Case Study Analysis of an 83-Year-Old Man with Angina and Cerebral Vascular Accident

This case study involves the plan of care for an 83-year-old man with angina and cerebral vascular accident. The plan of care includes reducing anxiety, improving physical mobility, and maintaining fluid balance. Legal and ethical considerations are also discussed.

Running head: NURSING ASSIGNMENT
Nursing assignment
Name of the Student
Name of the University
Author note

1NURSING ASSIGNMENT
The following assignment involves the case study analysis of an 83-year-old man, Mr
Harold Blake who had a complex medical history of angina and left cerebral vascular accident.
He was admitted to hospital after an episode of left cerebral vascular accident (CVA) followed
by angina. The patient had an episode of CVA on his left side that impaired his mobility and
sudden weakness and numbness resulting in paralysis on one side of the body. Moreover, after
an angina episode, focused diagnosis is required looking into the medical history, physical
examination and various signs and symptoms assessed in the emergency department (ED).
Therefore, the assignment involves the plan of care for the patient along with rationale, short and
long-term goals for recovery followed by legal and ethical considerations required for the case
study analysis. The plan of care also requires inter-professional collaboration in giving well-
articulated care that will also be discussed in the following essay.
Anxiety is one of the main priorities after an angina episode, as Harold may fear of threat
of sudden death. The patient that is accompanied by autonomic response experiences the
condition of vague and uneasy feeling of discomfort or dread. This condition may be situational
crisis or threat as he had encountered a second angina episode or due to underlying
pathophysiological response (Anderson et al. 2013). In the case study, Harold was accompanied
by negative thoughts, as he was worried about the effect of the diseased condition on his lifestyle
and family. This was evidenced in him, as he was unable to comprehend as what was happening
to him accompanied by restlessness, uncertainty and apprehension. The immediate and main
nursing goals in the plan of care in reducing anxiety to a manageable level and verbalize
awareness among the patient about feelings of anxiety with effective demonstration of coping
skills. For reducing anxiety attributable to fear of unknown prognosis and diagnosis, it is
important to perform stress testing in order to gather information about activities that preceded

2NURSING ASSIGNMENT
and precipitated the episode of angina detecting his response to the condition. It is important to
promote the patient’s expression of fears and feelings because unexpressed feelings can create
turmoil and presence of negative talk contributing to exacerbation of the condition (Jespersen et
al. 2013). The nurse should administer tranquilizers, sedatives as indicated to relax him until he
is able to cope up with the present condition. The nurse need to reassure Harold that medical
regimen designed for him is aimed at reducing the future chances of angina attacks and increase
stability. The rationale for this intervention is to encourage Harold to control his present
symptoms, increase confidence and integrate his abilities in the plan of care (Amsterdam et al.
2014). As Harold is worried about his position in the family and lifestyle, his family need to be
encouraged to treat him as before so that he is reassured about his position in family and in turn
reduces his anxiety levels. This is both a short and long-term goal as family need to maintain
healthy relationships with Harold so that he feel secured and have fast recovery (Huffman et al.
2014).
The second priority for the plan of care is impaired physical mobility as CVA affected
his left side of the body and impaired mobility. The sudden onset of neurological deflects as a
result of compromised blood flow affected his mobility, verbal and non-verbal response (Inglis et
al. 2013). As a result, there is impaired physical mobility and affected physical movement in one
or more extremities in the body. Decreased superficial reflexes, weak neuromuscular
involvement, paralysis and perceptual or cognitive impairment can possibly evidence this
condition. The nursing goals increase in function and strength of physical movement by the
compensatory affected part and maintenance of optimal functioning in Harold and demonstration
of behaviours that enable his activities resumption (Yiğiner et al. 2016). The plan of care
involves assessing of extent of impairment on a scale from 0-4 because it helps to identify the

3NURSING ASSIGNMENT
deficiencies and strengths of Harold regarding recovery following the second day. He should be
made to change positions every 2 hours for reducing tissue injury, poor circulation and sensation.
He should also be positioned in prone position depending upon his activity level because it helps
to maintain his hip extension. There should also be beginning of passive (Range of Motion)
ROM after admission and encouraging exercises such as squeezing, gluteal exercise, and
extension of legs, fingers and rubber ball because there is minimization of muscle atrophy. This
also promotes circulation and prevention of contractures along with reduction of risk of
haemorrhage (de Oliveira Medeiros, de Araújo and de Araújo 2013). The nurse should assist
Harold in developing sitting balance by head raising from bed and assisting him to sit on the bed.
Moreover, the patient should also be supported at the lower back and knee positioning using
parallel bars. The rationale for this intervention aids in enhancing proprioception, retraining of
neuronal pathways and motor response. The long-term goal is to prevent pressure ulcers by
positioning the patient and aligning of extremities correctly using high-top sneakers for footdrop
prevention or pulsated mattresses (Evans et al. 2015).
Fluid imbalance is the third priority as it is a common complication in CVD. Electrolyte
and fluid imbalance can be life threatening for Harold due to rapid heart rate and tachycardia.
The nursing goal involves maintaining normovolemic conditions, demonstration of lifestyle
changes for avoiding dehydration progression and encouraging Harold to verbalize awareness of
behaviours and causative factors for detecting correct fluid balance (Aronson et al. 2013). For the
plan of care, the vital signs like heart rate and blood pressure should be monitored and
documented as alteration in heart rate and decrease in volume of circulating blood can result in
tachycardia and hypotension. There should also be assessment of oral mucous membranes and
skin turgidity for dehydration signs as elderly skin losses elasticity and hence skin turgor

4NURSING ASSIGNMENT
assessment is required (Floras and Ponikowski 2015). There should also be monitoring of fluid
status that is related to dietary intake and this is important to verify that Harold is on fluid
restraint or not. There should also be monitoring of serum electrolytes, urine osmolality to report
abnormal values as elevated levels of blood urea nitrogen may indicate fluid deficit. The patient
should be administered daily for fluid intake and need comparison with 24-hour output and
input. This is important because these measurements indicate intravascular volume. There should
also be monitoring of vital signs like orthostatic and hypotension and temperature elevation
because these measurements are helpful in the determination of fluid deficit from the body (Lee
et al. 2015). The nurse needs to ascertain the beverage preferences of Harold and encourage high
fluid intake while consuming foods because it relieves discomfort and thirst. The plan of care
should also involve taking safety precautions using bedside rails, bed placed in low position and
if required soft restraints should be used. This would help to prevent patient fall and injury as
decreased cerebral perfusion often results in altered thought process and created confusion
(Moorhead et al. 2014).
Legal and ethical considerations are present in geriatric care and in case of Harold;
ethical issues are involved as he is vulnerable as compared to an average adult. Ageing is a
dynamic and complex process that is intricately inseparable and interrelated psychological,
physiological and sociological aspects of human life. In this case, the ethical considerations
involve conflicts of interest that may arise between Harold and professional caregivers or his
family members. Harold’s interests may interfere with healthcare professionals and these
conflicts may interfere with the actual plan of care and treatment of Harold. Therefore, in context
to elderly care in the case study, confidentiality should be maintained, as substantial amount of
patient information like past medical history is required from Harold’s family members. The

5NURSING ASSIGNMENT
healthcare professionals owe a duty of confidentiality to the patient that personal information
should not be shared with others except for medical purpose (Carlson and Idvall 2015). In this
case, informed consents should be taken from Harold’s family maintaining confidentiality and
disclosing only with prior consent from the patient’s family. The legal consideration involves
decision-making capacity in case of elderly care, Harold. As the thought process is altered in the
patient due to CVD accident, he may or may not be competent in participating in the medical
decision-making process (Sahota et al. 2013). Therefore, in this case study, it is important for the
healthcare providers should focus on including the family members in the decision-making
process, as Harold is unable to think clearly about the medical decisions and consequences
thereafter.
For providing integrated care and assure that his needs are fulfilled, a specialist multi-
disciplinary team (MDT) comprising of healthcare professionals like cardiologist, cardiac
rehabilitation specialist, nurses, case managers and nutrition specialists are required. This
combination is helpful in providing spectrum of approaches and manages Harold individually
through tailoring in meeting patient’s needs. Depending upon the angina episode, cardiologists
attended by junior medical nurse staffs perform assessments and develop plan to manage the
emergency condition of angina episode. The case manager has the responsibility to undertake the
assessment, planning, monitoring and advocate Harold case, linked it with support and
rehabilitation services like cardiac rehabilitation specialist functioning for the illness
management and prevention of further angina episodes. Nurses play the most important role in
patient care as Harold is critically ill and it is their responsibility to relieve him from acute pain
and cardiac workload reduction. The nurses in collaboration with nutrition specialists execute the
plan of care for Harold monitoring his vital signs, fluid and nutrition balance, administration of

6NURSING ASSIGNMENT
medicines while working with families in indentifying their risk factors and necessary lifestyle
modifications (Feltner et al. 2014).
The allied healthcare professional in case of Harold is speech pathologist. Due to CVD,
Harold exhibited sudden weakness, numbness and paralysis that results in decreased verbal and
non-verbal response. Therefore, there is need for a speech pathologist or therapists for assessing,
diagnosing, treating and assisting Harold in speech, voice, language, swallowing, cognitive-
communication and fluency. Speech therapist is a part of team working in collaboration with
cardiologists, rehabilitation nurses and specialists and physicians in improving communication
and speech with Harold (American Speech-Language-Hearing Association 2016).
From the above discussion, it can be concluded that angina episode requires integrated
care for the better management of the patient by a MDT. In the case study, Harold was admitted
to hospital after an episode of angina and CVA and at the hospital, the MDT provided a plan of
care from emergency treatment to recovery. The plan of care involves three main priorities;
anxiety, impaired physical mobility and fluid imbalance. The essay discussed the plan of care
and rationale for the patient for managing and stabilizing his condition. Moreover, a MDT
approach is also required including allied health professional, speech therapist providing an
integrated care and better recovery of Harold. Therefore, the case study analysis provided an
insight into the better management and plan of care for the 83-year-old patient, Harold.

7NURSING ASSIGNMENT
References
American Speech-Language-Hearing Association, 2016. Scope of practice in speech-language
pathology.
Amsterdam, E.A., Wenger, N.K., Brindis, R.G., Casey, D.E., Ganiats, T.G., Holmes, D.R., Jaffe,
A.S., Jneid, H., Kelly, R.F., Kontos, M.C. and Levine, G.N., 2014. 2014 AHA/ACC guideline
for the management of patients with non–ST-elevation acute coronary syndromes: a report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Journal of the American College of Cardiology, 64(24), pp.e139-e228.
Anderson, J.L., Adams, C.D., Antman, E.M., Bridges, C.R., Califf, R.M., Casey, D.E., Chavey,
W.E., Fesmire, F.M., Hochman, J.S., Levin, T.N. and Lincoff, A.M., 2013. 2012 ACCF/AHA
focused update incorporated into the ACCF/AHA 2007 guidelines for the management of
patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. Journal of the American College of Cardiology, 61(23), pp.e179-e347.
Aronson, D., Abassi, Z., Allon, E. and Burger, A.J., 2013. Fluid loss, venous congestion, and
worsening renal function in acute decompensated heart failure. European journal of heart
failure, 15(6), pp.637-643.
Carlson, E. and Idvall, E., 2015. Who wants to work with older people? Swedish student nurses'
willingness to work in elderly care—A questionnaire study. Nurse education today, 35(7),
pp.849-853.

8NURSING ASSIGNMENT
College of Nursing and Health Sciences, 2016, CaseWorld™ - Harold Blake, Flinders
University, South Australia, https://flo.flinders.edu.au/course/view.php?id=37845 [Accessed
February 13, 2018].
de Oliveira Medeiros, H.B., de Araújo, D.S.M.S. and de Araújo, C.G.S., 2013. Age-related
mobility loss is joint-specific: an analysis from 6,000 Flexitest results. Age, 35(6), pp.2399-2407.
Evans, N., Wingo, B., Sasso, E., Hicks, A., Gorgey, A.S. and Harness, E., 2015. Exercise
recommendations and considerations for persons with spinal cord injury. Archives of physical
medicine and rehabilitation, 96(9), pp.1749-1750.
Feltner, C., Jones, C.D., Cené, C.W., Zheng, Z.J., Sueta, C.A., Coker-Schwimmer, E.J.,
Arvanitis, M., Lohr, K.N., Middleton, J.C. and Jonas, D.E., 2014. Transitional care interventions
to prevent readmissions for persons with heart failure: a systematic review and meta-
analysis. Annals of internal medicine, 160(11), pp.774-784.
Floras, J.S. and Ponikowski, P., 2015. The sympathetic/parasympathetic imbalance in heart
failure with reduced ejection fraction. European heart journal, 36(30), pp.1974-1982.
Huffman, J.C., Mastromauro, C.A., Beach, S.R., Celano, C.M., DuBois, C.M., Healy, B.C.,
Suarez, L., Rollman, B.L. and Januzzi, J.L., 2014. Collaborative care for depression and anxiety
disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in
Cardiology (MOSAIC) randomized clinical trial. JAMA internal medicine, 174(6), pp.927-935.
Inglis, S.C., Lewsey, J.D., Lowe, G.D., Jhund, P., Gillies, M., Stewart, S., Capewell, S.,
MacIntyre, K. and McMurray, J.J., 2013. Angina and intermittent claudication in 7403

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participants of the 2003 Scottish Health Survey: impact on general and mental health, quality of
life and five-year mortality. International journal of cardiology, 167(5), pp.2149-2155.
Jespersen, L., Abildstrøm, S.Z., Hvelplund, A. and Prescott, E., 2013. Persistent angina: highly
prevalent and associated with long-term anxiety, depression, low physical functioning, and
quality of life in stable angina pectoris. Clinical Research in Cardiology, 102(8), pp.571-581.
Lee, J., Louw, E., Niemi, M., Nelson, R., Mark, R.G., Celi, L.A., Mukamal, K.J. and Danziger,
J., 2015. Association between fluid balance and survival in critically ill patients. Journal of
internal medicine, 277(4), pp.468-477.
Moorhead, S., Johnson, M., Maas, M.L. and Swanson, E., 2014. Nursing Outcomes
Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.
Sahota, O., Drummond, A., Kendrick, D., Grainge, M.J., Vass, C., Sach, T., Gladman, J. and
Avis, M., 2013. REFINE (REducing Falls in In-patieNt Elderly) using bed and bedside chair
pressure sensors linked to radio-pagers in acute hospital care: a randomised controlled trial. Age
and ageing, 43(2), pp.247-253.
Yiğiner, Ö., Tezcan, M., Tokatlı, A. and Değirmencioğlu, G., 2016. Managing the treatment of
the patients with stable angina like a chess player: making moves considering the next move of
atherosclerosis. Journal of geriatric cardiology: JGC, 13(11), p.938.

10NURSING ASSIGNMENT
Appendix
Nursing diagnosis
ANXIETY
Issue- The patient that is accompanied by autonomic response experiences the condition of vague and
uneasy feeling of discomfort or dread.
Desired Outcome- The immediate and main nursing goals in the plan of care in reducing anxiety to a
manageable level and verbalize awareness among the patient about feelings of anxiety with effective
demonstration of coping skills.
Intervention Rationale
It is important to promote the patient’s expression
of fears and feelings
Unexpressed feelings can create turmoil and
presence of negative talk contributing to
exacerbation of the condition (Jespersen et al.
2013).
The nurse should administer tranquilizers,
sedatives as indicated
This relaxes him until he is able to cope up with the
present condition.
As Harold is worried about his position in the
family and lifestyle, his family need to be
encouraged to treat him
He is reassured about his position in family and in
turn reduces his anxiety levels.
This is both a short and long-term goal as family
need to maintain healthy relationships with Harold
so that he feel secured and have fast recovery
(Huffman et al. 2014).

11NURSING ASSIGNMENT
Nursing diagnosis
IMPAIRED PHYSICAL MOBILITY
Issue- CVA affected his left side of the body and impaired mobility. The sudden onset of neurological
deflects as a result of compromised blood flow affected his mobility, verbal and non-verbal response. As
a result, there is impaired physical mobility and affected physical movement in one or more extremities in
the body.
Desired Outcome- The nursing goals increase in function and strength of physical movement by the
compensatory affected part and maintenance of optimal functioning in Harold and demonstration of
behaviours that enable his activities resumption.
Intervention Rationale
assessing of extent of impairment on a scale from
0-4
It helps to identify the deficiencies and strengths of
Harold regarding recovery following the second
day.
He should be made to change positions every 2
hours.
It reduces tissue injury, poor circulation and
sensation.
Beginning of passive (Range of Motion) ROM
after admission and encouraging exercises such as
squeezing, gluteal exercise, and extension of legs,
fingers and rubber ball
There is minimization of muscle atrophy. This also
promotes circulation and prevention of contractures
along with reduction of risk of haemorrhage (de
Oliveira Medeiros, de Araújo and de Araújo 2013).
The nurse should assist Harold in developing
sitting balance by head raising from bed and
assisting him to sit on the bed.
The rationale for this intervention aids in enhancing
proprioception, retraining of neuronal pathways
and motor response.
Moreover, the patient should also be supported at
the lower back and knee positioning using parallel
The long-term goal is to prevent pressure ulcers by
positioning the patient and aligning of extremities

12NURSING ASSIGNMENT
bars. correctly using high-top sneakers for footdrop
prevention or pulsated mattresses (Evans et al.
2015).
Nursing diagnosis
FLUID IMBALANCE
Issue- it is a common complication in CVD. Electrolyte and fluid imbalance can be life threatening for
Harold due to rapid heart rate and tachycardia.
Desired Outcome- To maintain normovolemic conditions, demonstration of lifestyle changes for
avoiding dehydration progression and encouraging Harold to verbalize awareness of behaviours and
causative factors for detecting correct fluid balance (Aronson et al. 2013).
Intervention Rationale
There should also be assessment of oral mucous
membranes and skin turgidity for dehydration
signs.
Elderly skin losses elasticity and hence skin turgor
assessment is required (Floras and Ponikowski
2015).
There should also be monitoring of fluid status that
is related to dietary intake and serum electrolytes,
urine osmolality to report abnormal values as
elevated levels of blood urea nitrogen.
It verify that Harold is on fluid restraint or not and
fluid deficit.
The patient should be administered daily for fluid
intake and need comparison with 24-hour output
and input.
These measurements indicate intravascular volume.
There should also be monitoring of vital signs like These measurements are helpful in the

13NURSING ASSIGNMENT
orthostatic and hypotension and temperature
elevation.
determination of fluid deficit from the body (Lee et
al. 2015).
The nurse needs to ascertain the beverage
preferences of Harold and encourage high fluid
intake while consuming foods.
It relieves discomfort and thirst.
The plan of care should also involve taking safety
precautions using bedside rails, bed placed in low
position and if required soft restraints should be
used.
This would help to prevent patient fall and injury as
decreased cerebral perfusion often results in altered
thought process and created confusion (Moorhead
et al. 2014).