APPLICATION OF CLINICAL REASONING SKILLS FOR CLINICAL PATIENT SCENARIO

This document explores the application of clinical reasoning skills in a patient scenario involving Jon, a patient presenting with chest pain. It delves into the pathophysiology of angina, associated risk factors, and treatment options. The document also outlines three nursing assessments for Jon, their rationale, and three nursing interventions to improve his chest pain. The administration of sublingual Glyceryl Trinitrate is discussed, along with its mechanism of action and potential side effects. Finally, the major abnormal finding in Jon's case, elevated ST segment, is highlighted, emphasizing its significance and implications for treatment.

APPLICATION OF CLINICAL REASONING SKILLS FOR CLINICAL
PATIENT SCENARIO
Contents
1.1 Pathophysiology of angina with the associated risk factors and treatment options for Jon’s
case 1
1.2 Three nursing assessments for Jon and their rationale...............................................................2
1.3 Three nursing interventions to improve the outcome of Jon’s chest pain...................................3
1.4 Administration of sublingual Glyceryl Trinitrate..........................................................................4
1.5 Major abnormal finding of this case............................................................................................5
REFERENCES................................................................................................................................................6
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1.1 Pathophysiology of angina with the associated risk factors and treatment options for Jon’s
case
Angina pectoris is the clinical representation of the pain and discomfort that occurs when the blood
supply to the heart muscles do not meet its cellular demands. It is due to the myocardial ischemia causing
an imbalance between the Oxygen demand and Oxygen supply at the cellular level. The classical
presentation of angina is an acute pain with a heaviness that radiates through the chest to back, arm or the
jaws (Tarkin and Kaski, 2013). Other associated symptoms that are often associated with this condition
include discomfort in breathing, nausea, vomiting, shortness of breath, weakness, and sweating. This
condition gradually progresses with time and causes difficulty for the suffering individuals to perform
those activities that were simple to perform once (Münzel and Gori, 2013). At times, the symptoms
appear to arise from other body parts and do not present to be associated with the heart muscles. Angina
is left unattended may lead to myocardial infarction or heart attack that may have a fatal outcome. As per
the provided case study, Mr. Edwards was admitted to the hospital with the case of cellulitis in the left
lower leg and had a past history of hypertension hypercholesterolemia and angina for the last 3 years.
The occurrence if angina is exacerbated by the presence of certain risk factors which further limits the
availability of oxygen for the heart muscles (Siama, et al. 2013). These risk factors include hypertension,
dyslipidemia, diabetes, smoking, obesity, age, sedentary lifestyle, psychological stress, family history of
early heart disease, etc. The typical presentation of angina is expressed by factors such as exertion,
emotional distress, eating, exercise, or exposure to cold and lasts for about 1-5 minutes (Puchner, et al.
2014). Mr. Edwards in the case study has a history of smoking 20 cigarettes every day for the last 25
years and does not do any physical exercise. Moreover, his father died at an age of 48 years due to the
heart attack which is also a risk factor for him.
The management strategy begins with the lifestyle modifications, medicines, elimination of the risk
factors, medical and surgical procedures, if necessary. Cessation of smoking, controlling the body weight,
avoiding heavy meals, eating a healthy diet rich in fruits, vegetables, low in fat content and rich in grains
should be encouraged (Tegn, et al. 2016). This would be especially helpful in the case of Mr. Edwards.
Along with this, the patient has a history of coronary artery disease should be placed on the therapy to
monitor and reduce their body cholesterol levels. Adequate rest must be emphasized between intervals so
as to prevent the occurrence of an angina attack (Morton, et al. 2013). Further, the pain gets relieved with
nitroglycerin and nitrates are found to be the most effective drug therapy as it widens the blood vessels
and replenishes the Oxygen requirement. Mr. Edwards is already with Glyceryl trinitrate spray to reduce
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the chest pain associated with angina. Other pharmaceutic treatment includes beta blockers, Angiotensin-
converting enzyme inhibitors, calcium channel blockers, anticoagulants, etc. Mr. Edwards has been
advised with Metoprolol (beta blocker) for improving the blood flow in the body by reducing the heart
rate and relaxing the blood vessels. He is also advised with pravastatin which is a form of statin to lower
the body cholesterol levels (Mentz, et al. 2014). Further, the drug aspirin is advised to control the pain
and is especially useful for its blood thinning effect.
1.2 Three nursing assessments for Jon and their rationale
Upon general investigation, Mr. Edwards is found to complain about the severe chest pain that he was
experiencing after the shower. The usual vital signs were examined and the reports gave some abnormal
results: his pulse was irregular with 110 beats per minute, the temperature was 35.8 degree Celsius, Blood
Pressure was 110/90 mm Hg, Respiratory Rate was 24 beats per minute, and blood Oxygen saturation
was found to be 93% (Lanza, et al. 2014). These signs necessitated the requirement of the advanced tests
so as to diagnose the problem he was facing. Therefore, based on his case history and the vital signs, the
following investigations were carried out:
Electrocardiogram (ECG) test – this requires placement of the leads at specific places on the body to
analyze the underlying heart condition. This test is applicable to the provided case study as it can help to
analyze the details such as heart rate, rhythm, damage to various part of the heart muscle or impaired
blood flow, etc. The ECG test would appear normal after the attack subsides however if this test is
conducted immediately, then it can rule out the presence of angina attack by classical findings such as ST
segment depression and T wave inversion (Libby, 2013). It is a classic test to rule out any abnormality
associated with coronary artery defect and can help in diagnosing the case, managing the risk factors and
analyze the management strategies.
Exercise Stress Testing is an effective test carried out for patients complaining of chest pain. In this case,
it can help to rule out the presence of stable angina pectoris and will also help to understand the extent of
the disease (McGillion, et al. 2014). This test can be performed by asking Mr. Edwards to walk on a
treadmill or ride a stationary bicycle. He should be examined while the exercise is being performed to
understand if his heart receives adequate Oxygen or not especially when it is required. This test is helpful
to monitor the blocked coronary arteries and the extent of effect this has created on the heart muscles
(Jespersen, et al. 2013). However, this test should be abandoned if the chest pain progresses or weakness
is observed.
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An echocardiogram is useful in this case as this will utilize the sound waves to produce images of the
heart and will help to analyze whether heart muscles are receiving sufficient blood supply or not (Ikeda,
et al. 2014). This would then help to detect the presence of angina by helping us to locate the areas of
restricted blood supply and the affected heart site.
1.3 Three nursing interventions to improve the outcome of Jon’s chest pain
Considering Jon’s medical condition and his medical history, the following three nursing interventions
must be initiated immediately:
• Oxygen therapy and assisted ventilation
This must be initiated immediately at approximate volume of 3 liters/minute through a nasal cannula. The
anginal attack leads to constricted blood flow to the heart muscle which causes the deprived volume of
Oxygen being delivered to the body tissues. Therefore Oxygen therapy can replenish the required amount
of Oxygen to the heart muscle and improve the Oxygen saturation levels in the blood (Ferrari, et al.
2013). As a result, this can further help in controlling the chest pain that occurs due to ischemic condition
of the heart.
• Adequate rest
Jon must be advised to take adequate rest and should lie down in semi-Fowler’s position to facilitate the
blood flow within the body. Further, there should not be any unnecessary exercise that he must be
engaged in so as to avoid any kind of stress that may further deteriorate the body condition
(Finnbjornsdottir, et al. 2013). All the avoidable noise sources must be kept away from him so as to avoid
any distraction.
• Identify angina precipitating factors and eliminate them
This would be an essential step in the case of Jon as there are several factors that are precipitating the
angina attack. Jon must be advised to stop smoking and alcohol with immediate effect. Dietary
instructions must be provided to the staff for him which should include a diet that is fat-free and rich in
whole grains. His diet should not have any meal which is heavy but rather he must be encouraged to
consume light meals throughout the day (Husted and Ohman, 2015). An exercise plan must be prepared
for Jon that should encourage him to follow the advised exercises every day. Further, he should only be
asked to do those exercises which are beneficial for him and does not augment the stress levels. Any kind
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of stress should be avoided by Jon and stress management sessions should be planned once his pain is
relieved.
1.4 Administration of sublingual Glyceryl Trinitrate
Angina results in chest pain because the heart muscle does not get the required supply of blood and
Oxygen due to narrowing of the coronary arteries. Jon has been advised with sublingual glyceryl trinitrate
to relieve the chest pain and provide comfort. Glyceryl trinitrate gets converted into the body into a
substance called as nitric oxide. Nitric oxide works by relaxing the blood vessels and widens the artery
which makes it possible for an increased amount of blood to reach the heart muscles. This reduces the
amount of work and effort that the heart has to exert in pumping the required amount of blood to the body
(Avanzas and Kaski, 2015). This drug is extremely helpful in restoring the balance between the Oxygen
demand and nutrient supply to the heart. Further, this helps to relieve breathlessness and improves the
exercise doing capacity.
Glyceryl trinitrate is available in the form of tablets, transdermal patches, sprays, skin or rectal ointment,
injection, etc. Sublingual tablets or sprays are advised to obtain the required effect in a relatively shorter
time span and are placed or sprayed under the tongue. Usually, the sublingual tablet or spray works to
relieve the pain within a minute. The sublingual spray should be administered in a drug dose of 400
micrograms per dose If the first sublingual administration of the drug has not been effective then the
second dose can be administered after five minutes (Cho, et al. 2013). Before administering this drug to
Jon, he must be advised about the common side-effects and the necessary precautions. The common side
effects that are caused due to GTN administration include:
• Dizziness after the drug administration
• Hypotension
• Bradycardia
• Circulatory collapse
• A headache
Jon must be advised not to swallow the tablet once placed under the tongue as it will get absorbed to
show its effect. This drug should not be taken without the doctor’s prescription and also should not be
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administered in an excessive dosage than what is prescribed. Jon must also be advised to take this
medication only till the time it has been prescribed and ensure that it is taken at the same time of the day.
As this causes dizziness and blurred vision, the patient must avoid driving or operate any machinery after
its administration (Cooper and Marshall, 2013). Jon must also be advised to stop drinking alcohol as this
can exacerbate the side effects of glyceryl trinitrate. Also, the tablets must be kept in the same container
as they were dispensed in (Ding, et al. 2013). The patient must be advised to call out for immediate help
in case of extreme situations such as trouble in breathing or dizziness.
1.5 Major abnormal finding of this case
The major abnormal finding that has been found in Jon’s case is elevated ST segment. The elevation in
the ST segment indicates Myocardial infarction can be life-threatening as it indicates acute infarction
caused due to occlusion of the coronary artery. This indicates restricted blood supply to the heart thereby
resulting in Oxygen deficiency which can cause permanent heart necrosis or result in acute attack thereby
leading to death. Further, the pulse is observed to be arrhythmic in the ECG which has a varying distance
between the QRS spikes. QRS complex indicates depolarization of both the ventricles of the heart and
normally lasts for 80-120 ms. Any blockage in the bundle branch would lead to widened QRS complex
and its duration, morphology and amplitude would be helpful in determining cardiac arrhythmias,
hypertrophy, myocardial infarction, etc. (Wienbergen and Hambrecht, 2013). This condition must be
immediately highlighted to the doctor as necessary interventions should be planned and initiated urgently.
Further, these findings are essential to planning the treatment strategy as it helps to diagnose the existing
medical condition on the basis of which appropriate pharmaceutical management can be planned ( Arts, et
al. 2014). Also, there needs to be a planned surgical approach such as Coronary Artery Bypass Grafting
or Percutaneous Coronary intervention ready for immediate requirement if the medical approach does not
provide useful results.
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