{Author Name [first-name middle-name-initials last-name]}
{Institution Affiliation [name of Author’s institute]}
Health History and Physical Examination
A 50 years old American Male comes to the hospital with angina-like symptoms.
Subjective Data
Demographic data: There exists a risk of cardiovascular ailments or malfunctioning. The patient is an IT professional with long sitting schedules.
Reason for care: The patient was admitted to the emergency ward due to the severity of the pain 6 days back.
Present illness: Currently facing chest congestion with breath shortness and exertion, with heavy perspiration, recommended cardiac catheterization.
Perception of health: Patient is an educated, independent and sincere individual who thinks that he is healthy and with several precautions he will overcome the current situation. He is little worried about his excessive weight and high blood pressure problem.
PMH: Following the symptoms observations and evaluation the patient was recommended for urgent stent placement five days back. The patient came to the hospital six days back with crushing chest pain for a duration of five hours along with the feeling of tightness of chest, shortness of breath and diaphoretic. Based on the intensity of the symptoms he was shifted to the intense care unit of the cardiovascular department where he was recommended for cardiac catheterization. According to subjective data, the symptoms has been a year old that used to become negligible after some rest. Though patient had observed that he was not able to conduct laborious work or long sittings that exacerbated the chest pain with more frequency. Once he was prescribed some blood pressure medication that he could not continue properly. He also used to be a chain smoker but not currently. The pain usually starts from the substernal area reaching up to the jawline. The patient was unaware of the severity of his condition.
Family medical history: The patient’s family showed a positive history as his father was a heart patient.
ROS: The other systems were functioning properly, except a little high blood pressure.
Developmental considerations: Patient was concerned regarding post-surgical impacts that will impact his lifestyle.
Cultural considerations: The patient is not so religious and comfortable with the healthcare professional with any background, his only concern is quality care and fast recovery.
Psychosocial consideration: Patient has been less social due to his hectic work schedules, though he is concerned and understands that the surgical procedures will impact his social activities.
Presence or absence of collaborative resources: Patient is well settled individually with strong family support from his wife and a son. Though he is unaware of community resources as well as the healthcare system.
Objective data
Vital signs
Slightly high BMI, and associated risk factors observed in the patient are:
High blood pressure
Obesity
Smoking habits
Positive family history
Physical Assessment results:
High Cholesterol (190) & high Triglycerides (250)
HEENT: Normal
Neck: Normal
Respiratory system: Condition of dyspnea present. CXR demonstrate slight hyperinflation of lungs that may be due to previous smoking habit.
Cardiovascular system: Remained asymptomatic for last few years, until the pain, got severe. Palpitations present at a various rate that indicates cardiac dysrhythmias. Angina results from oxygen deficiency to the cardiac tissues that may be due to several reasons. Patient has high cholesterol that is the reason of capillary constriction and reduced blood supply.
Neurological system: Existence of dizziness or vertigo shows reduced perfusion to the brain. Gastrointestinal system: No complaints related to gastrointestinal system.
Musculoskeletal system: Fatigue is also a common problem is such patient if anemia exists. In this case, fatigue was not observed.
Peripheral vascular system: Cyanosis was observed that indicates tissue discoloration due to cardiac involvement and lacked oxygenated blood. The presence of edema also indicates elevated venous pressure. Pulmonary hypertension, hyperventilation, and orthostatic hypotension may be a reason of syncope.
Integumentary system: Presence of xanthelasma on the patient’s eyelid can also be a good clue for high cholesterol and underlying heart problem.
The goal of this holistic care plan is to reduce the incidence and severity of further anginal attacks, to stop the additional development of underlying disease to avoid more complications. The aim of this intervention will be to design and collaborate on a self-care plan that will involve patient as well as his family and friends (Doenges, Moorhouse & Murr, 2016). Planning activities to lower such angina episodes in future is the primary agenda. Based on the health history and physical assessments and findings the individual may be educated on certain essential points that may prevent a further incident of stable angina. The primary educational point is changing the lifestyle. Secondly, the patient should be educated how to monitor his blood pressure levels, cholesterol levels, and blood sugar levels (Lee & Daugherty, 2016).
Lifestyle adjustments will impact the frequency, severity and chances of angina attacks in future and it may also control the progression of the disease. The changes in lifestyle may include changes in diet and exercising schedules. A diet rich in whole grains, vegetables and fruits can improve the condition. Such habits help in preventing chronic conditions like hypercholesterolemia, high blood pressure, and diabetes. The patient does not have diabetes but has positive family history of cardiac problems and high blood pressure with weight. Such conditions increase the risk of developing diabetes that can further worsen the symptoms.
Self-care will help the patient to be updated and limit the conditions that can worsen the diseases such as hypotension increases the risk of clotting while hypertension elevates the stress on the spot. Maintaining adequate oxygen supply for reducing the myocardial workload prevents the risk of organ failure (Fredericks et al., 2010).
According to Lewin little evidence support the beneficial impacts of lifestyle change though it has directed towards better obedience to self-care management and enhanced quality of life with lowered hospitalization episodes and mortality rate (Lewin et al., 2002). Another randomized controlled trial evidenced that changing lifestyle along with perception regarding disease can impact the disease outcomes (Petrie et al., 2002).
Reflection
The patient was educated and aware of his conditions and wanted to recover fast. I hope that he will follow the given educational tips and recommendations. I was expecting this interaction more interactive as compared to retrieved data because the patient was educated and independent but a little unaware of resources. His less social active behavior might be a reason.
The patient was confident and had a perception of being completely healthy which was the main barrier while executing the complete evaluation. This negligence for last one year had led him to this condition. To overcome this barrier first I built a good rapport with the patient through understanding his perceptions and then I described him his complete condition.
Not any significant unanticipated challenges I encountered during this assignment. The best part of this assignment was that the patient was educated, independent, self-aware and ready to change which facilitated the whole intervention with full co-operation.
After being open, patient provided all the possible information. Not much data could be retrieve regarding family history and his spiritual beliefs.
Next time I will prefer being more specific, and try an open-ended question-based interaction that may extract those data which could not retrieve this time.
References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual: planning,
individualizing, and documenting client care. FA Davis.
Fredericks, S., Beanlands, H., Spalding, K., & Da Silva, M. (2010). Effects of the characteristics
of teaching on the outcomes of heart failure patient education interventions: a systematic
review. European Journal of Cardiovascular Nursing, 9(1), 30-37.
Lee, E., & Daugherty, J. (2016). An Educational Plan for Nursing Staff in the Procedural
Treatment Unit of the Sulpizio Cardiovascular Center. Journal of PeriAnesthesia
Nursing, 31(2), 134-145.
Lewin, R. J. P., Furze, G., Robinson, J., Griffith, K., Wiseman, S., Pye, M., & Boyle, R. (2002).
A randomised controlled trial of a self-management plan for patients with newly
diagnosed angina. Br J Gen Pract, 52(476), 194-201.
Petrie, K. J., Cameron, L. D., Ellis, C. J., Buick, D., & Weinman, J. (2002). Changing illness
perceptions after myocardial infarction: an early intervention randomized controlled trial.
Psychosomatic medicine, 64(4), 580-586.
