Application of Clinical Reasoning Skills for Clinical Patient Scenario

This document discusses the application of clinical reasoning skills for a clinical patient scenario. It covers the pathophysiology of angina, physical nursing assessments, and nursing interventions for improving physiological outcomes. The document provides study material and solved assignments related to this topic.

APPLICATION OF
CLINICAL REASONING
SKILLS FOR CLINICAL
PATIENT SCENARIO

Table of Contents
CASE STUDY.................................................................................................................................1
1.1 Pathophysiology of Angina...................................................................................................1
1.2 Physical Nursing Assessments..............................................................................................2
1.3 Nursing Interventions for improving physiological outcomes .............................................3

CASE STUDY
1.1 Pathophysiology of Angina
Cardiovascular disease is the prime cause of deaths in Australia. Annually, more than 353,000
Australians are affected by this disease and nearly 72,000 hospitalized. Angina or angina pectoris is a
type of predictive heart condition that arises when the heart is not able to supply sufficient amount of
oxygen and blood to myocardium for meeting its needs (Boden and et.al. 2012). It is caused by
myocardial ischaemia or emotional stress and exertion. Coronary arteries are responsible for supplying
oxygen and blood to heart muscles, in case these arteries narrow down, the heart muscle is unable to
function properly leading to development of fatty plaques in the walls of arteries. This phenomenon is
known as 'Atherosclerosis' (Economou and et.al,2015). A patient can experience stable or unstable
angina, however, it should not be confused with a heart attack as the former is only temporary in nature
and does not damage one's heart muscles. In the given case scenario, Jon Edwards has been diagnosed
with Angina condition for last 3 years. Symptoms of Angina include chest pain with a feeling of
squeezing, pressure or tightness, pain in arm, shoulder, neck or back, unable to breathe properly,
fatigue, sweating, dizziness and nausea. Jon's past history shows that he has been a regular smoker
consuming 20 cigarettes per day for 25 years until now with fairly healthy eating habits and regular
consumption of red wine (four times) per day.
Out of 90% Australians, at least one has risk factor for heart diseases. These risk factors
associated with this disease are both modifiable and unmodifiable in nature including tobacco use,
diabetes, high blood pressure and blood cholesterol, older age, lack of exercise, stress and obesity. Thus,
in terms of preventative pharmacology, Jon has been suggested to quit smoking which he has recently
and in order to reduce stress he walks his dog daily. Some of the preventative measures that can be
adopted by a patient of such disease include quitting smoking, maintaining a healthy diet, reducing
stress, limit alcohol consumption, regular check-ups and increased physical activities (Harskamp and
et.al., 2013). Since he is 64 years old, his condition cannot be treated completely although it is

preventable. Angina can be treated through medication and surgery as well as adopting healthier
lifestyle choices. Medication usually includes nitrates that dilate blood vessels and increase blood flow
to heart. Jon is prescribed Aspirin that helps in preventing clots in narrowed arteries, he should reduce
alcohol consumption and include additional exercise to treat high blood pressure and stress.
1.2 Physical Nursing Assessments
Assessment is a crucial part of nursing practice regulated by Nursing and Midwifery Board of
Australia (NMBA). A physical nursing assessment helps in obtaining complete assessment of the patient.
These assessment includes history, observation and inspection, palpation and auscultation(Jukema and
et.al., 2012). As chest pains can be false alarms it is important to confirm angina by assessing other
symptoms that trigger it. Typically angina shows sign of discomfort or pain in chest, arms, shoulders with
tightness and burning sensations. The most important diagnostic tool to evaluate angina is ECG.
However ECG cannot be used in isolation to fully evaluate the left ventricle's posterior, lateral and apical
walls. Jon has been hospitalized with cellulitis and has a medical history that shows signs of alcoholism,
smoking, hypertension, hypercholesterolaemia and Angina for past 3 years. A standard 12 lead-ECG or
Electrocardiogram report is a medical test that can help in diagnosing any kind of severity in Jon's heart
condition in the past three years by mere comparison of current and previous ECG reports.
As far as observation or monitoring is concerned, electrocardiograph findings may not be
detected through this assessment (Kemp and Conte, 2012). On the other hand, observation
assessment can be helpful to determine the mental health of Jon to see whether he is depressed or
overstressed as high stress levels can be a trigger to angina attacks too. This can also be done through
stress testing using a bicycle or a treadmill for patients that are allowed to exercise. Additionally, a nurse
can assess the weight of Mr. Edwards to ascertain whether he is obese or not as these factors will help
in verifying his high blood cholesterol levels and blood pressure. Another assessment that can be carried
out for Jon involves imaging coronary arteries through Computed Tomography (CT) scans(Latsios and
et.al., 2013). As mentioned earlier, narrowing of coronary arteries results in angina pectoris, a CT scan
of the arteries without contrast injection can help in finding a correlation between coronary calcification
and degree of luminal narrowing. If the patient tend to have a high risk of uncontrollable cardiovascular
outcome, angiography must be recommended. Also, lifestyle habits of Jon should also be monitored by
keeping him under a strict diet with low or no consumption of alcohol and increased physical activities
incorporated in it. This is because smoking and alcoholism are strong and independent risk factors that
contribute to increased blood pressures, obesity and possibility of developing Type 2 Diabetes.
1.3 Nursing Interventions for improving physiological outcomes
Nursing interventions include treatments and actions performed by a nurse to help a patient
attain goals that are set for them using critical thinking skills, knowledge and experience. There are three
types of Nursing interventions namely independent, dependent and interdependent actions (Lippi and
et.al., 2012). Independent actions are those that a nurse is able to carry out independently such as
health promotion. Dependent actions require permission from another healthcare provider such as a
physician or a doctor and cannot be carried out solely by a nurse. Interdependent actions need
participation of a number of members of health care team.
In the context of given case scenario, the nursing interventions that would help in improving
physiological outcomes for Mr. Jon Edwards suffering from Angina pectoris would include instructing Jon

to stop all activities and take rest in a semi-Fowler's position and administer his nitroglycerin
sublingually. Semi- Fowler's Position helps in reducing pain, nausea and provides comfort, especially to
cardiac patients, by inclining the patient's bed at angle of 30 to 45 degrees. As Jon is experiencing severe
chest pain, a semi-Fowler position will help in reducing tightness around the chest and keep him from
fainting due to severe nauseousness. A diagnosis would be carried out for calculating death anxiety
levels and stress to explore its implications on the illness on the basis of which important preventing
measures will be listed for Mr. Edwards. Since depression and stress have a direct effect on heart,
emotions and mental health of an individual it is important to prevent progression of such variables to
extremity(Moreno and Clancy, 2012). Apart from this, a review of assessment findings through ECG
tests, CT Scans, Stress Testing help in identification of extent to which Jon's pain was caused. This will
help in planning his daily activities for reducing future probability of experiencing an angina spasm.
While angina is caused due to shrinkage in coronary arteries, it is important that proper activity plans
must be enforced including Mr. Edwards family and pets to ensure proper balance is maintained
between his oxygen demand and supply by following such activities. These may include incorporating
treadmill routine in his lifestyle along with healthy meals comprising fruits, vegetables and whole grains
along with low-fat dairy products like skim milk, low sodium-level foods, chicken,fish and beans. These
staples will help in keeping blood pressure controlled to 130/180 and HbA1c as well as blood sugar at
recommended levels which will ultimately reduce cholesterol, diabetes and obesity.