Application of Clinical Reasoning Skills for Clinical Patient Scenario

This case study explores the application of clinical reasoning skills for a clinical patient scenario of angina. It covers the pathophysiology of angina, nursing assessment, interventions, patient education on sublingual Glyceryl trinitrate therapy, and findings in the ECG report. The study provides insights into the risk factors, nursing care plan, and medication for angina.

Application of clinical reasoning skills for clinical patient scenario
A case study of angina
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Contents
1.1 Pathophysiology of Angina-...................................................................................................................1
1.2 Nursing assessment in the case study-..................................................................................................3
1.3 Nursing intervention for Jon-.................................................................................................................4
1.4 Patient education on sublingual Glyceryl trinitrate therapy-.................................................................5
1.5 Findings in ECG report-..........................................................................................................................6
References-.................................................................................................................................................7

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1.1 Pathophysiology of Angina
The development of myocardial ischemia occurs when the coronary blood flow gets
inadequate in order to meet the demand for oxygen. It causes the switching of myocardial cells
from aerobic to anaerobic metabolism and impacts the electrical, mechanical and metabolic
functions of cells. The most common clinical manifestation of this heart condition is Angina
pectoris (Nakashima et al., 2016). Angina is caused because of mechanical and chemical
stimulation of sensory afferent nerve ends present in the myocardium and coronary vessels.
Reports suggest that adenosine is the major chemical involved in anginal pain. Adenosine is
formed as a degradation product of ATP and gets diffused to extracellular spaces. The process,
therefore, causes arteriolar dilation and leads to anginal pain (Iqbal, Ashraf, & Muhammad,
2016). Angina induced by the adenosine occurs because of A1 receptor stimulation in the cardiac
nerve endings. The myocardial wall tension, inotropioc state, heart rate are the major
determinants of metabolic activities and oxygen demand in myocardial cells. The myocardial
contractile state and an increase in heart rate results in high oxygen demand in myocardial cells.
Increase in aortic pressure and ventricular diastolic volume leads to proportional elevation of the
tension in the myocardial wall and hence the myocardial oxygen demands increases (Blonski and
Ritcher, 2018).
Risk factors-
There are several risk factors associated with angina pectoris. The major ones include
increased age and high cholesterol. The increased ages with male gender are highly prone to
angina. The health history of the family also associated with the occurrence of angina. Family

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history with cardiovascular disease and increased smoking are other risk factors of angina.
Hypertension and diabetes also lead to ventricular hypertrophy and vascular damage respectively
(Glover, 2016). Angina can be prevented and John will be prescribed with certain medication
such as metroprolol i.e. beta-adrenergic blocking agent that has a direct effect on the beta
adrenoreceptors located in the cardiac muscles. The medication is mainly prescribed to the
patient suffering from angina pectoris, hypertension, and ischemia (Winchester and Pepine,
2015). Another drug that was prescribed is Aspirin that helps in pain relief as well as act as an
antiplatelet factor (Almas et al., 2018). Pravastatin was also prescribed that helps in lowering
down the LDP content in blood and improve the hypercholesterolemia condition. The
medication is a preventive measure to reduce any future heart ailment. Further, it is required to
reduce the stress on the heart and for dilation of blood vessels are required. Glycerine trinitrate is
used as the medication to reduce the stress on the heart (Solomov, 2018).
The current case study presents John, who has the habit of smoking on a regular basis and
cessation of smoking can be an effective measure to prevent further heart ailment. The scope of
this article will also present certain treatment of hypertension, diabetes, obesity and high
cholesterol etc. The article will also highlight a complete assessment of John before providing
any medication (both pharmacological and non-pharmacological).
1.2 Nursing assessment in the case study
Jon is a 64 years elderly patient who was recently admitted to the hospital due to cellulitis
in his left leg. On arrival to his bedside, the Jon reported having a severe chest pain experienced
after completing his shower. On assessing his vital signs it was reportedly as pulse rate 110 bpm,
the temperature is 35.8, blood pressure is 110/90, and respiration rate is 24 and 93% of saturated

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oxygen concentration. There can be several reasons associated with chest pain. Some of them
include muscle strain, indigestion etc. But in Jon's case, there can be certain cardiovascular
ailment associated with a sudden increase in chest pain. Health history of Jon suggests that he
has been suffering from angina for the past three years and because of this it is important to
assess the pain in the context of a heart ailment. The initial assessment of pain can be done
through PQRST assessment method where P (position or provoking factors), Q( Quality of pain),
R (Radiation of pain), S (Sensitivity), T (time). This method will allow a thorough assessment of
pain to achieve the severity of pain, its location, and type of pain. Using the assessment data, the
nurse can initiate a pharmacological intervention to subside any serious complication associated
with chest pain. The pain score will allow understanding the intensity of pain and intervention
against it can be designed. It will also allow knowing whether it is stable or unstable angina. The
ECG report of Jon can be taken out to understand the function of the heart. ECG will provide
critical information on both diagnostic and prognostic values (Vrints et al., 2016). There are
several ways through which the nurse can make a diagnosis of angina. If the angina pain is
during rest it will show an ST elevation or inversion of T wave and that will indicate ischemia.
ECG will also help in predicting the condition of the heart and its complication such as MI and
likewise certain intervention can be taken. Another assessment is to monitor the automated ECG
machine on a regular basis to assess the presence of unstable angina. The duration of angina can
be assessed and the ECG reports will suggest pain more than 10 minutes during rest or activity
will allow making a full proof diagnosis. With the reduction of pain, there will be an indication
of ST depression in the profile.
1.3 Nursing intervention for Jon

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The cues received after a thorough assessment of Jon's condition will help in designing a
nursing care plan for the patient to reduce the angina pain and abnormal vital signs.
Oxygen therapy and patient positioning – As the patient was feeling restless due to chest
pain and there was a reduction in the saturated concentration of oxygen, it is better to place the
patient on oxygen therapy. It is because the oxygen supply was quite poor due to cardiovascular
issues. The heart muscles are more pressurized to meet the demand for oxygenated blood. The
oxygen supply will decrease the burden on the heart and allow the patient to feel comfortable.
As a part of the nonpharmacological intervention, the patient can be positioned in such a way
that he can inhale fresh air through natural process (Losclazo, 2017).
Glyceryl trinitrate therapy- The medication as discussed in the introductory section of this
article is used for coronary vasodilation. The medication is available in the form of intravenous
infusion, tablet or sublingual spray. The drug use to get an immediate effect on the dilation of the
smooth muscle of arteries and veins. The intracellular calcium level also reduced and helps in the
dilation of the coronary vessel. It improves the oxygen supply and coronary perfusion of the
heart. The drug also reduces the elevated rate of respiration and help to normalize the blood
pressure. The nurse initiates this therapy for the hypertensive patient.
Antiplatelet aggregator therapy-
The drug aspirin is well reported to have antiplatelet activity and it has to be
administrated at the right dosage to the patient having condition as Jon has. The platelet
formation is inhibited by getting attached irreversibly to the platelet and inhibits the action of
cyclooxygenase. Therefore, the formation of thromboxane is also inhibited and lead to
aggregation of platelets. The interventions designed are well reported to have a reduction effect

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on the chest pain by the action of inhibition of platelet aggregation, adequate supply of oxygen
and dilation of the coronary artery. Therefore, it will help in reducing the instances of MI,
ischemia and other ailment resulting in angina (Igjatovic et al. ,2016).
Allowing the patient with adequate sleep and proper rest can also facilitate a reduction in
the episode of angina. It is because the demand of oxygen will decrease and allow the heart to
get back to normal state.
1.4 Patient education on sublingual Glyceryl trinitrate therapy
Appropriate education about medication is a must to get a better health outcome. The
patient needs to know about the ways of administration, risk and benefits and contraindication of
the medication before administrating it. In this section, education on GTN will be provided to the
patient that is a vasodilator and improves the function of the heart. The role of the drug is to
reduce the peripheral resistance to blood and increase the supply to compensate for the oxygen
demand. It reduces the pressure on the heart by dilating the blood vessel (Kwon and Rosendorf,
2017). This medication is mainly used to subside the angina pain, hypertension etc. The drug has
a certain risk factor that mostly becomes complicated on its prolonged usage. The drug may
induce hypoxic condition on the patient with a certain lung ailment. The contraindication of
GTN includes certain hypertensive reaction to form organic nitrates. It is not advisable to
consume GTN if the patient is hypotensive. The patient with severe anemia is advised to take
alternative therapy of GTN (Tarkin and Kaski, 2016). The education about the position of
sublingual administration of the drug has to be given to Jon. The patient must be trained in such
a way that Jon can use it as soon as he feels angina pain. The spray is an inflammable agent and
the patient will be therefore advised to keep it away from the fire. The patient will not be advised

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to carry it while driving or doing certain mobile activities. While administration of medication,
the patient will be advised to be on seated position. The adverse effect of GTN such as headache
and nausea must be known to the patient. In case of an emergency, the patient will be advised to
take immediate medical attention.
1.5 Findings in ECG report
Jon is suffering from angina due to an ischemic heart condition. The ECG report will help
in understanding the electrical changes occurring due to the change in voltage. If there is an
injury, there will be a deflection in the ST curve. The given ECG report shows a long QT interval
and it can be because of ventricular arrhythmia. There is a presence of chaotic heartbeats. If
angina persists for a long time, it may lead to a severe heart ailment and will require immediate
nursing intervention. In the same way, there is an ST elevation and from that, it can be concluded
that the patient is having ventricular tachycardia (Vrints et al., 2016). The widening of QRS
complex indicates the increased pulse rate. The abnormal electrical signals can fluctuate the QRS
signal and result in its widening. The ST elevation also demonstrates myocardial infarction but
one must not get confused with the ischemic condition (Li et al., 2018). There is a presence of
third-degree blockage as shown in the ECG rhythm. At diastolic condition, there is a depression
in the PT and PR segment. These are considered as the baseline and therefore if there is an
elevation in the ST curve, it can be an indication of MI. The finding from the current ECG graph
shows the patient is having a blockage in a blood vessel and requires immediate nursing
attention.

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References
Almas, A., Ghazni, M. S., Hashman, S., & Mushtaq, Z. (2018). Aspirin in Primary Prevention of
Myocardial Infarction/Angina and Stroke in Hypertensive Patients.
Blonski, W., & Richter, J. E. (2018). Chest Pain of Esophageal Origin and Reflux
Hypersensitivity. In Gastrointestinal Motility Disorders (pp. 39-53). Springer, Cham.
Böhm, M., Reil, J. C., Deedwania, P., Kim, J. B., & Borer, J. S. (2015). Resting heart rate: risk
indicator and emerging risk factor in cardiovascular disease. The American journal of
medicine, 128(3), 219-228.
Glover, K. (2016). 10 Stable Angina. Clinical Guide to Cardiology, 138.
Ignjatovic, V., Pavlovic, S., Miloradovic, V., Andjelkovic, N., Davidovic, G., Djurdjevic, P., ...
& Petrovic, N. (2016). Influence of different β-blockers on platelet aggregation in
patients with coronary artery disease on dual antiplatelet therapy. Journal of
cardiovascular pharmacology and therapeutics, 21(1), 44-52.
Iqbal, M. N., Ashraf, A., Muhammad, A., Alam, S., Xiao, S., Ali, S., & Irfan, M. (2016).
Prevalence of Angina Pectoris in relation to various risk factors. PSM Biological
Research, 1(1), 6-10.
Kwon, L., & Rosendorff, C. (2017). The Medical Treatment of Stable Angina. Chronic
Coronary Artery Disease: A Companion to Braunwald's Heart Disease, 280.
Li, H., Lin, X., Liu, Q., & Zhang, Y. (2018). Curative effect of Danhong injection on the clinical
symptoms, adverse reactions, and electrocardiogram of angina pectoris of coronary heart
disease. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL
MEDICINE, 11(2), 910-915.
Loscalzo, J. (2017). Is oxygen therapy beneficial in acute myocardial infarction? Simple
question, complicated mechanism, simple answer. N Engl J Med, 377(13), 1286-1287.

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Nakashima, T., Noguchi, T., Haruta, S., Yamamoto, Y., Oshima, S., Nakao, K., ... & Kawasaki,
T. (2016). Prognostic impact of spontaneous coronary artery dissection in young female
patients with acute myocardial infarction: a report from the angina pectoris–myocardial
infarction multicenter investigators in Japan. International journal of cardiology, 207,
341-348.
Solomonov, M. (2018). Ludwig Angina after First Aid Treatment: Possible Etiologies and
Prevention—Case Report.
Tarkin, J. M., & Kaski, J. C. (2016). Vasodilator therapy: nitrates and nicorandil. Cardiovascular
drugs and therapy, 30(4), 367-378.
Vrints, C. J., Senior, R., Crea, F., & Sechtem, U. (2016). Assessing suspected angina: a requiem
for coronary computed tomography angiography or exercise
electrocardiogram?. European heart journal, 38(23), 1792-1800.
Winchester, D. E., & Pepine, C. J. (2015). Angina treatments and prevention of cardiac events:
an appraisal of the evidence. European Heart Journal Supplements, 17(suppl_G), G10-
G18.