diet will aid his hypertension and lower his risk of developing LVH and in turn lower his risk of short and longer term MI ( Du Calair, Ribstein & Mimran, 2002 ;cited in Strazulla et al, 2009).  Since George is of significant risk of MI, he is likely prescribed a blood thinning medication such as aspirin.  Management of correct dosage and timing of dosage and its correct ingestion by the patient is of primary responsibility of the RN who should also monitor the patient for the onset of potential side affects of this medication such as gastrointestinal bleeding, headache and constipation.  In the case of significant side-effects apparent the medication and/or its dosage may need to be changes.

Another nursing problem is fluid overload. Some patients with the pulmonary congestion develop this  rapidly because of a sudden increase in left ventricular (LV) filling pressures caused by conditions such as acute myocardial ischaemia or uncontrolled hypertension (Pellicori, 2015).  (‘flash’ pulmonary oedema).  Pulmonary oedema, (PO) the build up of fluid on the lungs is associated with coronary heart disease.  Conditions such a LVH, congestive heart disease or a MI could lower the ability of the ventricles of the heart to circulate blood through the blood capillary network in the lungs.  The stagnation of blood in this network causes build up of pressure that forced blood fluid into the interstitial tissue of lungs (Pellicori, 2015).

A possible nursing intervention associated with onset of PO is to supply adequate oxygen to the patient, usually by an appropriate mask.  This will improve the supply of oxygen to the heart and assist in gas exchange affected by the presence of fluid in the lungs (Pellicori, 2015). The nurse needs to monitor the supply of oxygen at an appropriate continuous rate and that the patient is fitted correctly with the mask (Pellicori, 2015). A medication such as frusemide may be prescribed as this not only treats the pulmonary oedema build up directly but also acts to relieve hypertension.  This could be given by injection or possibly as an IV.  Nursing staff could be responsible for the administration of injections at the right times with correct dosage or set up and monitoring of the IV drip, replacing bags as needed.  Nurses also should be vigilant as to the possibility of side affects such as ringing in the ear, loss of hearing and light headiness known to be associated with frusemide (Sanmuganathan, 2001).

Discharge planning is a process in which a patient is educated to help care for themselves at home safely and also address any questions or concerns to them. It also assists patients with communication with any caregivers and primary care providers about how best to manage their chronic needs once they have left hospital, (Mennuni at el 2017).

Generally discharge planning has a multidisciplinary approach when several different specialist health industry professionals collaborate together. For a cardiac patient like Mr. Orwell the specialists may comprise of the GP, cardiologist, heart failure nurse, home carer, internist, dietician, pharmacist, social worker, psychologist, physical therapist and geriatrician but its composition is ultimately dependent on the local health care system, (Jaarsma, 2005).

The role of the RN for a coronary disease outpatient includes essential monitoring of vital signs so that they remain normal to allow settling back into an at home life., they can also play a large role in informing a heart disease patient how to manage their condition in a home life, using various techniques such as discussion and repetition of facts to assist them remember important details for management (Riley, 2015).. With respect to sufferers of acute PO, helping them with medication such as spinoralactone dosage and reasons they must take once in home life as well as key monitoring of blood pressure and renal function could directly involve the nurse or assigned as part of the patient education (Sanmuganathan, 2001).

A patient presents to the hospital with a history of coronary heart disease and risk factors for worsening of this condition.  The pathology of this condition is associated with blockage of vessels supplying arterial blood the vital heart muscles responsible for passage of circulating blood in a health patient. Nursing problems of this condition are MI and PO, ischemia and build-up of fluid in lungs respectively. The RN is directly responsible in these events.  An intervention for MI is vital sign monitoring as declining quality of vital signs is associated with MI, including low pulse and blood pressure and shallow short breathlessness.  Key medication may be the effective blood thinning aspirin and the monitoring of occurrence of any of the undesirable side-effects of its use.  Similarly, oxygen supplied by a mask could be a suitable intervention of someone with acute PO.  Follow up medication could be frusemide.  Discharge is multiteam process where careful planning occurs for successful return of patient to home life.   The RN on this team could be responsible to successfully educating the patient for home life adaptability with medication and any caring regimes required.

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