NUR3005 Chronic Illness Management

Introduction

Chronic condition are diseases that last more than three months and cannot be prevented by vaccines or relieved by medication. This kind of diseases tend to occur in adults and cannot be cured or prevented in anyway. The common type’s chronic illness include arthritis, cancer, stroke, heart diseases and diabetes (Rosamond, Flegal, Furie, & Greenlund, 2012). Chronic diseases are the leading cause of fatal burden of disease in most age group and sex groups and the leading cause of illness, disability and death in Australia. The main objectives of this essay will include pathophysiology of the chronic illness, how the signs and symptoms affect a person’s life and lastly role of a nurse in delivering inter professional person centered care, promoting self-management and response to changing patient needs. The chosen chronic condition is myocardial infarction (MI) in women of age group 60-70 years.

Myocardial infarction

Myocardial infarction is a permanent damage to a part of the heart or the myocardial tissue that is caused by ischemia and hypoxia eventually necrosis of the myocardial cells. Hypoxia is as a result of blockage of the coronary arteries that supply blood to the heart. This condition is mostly caused by ecstasy of an atherosclerotic lesion found in the coronary artery. This causes the thrombus to block the artery, preventing it from supplying blood to some regions of the heart. Myocardial infarction is one of the leading killer in Australia. Women of age 60-70 years are at high risk of getting myocardial infarction than men of their same age. A woman’s heart may resemble a man’s heart but there are significant differences. For example, the interior chambers of a woman’s heart are usually smaller. The walls that separate these heart chambers are also thinner. Her heart pumps blood faster than a man’s expelling 10 percent less blood at each squeeze. During stress the pulse rate of a woman rises pumping more blood as compared to a man whose blood vessels of the heart constrict elevating the blood pressure. This differences matter because gender plays a grate part in the symptoms, therapy and consequences of coronary artery disease (Coventry, Finn, & Bremner, 2014).

Some conditions that only affect women increases the risk of coronary artery disease which is the leading cause of MI. they include high blood pressure during pregnancy, endometriosis, diabetes, and polycystic ovary disease. Estrogen provide protection in women from heart diseases until after menopauses, when estrogen severely decreases. The reason why there is a higher rate of women dying of MI is because coronary artery disease is sometimes hard to diagnose. Coronary artery disease mostly affects the small arteries which cannot be checked clearly on an angiogram.

Development of atherosclerosis

Atherosclerosis is a disease caused due to disturbance of lipid and protein metabolism with formation of atheroma in the large and medium sized blood vessels (Virman, Burke, & Farb, 2012). Risk factors of atherosclerosis include obesity, smoking, high arterial blood pressure, hereditary and ethnic factors and hormonal factors. Atherosclerosis starts by accumulation of lipid known as a fatty streak on the endothelial layer of the artery. As the disease progresses there is a chronic inflammation which cause the fatty streak to develop to fibro atheroma (Simoons & Saelman, 2014). The fatty streak is composed of smooth muscle cell, a fibrous connective tissue and fats. Vigorous blood flow due to the thickening of the vessel hinder the secretion of nitric oxide a strong vasodilator and provoke attraction of inflammatory cells to the site (Libby, 2015). T cells and monocyte attach to the endothelial cells and begin to take up the oxidized low density lipoprotein changing their name to foam cells. The T lymphocytes also secrete cytokine which cause smooth muscle cell to migrate from the media to the intima which proliferate under the influence of growth factors (Rodriguez, Agostoni, & Garcia, 2013). The collection of lipids, smooth muscle cells and the growing lesion decrease the lumen of the artery. Once the plaque raptures due to increase in blood pressure, it may activate thrombosis by triggering platelet production (Pedrigi, Silva, & Bovens, 2014).

Myocardial cell death

Platelet production may trigger formation of blood clots which may travel to the coronary arteries and cause blockage leading to a decrease in oxygen supply to the tissues. Ischemia develops due to deprivation of myocardial cells with oxygen, the cells are damaged, and after some time due to continuous lack of oxygen leads to infarction or the cell death

Signs and symptoms

They include fatigue, weakness, shortness of breath, abnormal heart beats, sweating, anxiety, feeling of indigestion, abnormal headache, nausea and vomiting, sudden chest pain that is felt behind the sternum and sometimes travels to the left arm or the left side of the neck.

How the signs and symptoms impact a person’s life

The signs and symptoms resulting from MI may affect an individual’s lifestyle that is what we eat, how we exercise and the kind of activities done during the holiday. After the condition has been stabilized the individual will be forced to attend cardiac rehabilitation center. The individual is taught on how the can recover quickly and begin a new life (Abreu & Seidi, 2014).

Long term effects of MI may affect the relationship between family and friends. It may not be easy to express your feelings on the condition you have to people even if how close they are to you. Individuals affected tend to experience a lot of different emotions since the community reacts differently and that goes for the family and friends (Scherer, Stumm, & Loro, 2013). Family members maybe scared of reemergence of the condition, get bored of taking care of you or feel frustrated that you are consuming much of the time due to the responsibility of helping

If an individual had recently had a heart surgery, she may be concerned with her sex life. Activities during sex may cause breathlessness or chest discomfort. Energy required during sexual activity is the same as the energy needed to walk about half a mile. This kind of activity may cause one to become tired and short of breath. For most heart patients the frequency and satisfaction of sex reduces significantly, the reduced libido is known to be caused by depression (Debusk & Robbert, 2102). The heart medication such as the diuretics and beta blockers reduce the desire in men and women and also cause erectile dysfunction in men. Lack of sexual satisfaction to the partner may lead conflicts which may lead to divorce.

The individual’s ability to go to work may be affected especially if it involves doing of hard tasks such as driving or on a construction industry. The individual may be forced to avoid hard tasks that may trigger pain or shortness of breath, hence one may be forced to quit the job which may lead to financial instability (MacDonald, Pulley, & Hein, 2015). The signs and symptoms of MI which may put the individual at risk include fatigue, breathlessness, and loss of consciousness. Jobs which are linked with safety issues such as operators of buses, ships and planes may put other individuals at risk incase this symptoms arises. Physical hazards such as intense heat or cold have increased the risk of cardiovascular issues since it increases the risk of ischemia in an individual with a history of coronary vascular disease. Other hazards such prolonged exposure to a noisy environment may trigger a blood pressure elevation.

Emotional impacts

Patients with MI frequently fear loss of their roles within the family and society.  The fear is that the condition may lead to death. Fear may lead to anxiety which may worsen MI. The other factor that may cause stress is financial problems, the individuals having resigned from the job due to his medical condition, may experience financial problem due to, billing of the hospitals and the buying of drugs with no source of income. The individual may feel like a burden to the family and friends and may be reluctant in asking for financial help. Many of the patients who have suffered from heart diseases are prescribed benziodiazepam after discharge from the hospital due to depression issues. Too much depression without treatment may lead to the patient committing suicide. Depression is thought to be brought by poor communication, that is family members cut contact with the patient hence the individual lacks a close person with whom he may share problems with. Wife’s who had their husbands in hospitals experienced depression this is because they faced lots of responsibilities such as hospital visits, extra house hold chores, and children responsibility.

Nursing management

1. Registered nurse responsibility for patient assessment

Clients with the following chief complaints demand for a prompt assessment, persistent shortness of breath, indigestion, chest discomfort and pain in the neck, jaw back and shoulders. If the symptoms are present, ECG and vital signs should be checked immediately and given to the physician on duty. The nurse should ensure that initial history is taken together with the assessment of current or past history of, medication use, nitroglycerine use to relieve chest discomfort, coronary artery disease, history of arrhythmia and risk factors which include family history of coronary artery disease, hypertension, hyperlipidemia and diabetes mellitus.

1. Nurses role in general treatment and intervention

     The client should be connected to a continuous cardiac monitoring. Immediately on the patients arrival to the hospital and initial assessment and a 12 lead ECG should be done. The results should be reported to the attending physicians for immediate interpretation. The objective of medical management is to reduce myocardial damage and prevent complication (Ricco, Sommaruga, & Casella, 2012). Morphine is administered to reduce pain and anxiety, ACE inhibitors are given, and they act by locking the conversion of angiotensin I to angiotensin II which reduces blood pressure. Thrombolytic are given so as to disintegrate thrombus in the coronary artery facilitating the flow in the coronary artery. The nursing intervention performed by registered nurse include, oxygen delivery alongside with medication treatment to help with relief of symptoms, recommend enough bed rest with the back raised to reduce dyspnea and chest discomfort, recommend for modifications of sleep positions often to help reduce accumulation of fluid in the lungs, peripheral pulse and skin temperature is frequently monitored,

Nurses role in discharge and homecare guidelines

1. Education

Controlling cholesterol abnormalities

The nurse should ensure that the client is educated on the effects of cholesterol in the body. The client should be able to distinguish between low density lipoprotein and high density lipoprotein. High density lipoprotein facilitate the use of cholesterol by transporting the low density lipoprotein to the liver where it’s digested and removed. Low density lipoprotein increases the formation of atherosclerosis on the arterial wall. The client is advised to have a fasting lipid profile performed at least once after every five years and also assessment of low density lipoprotein cholesterol level within sixty to three hundred and sixty five days after the event. The client is also advised on avoiding conditions such as physical inactiveness, obesity, diabetes, alcohol intake and high carbohydrate intake which may cause and increase in triglycerides. Management of triglycerides focuses on increased physical activity, weight reduction and administering medication such as fibric acids and nicotinic acids which lower triglyceride level that is above 500mg/dl (Gordon & Cooper, 2012).

Dietary measures

The nurse in charge should refer the patient to a registered dietitian, where he is advised on the kind of foods one should take and avoid. The client is enlightened on the importance of soluble dietary fibers which act by reducing the cholesterol levels in the blood. The client is educated on the mechanism of action of soluble fibers found in food such as fresh fruits, legumes, cereal grains which act by facilitating the excretion of metabolized cholesterol. The dietician provides the client recipes and cook books that consist of nutritional break down foods, label information of a healthy diet such as amount of fiber per serving, amount of total fat per servings, serving size expressed in house hold measures and lastly amount of saturated fat per serving (Ingram, & Mussolino, 2013).

Promoting physical activity

Nurses role include educating the client on importance of regular physical activity on health since it decreases the triglyceride levels and increases the high density lipoprotein level. The client is educated on 30minutes exercises that must be done three to four times a week. The nurse assists the client on setting achievable goals that is the client should start with activities that last for three minutes, the patient should first begin with a five minute warm up as they prepare the body for exercise (Moret, Rochedreux, & Lombrail, 2012). The client should also finish the exercise with a five minute cool down where they reduce the intensity of the work out hence a sudden decrease in cardiac output. Patients are advised to engage themselves in activities that interest them so as to get motivated to keep on working out. The client is advised to exercise in the early mornings when the weather is hot and humid and when the weather is cold to wear a layer of clothing. The nurse should inform the patient to cease any activity if they develop nausea, chest pain, dizziness, unusual shortness of breath and light headedness.

Promoting cessation of tobacco use

The client is educated on how cigarettes smoking adds to severity of coronary artery disease. First smoke inhalation raises the blood carbon monoxide level causing the hemoglobin which carries oxygen in the blood to readily combine with carbon dioxide rather than oxygen (Ralph, Paul, & Deesha, 2012). Decreased oxygen supply reduces the hearts ability to pump blood. Second, nicotine which is a component in tobacco, triggers the production of catecholamine’s which increases the heart rate and blood pressure. Nicotine causes the constriction of the coronary arteries. Third, tobacco use causes an increase in platelet production leading to a higher probability of thrombus formation. A tobacco addict is counselled, given medication and motivated to join support group. Clients are advised on the use of medications such as bupronin, nicotine patch which may help stop the use of tobacco (Stead, Buitrago, Preciado, & Sanchez, 2013).

Gender and estrogen level

Women are more likely to be affected with coronary artery diseases than men this is because women tend not to recognize the signs and symptoms early so as to seek medical assistance (Stramba, 2014). Women of age 55 years and above are recommended to seek hormone replacement therapy for menopausal women (Morley & Perry, 2013).

Most clients with myocardial infarction take nitroglycerine on a daily basis. The nursing role in such cases is educating the patients about the medication and how to take it. The client is instructed to make sure the mouth is moist and saliva is not swallowed until the nitroglycerine tablet is dissolved (Kaplan, Taber, & Davison, 2103). The client is advised on the storage condition of the drug, nitroglycerine is very unstable hence it should be in a dark container, nitroglycerine is volatile and can be easily be inactivated by light, heat and moisture therefore it should be renewed after every six months (Fye & Bruce, 2013). The client is informed that the drugs are only taken when the individual wants to do any activity that may produce pain such as sexual intercourse, stairclimbing and exercise. The client is advised to note how long it takes for the nitroglycerine to relieve discomfort. The patient is advised if the pain persists, emergency medical services should be called.

After the myocardial patient is free from symptoms, a rehabilitation program is initiated. The home care nurse helps the client with programming and follow up of appointments. The objectives of rehabilitation of clients with MI is to prolong and improve life. The main objective is to prevent the progression of atherosclerosis, promote the psychosocial status of the client and prevent any other cardiac event (Amedeo, Ponti, & Sorbara, 2015). Phase one of cardiac rehabilitation begins with diagnosis of atherosclerosis. It is composed of decreased activities and education of the family and the patient. The patient teaching is prioritized to self-care. Hospital education priorities include rest activity balance, follow up appointments with the physician, signs and symptoms that may indicate the need to call 911 and medication regimen.

Phase two of cardiac rehabilitation commences after the patient has been discharged. This outpatient program consists of education and counselling related to lifestyle modification, ECG checking, support and guidance related to the treatment of the disease, and exercise training (Beswick, Rees, & Griebsch, 2013). Outpatient cardiac rehabilitation programs are made to motivate families and patient to support each other. This programs involve educational sessions that are given by nurses, dietician and health care professional.

Phase three centers on maintaining the cardiovascular stability. In this case the client is self-motivated and does not require a supervised program from the nurse in charge.

Follow up care is briefly described as the act of making contact with a caregiver e.g. a nurse to monitor the patient’s progress. Significance of follow up care is it gives room for further attachment, answers questions and facilitates a good working relation between patients and the care givers. The role of a nurse during follow up care include sharing of lab results, monitor health, confirm medicine regimens, schedule appointments, verify and follow through on referrals and lastly reinforce knowledge and action plans.

Conclusion

In summary myocardial infarction is a condition that results from necrosis of blood cells due to a decreased blood supply. Risk factors associated with MI include smoking, hypertension, obesity, diabetes and family history (Valensi, Lorgis, & Cottin, 2012). The signs and symptoms of MI affects an individual socially and emotionally. Social impacts include a broken relationship between the family and friends, a decrease in sexual desires and work related problems. The nurse manages MI by administering medications such as thrombolytic, morphine and ACE inhibitors. Other roles of nurses in managing MI include education on controlling cholesterol abnormalities, dietary measures, promoting physical activity, promoting cessation of tobacco use, education on administration of nitroglycerine, cardiac rehabilitation and lastly follow up monitoring.

References

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