Chest heaviness and shortness of breath

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Nursing Case Study
Student’s Name
University
Date
Course
Instructor

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Nursing Case Study
Introduction
Mr. Orwell presents the case of heart-related complications that include chest heaviness
and pain. The patient has a medical history of cardiac problems having undergone a coronary
artery by-pass five years and has a history of having had a myocardial infarction (Chow, Chan,
Ho, & Chun 2017, P. 5). Heart disease patients present challenges that require proper
management to lower the risk of a heart attack and at the same time to keep the patient out of
future episodes. The patient history shows that he needs to be assisted to recover from the
symptoms and a proper discharge plane needs to be used so that he can be able to lead a better
life. Evidence-based approaches require that care is designed based on the needs of the patient.
Thus the role of the nurse is to work collaboratively with the patient to achieve the quality of life.
This report gives an overview of the patient through primary diagnosis to identify the nursing
problems which will form the basis of a discharge plan that will be developed for the patient.
Primary diagnosis
The nursing notes for Orwell show that he was admitted for chest pain and shortness of
breath which were not responding to the normal GT spray that is supposed to be used during
episodes. Chest heaviness and shortness of breath are symptoms of cardiac-related problems that
develop due to blocked arteries from extracellular matrix forming atherosclerotic plaques that
narrow the luminal space. Blocked arteries lead to reduced blood circulation that is seen in the
squeezing and discomfort that the patient feels when breathing. In other cases, this leads to
uncomfortable pressure extending from shoulder, neck, and jaw. Berliner, Schneider, Welte, &
Bauersachs (2016, p. 835) suggests that there are different causes of this condition that depend
on the nature and lifestyle of the patient. In most cases, this is related to the exposure to risk
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situations and the ability of the patient to notice the warning signs of an episode before the
symptoms become serious.
Yasue, Nakagawa, Itoh, Harada, & Mizuno (2014, p. 11) argue that chest pain onset is
dependent on many factors that are mostly dependent on the medical history and the lifestyle of
the patient. Patients who have had heart-related problems are at a risk of these symptoms since
they can be triggered by any cause. In the case of Orwell, the pathophysiology of this problem
relates to the coronary artery disease that he had in the past which was managed through surgery.
Coronary bypass is used to treat coronary artery disease that develops as a result of narrowing of
the blood vessels due to the build-up of fatty material limiting the supply of oxygen. Thus
bypassing is used to treat this blocking restoring the patient to normalcy. However, this is not a
permanent solution to the since the patient is required to have a lifestyle change so that the
exposure to the risk factors can be reduced (Grech, 2013, p 3; Fleg, 2016, p. 9). Orwell seems not
to have managed his problem since he is obese and smokes fifteen cigarettes everyday which can
all increase the risk. The medical notes also show that he is diabetic with high blood pressure and
a tendency to not following the medication as prescribed. This shows that the lifestyle increased
the risk factors which could have led to increased blocking of arteries.
Thus the pathophysiology of the chest pain and breathlessness can be traced to the
lifestyle of the patient. Ewert, Bahr, Henschei, & A Rink (2016, P. 124) states that most patients
who have been able to manage to live with heart-related patients understand what it means by
lifestyle change and the need to live within medical requirements of the condition that they have.
This can be seen in the case of this patient whose lifestyle could have led to the admission and
the episodes that he is experiencing. Orwell suggests that he forgets taking his medication and
does not like taking the fluid balancing medications when going out because of the side effects.
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The past medical history and the medications of the patient are an indicator that he has difficulty
managing the condition through following medications as prescribed and leading a lifestyle that
has lesser risks.
Nursing problems
Management of the heart-related symptoms
The first nursing problem for patients with heart-related patients is to manage the
symptoms and prevent the development of a heart attack or stroke. The feeling of chest pain and
breathlessness during exertion is a warning sign of a developing episode of a heart attack. Heart-
related patients experience chest pain in most cases when exposed to risk factors like physical
activity. Since the arteries are narrowed or sometimes blocked, the patient cannot manage high
physical activity which requires the heart to pump faster so that blood circulation can be
increased (Young & Melander 2013, p. 5; Burman, Zakariassen, & Hunskaar, 2014, p. 9). This
challenge can be related to patient lifestyle which is supposed to be based on reducing the
triggers of breathlessness and at the same time avoiding risk factors through lifestyle
management. Cigarette and diabetes are all risk factors that can expose the patient to the danger
of suffering from an attack (Kamimura, Cain, Mentz, White, Fox, Butler & Robertson, 2018,
2576). Orwell is also not following the drug prescriptions properly especially fluid balancing
drugs which are important in reducing the heart from straining. Thus, the approach of care that is
developed for such patients is a management plan that focusses on both the lifestyle and
medication intake at all times.
Patient education on lifestyle management
Doughty, Pilar, Audette, & Katz (2017, p. 4) argues that when dealing cardiovascular
problems patients, the best way for managing the condition is patient education to ensure that

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they fully understand the problem so that they can know when the episodes occur, how to
manage them and how to stay away from risk factors. The case of Orwell presents this as a
current and future problem that he is prone to still face thus increasing the chances of his
readmission. Anderson, et al. (2017, p. 15) add that the increasing number of people living with
heart-related conditions means that cardiac rehabilitation through improving the health outcomes
of people is the only option in reducing the risk of this problem. From the medical history of the
patient and examination of the information provided, the patient seems to be leading a risky
lifestyle that exposes him more to developing the heart-related complication. Being a smoker and
suffering from diabetes and hypertension he requires an adequate individualized plan that will
reflect the requirements of the lifestyle of the patient with cardiovascular disease.
Nursing management
Management of the heart-related symptoms
The first step in managing a patient with chest pain and breathlessness is to address the
symptoms before focusing on the lying condition. The fact that the chest heaviness problem is a
referral and the patient was not responding to the normal GTN spray requires physical and oral
examination of the patient to assess the state of the problem and the likelihood of a heart attack
(Hutchinson, Pickering, Williams, Bland, & Johnson, 2017, p. 5; Herren & Mackway-Jones,
2010, p. 8). Through history, examination to understand the previous medical situations that the
patient has suffered, the nurse and the doctor can gather information for decision making.
The treatment under this condition is based on the symptoms that the patient presents. A
range of medications like aspirin that acts as an anti-inflammatory drug for preventing clotting
and thinning of blood is used to reduce the intensity the pain. Atorvastatin is administered due to
the cholesterol level that arises from obesity while the rest of the drugs are used to increase
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circulation and reduce pressure from the heart. The nature of drugs that are administered to the
patient is determined by the GP who assess the condition of the patient to determine the best
drug.
Biesemans, et al. (2018, p. 6) suggests that in managing this condition, the nurse plays an
important role in administering the medication and monitoring the condition of the patient. Since
the patient was referred from another facility and an examination has revealed that the patient is
complaining of central chest pain, is anxious, and sweaty, then it means that a nurse has to
monitor the vital signs of the patient closely and report to the doctor. Zheng, et al. (2018, p. 3)
suggests that evaluation and management of patients with heart-related problems need to be done
continuously to determine whether the patient is responding to medication and if the risk factors
have been reduced. The nurse is required to administer the medication to the patient as required
and assess the progress indicators to determine the response of the patient to the medication and
any side effects.
Patient education on lifestyle management
Roysland, Dysvik, Furnes, & Friberg (2013, p. 919) a large number of patients suffer
from chest pain and other heart disease-related symptoms since in most cases, they lack
knowledge in understanding the different early warning signs of an oncoming episode. Labrunee,
et al. (2012, p. 329) adds that this process needs to be designed on a patient-centered approach to
meet the beliefs, perceptions, and expression of the signs by the patient. For patient education to
work properly, lifestyle management needs to be done so those healthy and unhealthy behaviors
are identified and addressed. In this case, the focus needs to be on smoking, reducing obesity,
managing blood pressure and diabetes. This assessment informs the nursing care plan that is to
be developed. Orwell needs to be put on a lifestyle change program that will address the lifestyle
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issues that can lead to increased risk of heart-related problems. By learning how to manage each
of the risk factors, the patient will be able to overcome the triggers of heart attack and its
symptoms. Cogan, et al. (2014, p.576) add that by assisting the patient to understand the different
triggers and signs hospitalization and readmission rates are reduced while healthcare outcomes
are increased
The role of the nurse is patient education is to work closely with the patient in developing
an individualized care plan that reflects the needs of the patient. In this case, the nurse works
with other multi-disciplinary teams in ensuring that the patient is educated on how to respond to
different signs and triggers of the (Mansour, Burke, Bauldoff, Gubrud-Howe, Levett-Jones,
Hales & Reid-Searl 2016, p. 9). The nurse works closely with the patient to ensure that the
lifestyle and the nature of the patient are understood so that a care plan can be designed to reflect
these needs. As seen in medical history, Orwell seems to be having trouble managing the risk
factors that trigger the problem.
Discharge plan
Fox (2015, p. 108) suggests that the role of a discharge plan in heart condition related patients is
to assist them to progress from clinical settings to personal care with the help of a
multidisciplinary team.
Medication management
Develop a plan for taking medication by linking the time for taking the medication with patient
personal activities. The nurse can also link with Orwell’s son to assist in managing the
medication.
Changing of lifestyle through social support

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The nurse needs to assist the patient in identifying support for people with heart conditions,
diabetes and smoking rehabilitation groups. The services of a social worker can help assist the
patient to address some of the challenges.
The nurse can work with the social worker and the son to link with a TB fitness program or other
support groups for exercise.
Link the patient to a dietician to assist in changing his diet to manage obesity, diabetes, and
pressure.
Identifying, responding and managing of early warning signs
The nurse needs to assist the patient in understanding and interpreting early warning signs so that
it becomes easy to respond or seek medication.
Conclusion
Heart-related diseases have no treatment but can only be managed if the patient learns to
live with the condition. Orwell presents the challenge that most patients face failing to adjust
their lifestyle so that they can avoid the risk factors that trigger the symptoms. The fact that he
fails to follow the proper medication dosage and has not made attempts to manage other
conditions that can increase the problem means that he is at the risk of regular attacks. Thus the
role of medication is to manage the condition while patient education focusses on reducing the
triggers by leading a healthy lifestyle. If Orwell can follow all clinical instructions, he can lead a
normal life.
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References
Anderson, L, Brown, JP, Clark, AM, Dalal, H, Rossau, H K, Bridges, C, & Taylor, RS 2017.
'Patient education in the management of coronary heart disease', The Cochrane database of
systematic reviews,, vol 6, no. 6, pp. 10-22.
Berliner, D, Schneider, N, Welte, T & Bauersachs, J 2016, 'The Differential Diagnosis of
Dyspnea', The Differential Diagnosis of Dyspnea, 113(49), p. 834–845.
Biesemans, L., Cleef, LE, Willemsen, RTA, Hoorwetg, BN, Renier, WS, Buntinx, F, Glatz, J,
2018, 'Managing chest pain patients in general practice: an interview-based study', BMC Family
Practice, vol. 19, no. 80.
Burman, R, Zakariassen, E & Hunskaar, S 2014, 'Management of chest pain: a prospective study
from Norwegian out-of-hours primary care', BMC Family Practice, 15(51).
Chow, S, Chan, Y, Ho, S & Chun, K 2017, 'Cardiac health knowledge and misconceptions
among nursing students: implications for nursing curriculum design', BMC Nursing, vol. 46, no.
16, pp. 1-10.
Cogan, J, Ouimette, MF, Vargas-Schaffer, G, Yegin, Z., Deschamps, A & Denault, A 2014,
‘Patient Attitudes and Beliefs Regarding Pain Medication after Cardiac Surgery: Barriers to
Adequate Pain Management’, Pain Management Nursing, vol. 15, no. 3, pp. 574-579.
Doughty, K, Pilar, N D, Audette, A & Katz, DL 2017, ‘Lifestyle Medicine and the Management
of Cardiovascular Disease’, Current Cardiology Reports, vol. 19, no. 116, pp. 1-10.
Ewert, C, Bahr, C, Henschei, F & A Rink, WJ 2016, ‘Number of patients with chronic dyspnea
in three German specialist practices’, Pneumologie, vol. 67, no. 2, pp. 123-130.
Fleg, L 2016, 'Healthy Lifestyle and Risk of Heart Failure: An Ounce of Prevention Well Worth
the Effort', Circulation. Heart failure, vol. 9, no. 4.
Fox, KF, 2015, ‘Investigation and management of chest pain’, Heart, vol. 91, no. 1, p. 105–110.
Grech, E, 2013, ‘Pathophysiology and investigation of coronary artery disease’, BMJ, vol. 326,
no. 1027.
Herren, K & Mackway-Jones, K 2010, 'Emergency management of cardiac chest pain: a review',
Emergency Medicine Journal, Vol 18, pp. 6-10.
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Pulmonary Medicine, vol. 17, no. 53, pp. 1-7.
Kamimura, D, Cain, LR, Mentz, RJ, White, WB, Fox, ER, Butler, J, & Robertson, RM 2018,
'Cigarette Smoking and Incident Heart Failure', Circulation, Vol 137, p. 2572–2582.
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Labrunee, M, Pathak, A, Loscos, M, Coudeyrede, E, Casillas, JM, & Gremeaux, V 2012,
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Physical and Rehabilitation Medicine, vol. 55, no. 5, pp. 322-341.
Mansour, H, Burke, KM, Bauldoff, G, Gubrud-Howe, P, Levett-Jones, T, Hales, M, Reid-Searl,
K 2016, 'Pattern of risk factors and management strategies in patients with acute coronary
syndrome, in different age groups and sex categories', Atherosclerosis Supplements, Vol 25, pp.
7-15.
Roysland, IO, Dysvik, E, Furnes, B & Friberg, F 2013, ‘Exploring the information needs of
patients with unexplained chest pain’, Patient Preference Adherence, Vol 7, p. 915–923.
Yasue, H, Nakagawa, H, Itoh, T, Harada, E, Mizuno, Y 2014, 'Coronary artery spasm--clinical
features, diagnosis, pathogenesis, and treatment', Journal of Cardiology,, vol. 51, no. 1, pp. 2-17.
Young, J & Melander, S 2013, 'Evaluating Symptoms to Improve Quality of Life in Patients with
Chronic Stable Angina. Nursing Research and Practice, vol. 6, no. 4, pp. 1-9.
Zheng, W, Wang, J, Xu, F, Zheng, J, Zhang, H, Ma, J,. Chen, Y 2018, ‘Evaluation and
management of patients with acute chest pain in China (EMPACT): protocol for a prospective,
multicentre registry study’, BMJ Open, vol. 8, no. 1.
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