Functional Assessment in the Middle Years - a Hypertensive Cardiovascular Disease - Case Study Example

Functional Assessment in the Middle Years A Hypertensive Cardiovascular Disease (HCVD) INTRODUCTION Cardiovascular disease is one of Australia’s largest health problems. It is the leading cause of death in this country accounting for 34% of all deaths in Australia in 2006 (National Heart Foundation of Australia, 2010). Hypertensive cardiovascular disease (HCVD), also called hypertensive heart disease, is a term applied generally to heart diseases that are cause by direct or indirect effects of uncontrolled and prolonged elevation of blood pressure (Riaz & Ahmed, 2010). High blood pressure increases the pressure in blood vessels making the heart work harder as it pumps against this pressure (Mikati, 2010). Risk factor is a range of non-modifiable and modifiable health-related behaviours and biomedical conditions that can affect the health of an individual in a negative way (Australian Institute of Health and Welfare, 2004, p.64). Major risk factors for cardiovascular problems, in addition to hypertension, include smoking, dyslipidimia or blood cholesterol levels, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, and family history of cardiovascular disease (Smeltzer, Bare, Hinkle & Cheever,, 2008, p.1023). Apart from medical treatment, lifestyle modification program is also an important aspect in managing HCVD cases. According to Shepard (2010, p.3) lifestyle modification programs are long term changes in the individual’s lifestyle in order to decrease the incidence and progression of heart disease through a variety of interventions designed to reduce modifiable risk factors. These may include exercise, nutrition, stress management, psychological counseling, education, and social support components, although the specific interventions may vary by program (Shepard, 2010, p.3) This case study is about functional health assessment conducted to a middle-adult female medically diagnosed to have hypertensive cardiovascular disease. The assessment was done base on Gordon’s functional health patterns (FHP) to establish a comprehensive nursing data base. According to Daniels (2004, p.63), FHP is a systematic holistic approach to evaluate all areas of human needs, recognizing that the needs are interdependent. FHP is categorized into 11 patterns of functioning including: health perception and health management; nutritional and metabolic; elimination; activity and exercise; sexuality and reproductive; sleep and rest; sensory and perceptual; cognitive; role and relationship; self-perceptual and self-concept; coping and stress; and values and beliefs (Jester, 2007, p.162). It is important for the nurse to assess the client’s functional health patterns because alterations in health can affect any of these areas, and alterations in functional health patterns, in turn, affect health (Weber, 2009, p.343). Analysis and health promotions for holistic patient care are also included for completeness of presentation. A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN 1) History of Present Illness Mrs. M.G. is a 59-year-old widow from Townsville who sought for medical help at the emergency department with chief complaints of chest pain and dizziness on July 21, 2010 at 6:45 PM. She is overweight, weighing 164 lbs at 5 feet 5 inches height. Two days ago, she attended a neighbor’s barbeque party and had taken some pork barbeque and champagne. That night, she experienced tightness of her nape but disappeared after she took some medication and rest. On the afternoon prior to her admission, while the patient was cleaning the house, she experienced a sudden onset of chest pain, dizziness, dimness of vision, tightness of her nape and fatigue. Thinking that these symptoms will just subside after taking one tablet of nifedipine (Procardia) 60 mg orally and some rest like she always did, she kept calmed. She rested for a couple of hours but still was not relieved from her symptoms (shortness of breath, nausea, chest pain, and intense headache). So she asked her daughter to take her to the hospital for immediate medical help. Initial vital signs were: blood pressure-180/110 mmHg; body temperature- 98.06° F; pulse rate-69 beats/minute; and respiratory rate-28 breaths/minute. 2) Treatment/Medication The client has not undergone any invasive treatment procedure but only medical treatment and lifestyle modification program. She had been taking norvasc 10 mg as daily maintenance to control her blood pressure (BP) for more than 5 years already. She monitors her blood pressure from time to time at home and whenever her BP exceeds 170/100 mmHg accompanied by some symptoms like tightness of nape and dizziness, she takes nifedipine (Procardia) 60 mg orally as needed. She also takes multivitamins everyday. This is the medication treatment regimen established by her physician coupled with some lifestyle modification when she was first diagnosed to have HCVD during 2005, the time when she was first confined in the hospital with the same symptoms she is having now. Her lifestyle modification program includes smoking cessation, walking exercise for 30 minutes everyday, low salt low fat diet, weight loss, and indulgence in social or community organizations that would keep her self busy. 3) Prevention Practices Prior to Mrs. M.G.’s onset of HCVD in 2005, she used to be a smoker for more 10 years during her early adult stage, consuming an average of 1 pack of cigarette everyday. She was physically active during that time and even engaged in strenuous physical activities like mountain biking and jogging. However, when she was diagnosed to have HVCD her physician made her aware that her smoking habit has a big contribution in the prognosis of her disease. From that time then on, she stopped smoking. Foods high in cholesterol and salt content were prevented and she was encouraged to lose weight. The client admitted that sometimes she is too lazy to follow all these lifestyle modification like walking daily for 30 minutes, she just do it twice a week. Also, she finds it hard to follow the strict adherence to low fat low salt diet for she still eats pork and some other fatty and salty foods especially once these has already been laid on the table. 5) Routine Health Examinations and Follow-ups The client undergoes a yearly general health check up and attends to scheduled follow-ups when needed. Some of her medications were changed by her physician to suit the appropriate combination of drugs that her body requires. B. NUTRITIONAL AND METABOLIC PATTERN 1) Weight Loss/Gain Mrs. M.G. recalled that she started to gain weight when she started to menopause when she was 47. Also during this period that she stopped working as a primary school teacher and just stayed home to take care of her two grandchildren whilst her husband, daughter, and son-in-law were out during the day for work. Her life then started to become sedentary. During the initial diagnosis of Mrs. M.G’s HVCD in 2005, the client weighed 172 lbs and she achieved a weight loss of 11 lbs for the entire 5 years--way far to the target weight that she was supposed to lose (which was at least 22 lbs) for she is still falls under the category of being an overweight with her present body mass index (BMI) of 26.8. According to the National Lung, Heart, and Blood Institute (2010), body mass index is a measure of body fat based on height and weight that applies to adult men and women with BMI categories as Underweight (BMI < 18.5), Normal weight (BMI = 18.5–24.9), Overweight (BMI = 25–29.9), and Obesity (BMI of 30 or greater). Prior to her present symptoms, she weighed 161 lbs and for the last 3 days only she gained 4 lbs (most recent body weight upon hospital admission is 165 lbs). She have noticed her extremities grew bigger compared to their regular size prior to symptoms. 2) Daily Food Intake Meal Usual Amount/Type of Foods Taken Time Breakfast 1 cup rice, egg, hotdog/bacon, & coffee 8AM Lunch 1 cup rice, vegetables, fish & fruit juice 11:30AM Dinner 1 cup rice, fish & soup, 7PM Snacks Bread & fruit juice 3PM 3) Daily Fluid Intake Total amount of fluid intake/day: 2500 – 3000 mL/day Kinds of fluid usually taken: Water, fruit juice, soda, & coffee 4) Drug and Alcohol Consumption No history of prohibited drug use and takes mild alcohol containing drinks (e.g. red/white wine) at very minimal amount seldom within a year. 5) Problems That May Contribute to Nutritional Imbalance No difficulty in swallowing. The patient is with dentures. E. ELIMINATION PATTERN 1) Bowel Habits Defecating frequency: Once to twice a day Amount: Moderate Problems or difficulties: None 2) Bladder Habits Voiding frequency: 5 times a day or more Amount/volume: Moderate (about 250-300 mL) Problems or difficulties: Urinary incontinence during postmenopausal period. 3) Recent Changes Two days prior to hospital admission, the client experienced some urethral discomfort and decrease in urine output due to fluid retention in her body. F. ACTIVITY AND EXERCISE PATTERN 1) Self-care and Activities of Daily Living (ADLs) Prior to the onset of symptoms, no problems can be noted with the client’s self-care and ADLs functioning as she stated that she managed to eat, bathe, dress, go to the toilet, and mobilize from one place to another by herself. At home, she spends most of her time sitting in front of her computer surfing the internet, watching television, or reading a book. She used to spend an hour of walk in the morning without any feeling of fatigue after this activity but these past years she realized that she easily gets tired when she walks even in short distances. She also noticed that during prolonged physical activity she experiences shortness of breath, tightness of chest, and exhaustion that were relieved through resting. 2) Exercise, Recreation, and Leisure Activity Doctor Gelfand (2010) of WebMD mentioned some exercise tips for heart disease patients and these are: (1) exercise is paced and balanced with rest, (2) avoid isometric exercises, (3) no outdoor exercises during extreme temperatures, (4) drink plenty of water even before thirst is felt, (5) avoid extreme hot/cold showers or sauna baths, (6) avoid working too hard or walking up on steep areas, (7) interrupted exercise program should be started with reduced level of activity once the patient is ready and gradually increasing it until old program is met. Walking is the only form of exercise and leisure activity of the client. She walks from home going to the nearby town garden for 30 minutes during weekends with her dog and grandchild. Sometimes, she would go out with her daughter’s family for a picnic or malling, or go to the beach for fun and relaxation. At home, she finds comfort in sitting at the front of her garden, watching the plants and flowers or browsing the internet with her laptop. G. SEXUALITY AND REPRODUCTIVE PATTERN 1) Menstrual History The client had her first menstruation when she was 11 years old. No problems or irregularities experienced during her menstrual period and cycle. She started to menopause when she was 47 years old and underwent some postmenopausal symptoms such as hot flushes, anxiety, palpitations, and increase in blood pressure due to hormonal changes but all eventually disappeared except the high blood pressure that occurred more often than before. 2) Sexual Practices Sexual activity of the client stopped sometime after postmenopausal period. She have not had any sexually transmitted disease as she was loyal to her husband and had never been promiscuous. She performed self-breast examination occasionally and not in a regular monthly routine and underwent PAP smear twice in her life. No history of sexual abuse traced. H. SLEEP AND REST PATTERN 1) Sleep Habits Usually sleeps at around 9:00 in the evening and wakes-up at 7:00 in the morning. Since the death of her husband a year ago, she claimed that she cannot sleep easily and sometimes experiences insomnia. She tried having a warm bath and drinks a glass of hot milk before going to bed which are sometimes effective for her to fall asleep. She always pray before going to bed. I. SENSORY AND PERCEPTUAL PATTERN 1) Sensory Client’s sense of sight, hearing, taste, smell, and touch are still functioning to acceptable levels. She is using an eye glasses for clearer vision acuity. 2) Perception She has excellent orientation to person, place, and time. On this recent ischemic attack, she perceived her felt chest pain as sharp, radiating to her left arm, with a rate of 8 out of 10 (10 as the highest in pain scale intensity). J. COGNITIVE PATTERN The patient’s highest educational attainment is a college graduate and she used to work as a primary school teacher. Her memory is still intact in terms of short and long term commemoration of the significant events in her life. Ability of concentration is not excellent since she still feels weak but is capable to decide for what is best for her self when all treatment alternatives are explained. Sufficient best rest is needed for her to regain strength. K. ROLE AND RELATIONSHIP PATTERN The patient had been a widow for more than a year since the death of her husband last year. The death of her husband has a major impact in her life for she had a very good marital relationship with him. She lives with her daughter and son-in-law, with their two children, and they are her major source of strength whenever she experiences emotional stress. As a mother and a grandmother, she feels that she had been able to portray her role in the best of her capacity. Outside her immediate family, one stressor identified was her resignation from work. This particular event had made her less active in social activities, as she used to spend more time with her colleagues before during work and social affairs, though she maintained a good social relationship with them up to now. She has moral supporters from the community’s organization where she is a member and some friends who cared for her. L. SELF-PERCEPTUAL AND SELF-CONCEPT PATTERN She is fully aware that she has been lax in maintaining the modified lifestyle that she ought to have as implemented by her physician when she was first diagnosed of HCVD 5 years ago, though she had been diligent in taking her medications. She appeared to be anxious about her present health situation that she always verbalizes the general body weakness that she is having presently. When asked of how she feels about her present situation now, she admitted that she regretted not to strictly adhere with the lifestyle modification program that she was bound to maintain. She is now convinced about the importance of lifestyle modification programs which are indeed essential for her survival. This realization and acceptance from the part of the patient conveys her willingness for the changes in her lifestyle that she must follow eventually. M. COPING AND STRESS PATTERN The loss of her husband a year ago has been a very depressing experience for the patient and she admitted that until now she still feels sad for his loss. Also, she noticed that her daughter looks problematic lately and she tends to argue with her husband more often. Her daughter is not vocal when it comes to emotional problems though she had known her to be a strong woman. With her family as her most significant source of strength, these two events may have significantly affected her in coping with her present illness. Outside the family circle, the client has two close friends within the community that have benefitted her in matters of being able to release her sentiments with. Unfortunately, one of them moved to another place of residence and she was not able to see her as often as she used to. Spending time with her grandchildren and surfing the internet were the two pastimes that had kept her preoccupied, helping her to momentarily forget the problems that she have. N. VALUES AND BELIEFS PATTERN The client has a mixed ethnicity of Asian and Australian roots. Her mother was an Asian and her father was an Australian. Both were deceased already and have history of hypertension. She acquired the values of close familial relationship and monogamy from her mother--the reason why her only child (her daughter) still lives with her even after having a family of her own. She is a practicing Roman Catholic by religion and believes in the power of faith in God. With the recent episode of ischemic attack, she realized and believed that treatment programs should be taken seriously indeed. ANALYSIS AND HEALTH PROMOTIONS Base on the above subjective cues achieved from detailed functional health assessment, some areas in Mrs. M.G.’s functional health patterns were identified to significantly affect the development and prognosis of her illness. Thus, health promotions focused on these particular areas of health pattern are essential for holistic patient care. As to health management, activity, and exercise patterns, the client needs more awareness to the importance of adherence to lifestyle modification program, thus she must achieve the 30-minute walking exercise everyday. Since the client’s present walking routine is only during every weekend, she is to start on that level of activity and increasing it at a time, like adding another day on the following week, so on and so forth at her tolerable capacity until desired goal is achieved. No walking on steep areas or overworking and have time for rest during physical activity. As to nutritional and metabolic patterns, the client is advised to strictly follow the low fat low salt diet. Her daughter is also advised to monitor her mother’s eating pattern. In such instances where foods rich in fat and salt are prepared for viand, there shall always be non-fatty and non-salty alternative foods to be prepared for the client. As to elimination pattern, when normal body fluid input and output patterns has been achieved, the client is advised to drink plenty of water everyday even before thirst is felt, not unless otherwise under fluid intake restrictions ordered by the physician. Encourage eating more fresh fruit and oatmeal for good digestion. As to role and relationship pattern merged with coping and stress pattern, it has been noted that the client was significantly affected by the loss of her husband. A referral to a professional counselor for coping and stress management is essential. The patient’s daughter is also made aware that her mother worries about her personal marital relationship. If openness is hard to achieve, as person’s individuality is highly respected, the daughter is at least encouraged not to show emotional hang-ups that may be stressful to the patient. In summary, strict adherence to treatment and lifestyle modification programs, strengthening of patient’s sources of strength, and providing a non-stressful environment for the patient are the ways to lessen the risks of cardiovascular attack in the future. References Australian Institute of Health and Welfare (AIHW) 2004. Heart, stroke and vascular diseases—Australian facts 2004, p.64, AIHW Cat. No. CVD 27, Canberra: AIHW and National Heart Foundation of Australia (Cardiovascular Disease Series No. 22), accessed 8 August 2010, from < http://www.aihw.gov.au/publications/cvd/hsvd04/hsvd04.pdf>. Daniels, R 2004, Nursing Fundamentals: Caring & Clinical Decision-Making, p.64. Delmar Thomson Learning, U.S.A. Gelfand, JL 2010, ‘Safe exercise for heart disease patients’ [Article review], WebMD LLC, accessed 8 August 2010, from . Harder, AF 2009, The developmental stages of Erik Erikson, accessed 7 August 2010, from . Jester, R 2007, Advanced Rehabilitation Nursing, p. 162, Blackwell Publishing, Australia. Mikati, I 2010, ‘Hypertensive hart diseases’, National Institutes of Health MedlinePlus, accessed 7 August 2010, from . National Heart Foundation of Australia 2010, Cardiovascular Disease Statistics, accessed 8 August 2010, from . National Heart, Lung, and Blood Institute 2010, ‘Calculate your body mass index’, Aim for a Healthy Weight, accessed 8 August 2010, from . Riaz, K & Ahmed, A 2010, ‘Hypertensive heart disease’, Medscape eMedicine Specialties, accessed 6 August 2010, from . 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