Clinical Reasoning Cycle: Case Study on Coronary Artery Disease

This presentation analyzes a case study of Mr. Tomasi Joni, a 56-year-old mechanical engineer with a history of hypertension, AMI, and other health complications. The presentation follows the clinical reasoning cycle to assess Mr. Joni's risk of developing coronary artery disease (CAD). It begins by considering the patient's situation, including his medical history, lifestyle, and current health indicators. The presentation then collects and processes information, identifying key cues such as elevated blood pressure, abnormal cholesterol levels, and other risk factors. The core of the presentation focuses on the pathophysiology of CAD, explaining the mechanisms of the disease and its clinical manifestations. Goals are established to restore balance between oxygen demand and supply and take action by administering medications and initiating lifestyle changes. The presentation concludes by discussing the outcomes of the nursing care plan and the importance of clinical reasoning in understanding and managing CAD. The presentation also includes references to support the discussed concepts.

Clinical reasoning cycle
Name of the Student
Name of the University
The purpose of the presentation is to select a potential health complication
from the case study and discuss it following the clinical reasoning cycle

Consider the patient situation
 Mr. Tomasi Joni is aged 56 years, a mechanical
engineer, and lives with his wife and children
 He belongs to the Fijian ethnic background
 He resides in Inner West City, Melbourne
 He has been referred for an annual health examination
by his GP
 On assessment, the practice nurse was able to identify
several health complications
Figure 1- Stages of clinical
reasoning cycle
Source- (Levett-Jones et al.,
2010)

Collect cues/information
 Currently he works for more than 50 hours each week
 He tries to perform physical activity during leisure
 He smokes and consumes alcohol and consumes takeaway food
regularly
 Medical history- hypertension, AMI in 2016, obstructive sleep apnea
(OSA) and CPAP for sleep
 Family history- Hyperlipidemia (father) and breast cancer (mother)
 Currently under three medications: metoprolol, aspirin and allopurinol

Process information
 BP 142/96 mm Hg provides indication for hypertension (Bloom, Kemp &
Lubel, 2015)
 Heart rate was 96 bpm that was within the normal limit of 60-100 bpm,
thus indicating normal functioning of the heart
 Respiratory rate of 22 breaths/min indicated a slight elevation from
normal condition, thus indicating shortness of breath (Anzueto &
Miravitlles, 2017)
 SpO2 was 96% on RA and normal
 Body temperature of 36.7°C indicated hypothermia or loss of heat at a
rapid rate from the body (Nassal et al., 2017)

Process information (2)
 Excess abdominal fat, indicating obesity
 Waist circumference of 104 cm
 Elevated level of blood cholesterol 9.2mmol/L (much higher than optimal
2.59-3.34 mmol/L) (Cahill et al., 2019)

Identify problems/issues
 Mr. Joni is at a risk of developing coronary
artery disease (CAD)
 This can be related to his history of
hypertension and AMI
 Also referred to as ischemic disease, the
condition involves a reduction in flow of blood
to the cardiac muscles (Arbab-Zadeh & Fuster,
2015)
 This limited blood flow is related to the
accumulation of plaque in the cardiac arteries
Figure 2- Coronary artery
disease
Source- (Torborg, 2018)

Establish goals
S Restoring balance between
oxygen demand and supply
M Measuring blood pressure and
cardiac output
A Administering medications
R Oxygen balance can be
restored
T 48 hours
S Reducing risk for coronary
artery disease
M Conducting stress
echocardiography
A Administering antiplatelet
drugs and nitro-glycerine
R Blood flow can be restored
T 48 hours
Restoring balance between oxygen
demand and supply Reducing risk for coronary artery
disease

Take action
 Administration of nitroglycerine
 Administration of calcium channel
blockers
Figure 3- Comparison of
normal heart and CAD heart
Source- (UChicago Medicine,
2018)

Take action
 Anti-platelet therapy
 External warming
Figure 4- Treatment plan
Source- (Skelly et al., 2016)

Conclusion
Hence, the case study suggested that the patient was at a risk of developing CAD.
The following outcomes will determine success of the nursing care plan discussed
previously:
 Reduction in blood pressure
 Reduction in respiratory rate
 No reports of angina episode
 Initiation of lifestyle changes
The clinical reasoning helped in gaining an understanding of risk factors for CAD
It helped in understanding pathophysiology of the health abnormalities manifested by
Mr. Joni. However, the nursing care plan could have been done differently, by placing
due focus on other treatment strategies such as, antiplatelet drugs, angioplasty, and
coronary artery bypass grafting.

References
Anzueto, A., & Miravitlles, M. (2017). Pathophysiology of dyspnea in COPD. Postgraduate medicine, 129(3), 366-374.
Arbab-Zadeh, A., & Fuster, V. (2015). The myth of the “vulnerable plaque”: transitioning from a focus on individual lesions to atherosclerotic disease burden for coronary artery disease risk assessment. Journal of the American College of Cardiology, 65(8), 846-855.
Bloom, S., Kemp, W., & Lubel, J. (2015). Portal hypertension: pathophysiology, diagnosis and management. Internal medicine journal, 45(1), 16-26.
Cahill, L. E., Sacks, F. M., Rimm, E. B., & Jensen, M. K. (2019). Cholesterol Efflux Capacity, HDL Cholesterol, and Risk of Coronary Heart Disease: a Nested Case-Control Study in Men. Journal of lipid research, jlr-P093823.
Campbell, G., Alderson, P., Smith, A. F., & Warttig, S. (2015). Warming of intravenous and irrigation fluids for preventing inadvertent perioperative hypothermia. Cochrane Database of Systematic Reviews, (4).
Chow, C. K., Redfern, J., Hillis, G. S., Thakkar, J., Santo, K., Hackett, M. L., ... & Bompoint, S. (2015). Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. Jama, 314(12), 1255-1263.
Cui, H., López, M., & Rahmouni, K. (2017). The cellular and molecular bases of leptin and ghrelin resistance in obesity. Nature Reviews Endocrinology, 13(6), 338.
Cury, R. C., Abbara, S., Achenbach, S., Agatston, A., Berman, D. S., Budoff, M. J., ... & Rybicki, F. J. (2016). CAD-RADSTM coronary artery disease–reporting and data system. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT),
the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. Journal of cardiovascular computed tomography, 10(4), 269-281.
Daw, J., Margolis, R., & Wright, L. (2017). Emerging adulthood, emergent health lifestyles: Sociodemographic determinants of trajectories of smoking, binge drinking, obesity, and sedentary behavior. Journal of health and social behavior, 58(2), 181-197.
Fletcher, G. F., Landolfo, C., Niebauer, J., Ozemek, C., Arena, R., & Lavie, C. J. (2018). Promoting physical activity and exercise: JACC health promotion series. Journal of the American College of Cardiology, 72(14), 1622-1639
Jäger, B., Piackova, E., Haller, P. M., Andric, T., Kahl, B., Christ, G., ... & Huber, K. (2019). Increased platelet reactivity in dyslipidemic patients with coronary artery disease on dual anti-platelet therapy. Archives of medical science: AMS, 15(1), 65.
Kristofik, N. J., Qin, L., Calabro, N. E., Dimitrievska, S., Li, G., Tellides, G., ... & Kyriakides, T. R. (2017). Improving in vivo outcomes of decellularized vascular grafts via incorporation of a novel extracellular matrix. Biomaterials, 141, 63-73.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y. S., Noble, D., Norton, C. A., ... & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’patients. Nurse education
today, 30(6), 515-520.
Maruhashi, T., Kajikawa, M., Nakashima, A., Iwamoto, Y., Iwamoto, A., Oda, N., ... & Watanabe, N. (2016). Nitroglycerine-induced vasodilation in coronary and brachial arteries in patients with suspected coronary artery disease. International journal of cardiology, 219,
312-316.
Nassal, M. M., Wan, X., Dale, Z., Deschênes, I., Wilson, L. D., & Piktel, J. S. (2017). Integrative Cardiovascular Physiology and Pathophysiology: Mild hypothermia preserves myocardial conduction during ischemia by maintaining gap junction intracellular communication
and Na+ channel function. American Journal of Physiology-Heart and Circulatory Physiology, 312(5), H886.
Skelly, A. C., Hashimoto, R., Buckley, D. I., Brodt, E. D., Noelck, N., Totten, A. M., ... & McDonagh, M. (2016). Noninvasive testing for coronary artery disease.
Tocci, G., Battistoni, A., Passerini, J., Musumeci, M. B., Francia, P., Ferrucci, A., & Volpe, M. (2015). Calcium channel blockers and hypertension. Journal of cardiovascular pharmacology and therapeutics, 20(2), 121-130.
Torborg, L. (2018). Mayo Clinic Q and A: Coronary artery disease — prevention and early warning signs. https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-coronary-artery-disease-prevention-and-early-warning-signs/
UChicago Medicine. (2018).Coronary Artery Disease and Chest Pain. https://www.uchicagomedicine.org/conditions-services/heart-vascular/coronary-artery-disease
Wallerstein, N., Minkler, M., Carter-Edwards, L., Avila, M., & Sanchez, V. (2015). Improving health through community engagement, community organization, and community building. Health behavior. Theory, research and practice. 5th ed. Hoboken, NJ:
Jossey-Bass, 277-300.
Warm, J. S., Matthews, G., & Finomore Jr, V. S. (2018). Vigilance, workload, and stress. In Performance under stress (pp. 131-158). CRC Press.