Nursing - Smoking and Heart Diseases - Essay Example

Assignment: Design a Management Plan for a Patient who Smokes and has recently been diagnosed with heart disease Identify at least two core Health Issues Outline at least two nursing interventions for each issue identified Identify potential and actual health problems Describe relevant primary and secondary interventions and their effectiveness Identify any legal or ethical issues relevant to your scenario April 27, 2008 Scenario John is a 47-year old divorced construction worker who visits his local health centre complaining of chest pains. He reports a history of smoking a pack of cigarettes per day since age seventeen. Diagnostic investigations confirm that John has angina pectoris. John is fairly surprised. He had thought the chest pains were due to a bad case of heartburn and had been taking antacid pills on and off for weeks. Although his dad died of a stroke at age 53, John considers himself to be as strong as a bull. He has never bothered to visit doctors-nor needed to before. He admits that especially since his divorce he hasn't been paying much attention to his health. Introduction The percentage of Australians who smoke nowadays is much less than in 1945 according to the Cancer Council (2007) statistics. But smoking is still a huge problem that causes many unhealthy side effects and can lead to death (Heart Foundation, 2002). It also presents a substantial financial burden for the health care system because of the resultant morbidity that is associated with smoking (Australian Bureau of Statistics, 2006; Heart Foundation, 2002; Ministerial Council on Drug Strategy, 2004). The scenario of a smoker who seeks medical care because of a heart condition is very plausible. Smoking and heart disease are often found together (Better Health Channel, 2002). The Australian Bureau of Statistics (2006) lists smoking as a key risk factor for ischaemic heart disease, and other fatal illnesses. Heart disease itself has a high prevalence. It is the most common cause of sudden death and also the single disease from which the most people in Australia-and most industrialised nations-die (Australian Institute of Health and Welfare 2006). There are many forms of heart disease, but coronary heart disease, or ischaemic heart disease is most common and often presents itself in form of angina (Australian Institute of Health and Welfare 2006), as in the case of our patient, John. This paper will deal with the actual and potential health issues in cases such as this one, examining the broader scope of matters to be considered in planning the management of such a case, as well as identifying specific actions that can be taken to improve the patient's situation. It will also reflect on possibilities for primary and secondary preventive measures and take into account as many factors that might be relevant for the overall well-being for this particular patient. Management Health Issues The two obvious core health issues of this patient are smoking and heart disease. However, both smoking and heart disease can be connected to other complaints (Heart Foundation 2002, JBI 2005). The first contact with patients is a good time to find out what is worrying them most. In John's case, the overall social situation will be of interest. His performance at work may be seriously impeded by his heart condition. If he is not accustomed to taking care of himself without a wife, his diet may be unhealthy and he may have emotional problems connected to the stress of divorce. Cigarette smoking has many detrimental effects (Heart Foundation, 2002). The main part of the problem is that many habitual smokers are addicted to nicotine (Ministerial Council on Drug Strategy, 2004). Addiction is a complex health problem, and Tan et al. (2000) report that almost 80% of smokers in Australia have already tried to quit but failed. In fact, the addiction itself makes it hard for smokers to want to quit. The drug nicotine affects the ability to make a rational decision. Because the brain and body suffer from withdrawal symptoms, quitting is unpleasant. Drug addicts will often make excuses to not stop the drug. It is the same thing with nicotine (Ministerial Council on Drug Strategy 2004). One key question for the management plan will be what the patient thinks about quitting. Because smoking has so many negative effects, a priority is to try to help the patient quit. But in the end, it is always a personal choice and John will have to decide for himself. Heart disease occurs in different forms (Australian Institute of Health and Welfare 2006). Coronary heart disease is the most common kind of heart disease in Australia (Australian Institute of Health and Welfare, 2006). Patients come in with angina, or in some cases heart attacks, or myocardial infarction. As this is a common cause of sudden death, it would be important to monitor patient. When in hospital, the patient may have to undergo many tests and intervention. Chest pains due to angina can be frightening. It is important for the patient to understand all the factors and symptoms and understand how we can deal with them (Deaton & Namasivayan, 2004). The overall management plan should cover as much information about the patient's general health status as possible (JBI, 2005). The Best Practises guidelines recommend the SF-36 "a short form health survey with 36 items measuring the following eight domains of health: physical functioning; role limitation due to physical health problems; bodily pain; general health; energy and vitality; social functioning; mental health; and role limitations caused by mental health problems" (JBI, 2005). The Hospital Anxiety Depression Scale can be used to check mental status. Depression can also be deadly and is sometimes missed by primary care providers. JBI also suggests using a 19-item instrument as "quality of life measure related to cardiac disease. It quantifies physical limitation due to coronary artery disease, angina stability over the preceding month, frequency of angina symptoms, satisfaction with treatment for coronary artery disease, and patients' perceptions of how coronary disease limits the quality of life" ( JBI 2005). By investigating all these aspects we reduce the risk of missing something important. These survey instruments are also good for follow-up later to determine the impact of care and treatment , which can be measured in following outcomes listed by Deaton and Namasivayan (2004): mortality, morbidity, and costs; psychosocial issues, quality of life, and functional status; symptom management; and self management/ behavioural change. Actual and Potential Problems John's most pressing and apparent problem is his angina pectoris. As his reason for seeking medical attention, it may well present an obstacle to functioning well at work. As John had no idea that his symptoms were due to a heart problem, this diagnosis might cause some uncertainty and anxiety (Deaton & Namasivayan, 2004; Mooney & Boxer, 2003). The coronary heart disease responsible for angina is also connected to an increased risk of heart attack and sudden death. Clots in coronary heart disease can also be associated with atherosclerotic changes in other blood vessels. There can be an increased risk of stroke. Also risk factors are hypertension, high blood cholesterol, diabetes, physical inactivity and overweight (Australian Institute of Health and Welfare, 2006). John will need to understand his symptoms and be educated on the proper management. The illness may affect his performance at work. There's a safety issue, as attacks may come suddenly, and if John is working on a scaffold, that might be very dangerous. The socioeconomic impact of the illness is another potential problem John may have to face. The fact that John is a manual labourer will make the severity of his heart disease very relevant. If the symptoms of angina are exercise dependent, John may be unable to do any hard work and may have to find a new job, or at least go on leave. A reduction in the level of functioning is common with cardiac patients awaiting treatment interventions (Deaton & Namasivayan, 2004; Mooney & Boxer, 2003). Another psychosocial aspect of the illness is the question of how much support and assistance John has from friends, family and neighbours. As a divorced man, the prospects may not be less than ideal. He may have to worry about alimony payments and be suffering from loneliness, anger or guilt. The second problem is cigarette smoking. Some smokers do not even consider this a problem. But smoking is connected to nicotine addiction and a lot of other problems, too (Australian Bureau of Statistics, 2006; Heart Foundation, 2002; Ministerial Council on Drug Strategy, 2004). The Heart Foundation (2002) list of problems associated with smoking is extensive. One problem is a negative effect on the endothelial cells that line the walls of blood vessels. This facilitates artery clogging (Atherosclerosis) leading to various cardiovascular problems. Things like heart attacks, strokes, aneurysms and peripheral artery disease can follow. Infact smoking can exacerbate or worsen John's existing heart problem. Smoking also causes lung and respiratory problems like chronic obstructive disease, or emphysema, lung cancer and cancers of many other organs. The Heart Foundation also mentions bad breath, discoloration of teeth and hair, and fingers, smelly hair and clothes, and wrinkles as well as impotence in men and fertility problems in women. If John suffers from sexual dysfunction, this might have played a role in his divorce, or affect his ability to find another partner. But smoking is not only a problem for smokers. Environmental smoke can affect the health of non-smoking. Passive smoking is linked with sudden infant death, bronchitis, asthmatic symptoms, lung cancer and cardiovascular disease, too (Heart Foundation, 2002). Nursing Interventions The most important intervention for both issues is probably education and information (JBI, 2005) which can take place in form of a patient conference early on. The patient could learn about the disease processes and get help understanding symptoms and complications. The team can discuss diagnostic procedures and treatments. Maybe John needs coronary angiography, revascularisation, or coronary artery bypass grafting. If so, he will benefit from good information about procedures and the nature of the disease and prognosis (Deaton &Namasivayan, 2004; JBI, 2005). For example, if the patient is given Nitroglycerin to treat angina, it is important to explain how to deal with attacks and possible side-effects and increase his competency in symptom management (Deaton &Namasivayan, 2004). Deaton and Namasivayam also say "Although nursing interventions in acute care (eg, monitoring patients for ischemia, reducing anxiety), chronic illness management, and secondary prevention may have significant effects on mortality, morbidity, and costs, few investigators have measured these outcomes and explicated the links between action and outcome." The second important intervention for the heart disease issue would be the comprehensive assessment mentioned in the management plan. Follow-up on the change in symptoms over time will help the team determine when treatment is working and if and when it should be changed. An important intervention for smoking would be to discuss whether the patient wants to try quitting. If so, then a plan would need to be made on how to achieve that. There are quitting programmes online, or one might look for a group intervention. If the patient does not want to quit, one intervention could be to try to increase motivation for quitting (Ministerial Council on Drug Strategy). Quitting smoking is not the only lifestyle change that can help, but it would be very significant for the progress of the heart condition. The Heart Foundation (2002) stresses that the risk of heart disease decreases after stopping smoking for 2-6 years; and it is never too late to quit. Lifestyle changes in general are an important part of nursing interventions for both issues (JBI, 2005; Heart Foundation, 2002). John could be offered assistance with stress management to reduce the urge to smoke, and reduce the frequency of heart symptoms (Deaton & Namasivayan, 2004). Progressive muscle relaxation techniques can help, or something like meditation, yoga, Chi Gong and Tai Chi. Dietary measures and regular exercise are also beneficial (Deaton &Namasivayan, 2004). Mooney & Boxer (2003) researched mainly heart failure patients, but some of their findings can apply to other heart disease, too. Especially the part about recognising patient needs. A general nursing intervention is to have an open ear and listen to the problems other health care professionals don't have time for, or avoid. Patients do not always recognise their own needs and some are shy of mentioning things to their doctors. It can help to talk about prognosis, and in some cases death and dying (Mooney and Boxer 2003). Primary and Secondary Health Prevention Primary Prevention: The epidemiology of tobacco smoking is well documented (Cancer Council, 2007) and risk groups have been identified (Kaleta et al. 2007). Primary prevention will be a large part of the strategy of the Ministerial Council on Drug Strategy (2004), and as research by Tan et al. (2000) shows, anti-smoking ad campaigns can be effective. Although tobacco companies are required by law to put a warning on the cigarette boxes, many smokers are unaware of the risks when they start to smoke (Ministerial Council on Drug Strategy, 2004). Nursing care providers can distribute educational material on quitting, and inform about the negative effects of smoking. Community nurses can visit schools and workplaces and perform anti-smoking activities (Ministerial Council on Drug Strategy, 2004). Perhaps if John had received anti-smoking information at an early age, the problem would not have occurred. Primary prevention of heart disease is a little more difficult to decide on. Napoli et al. (2006) mention several possibilities. For example, some people who belong to risk groups for developing heart disease take anti-inflammatory pills like aspirin to prevent the development of heart disease. But this can also have negative side effects like any medicine. So it is good to consider the risk as well as the benefits of such a measure. Obesity can lead to early changes of atherosclerosis in the cell walls even in children (Napoli et al. 2006). So primary counselling on diet and exercise, should begin in schools in order to be most effective. Diet can help to reduce cholesterol in some people if they avoid the wrong kinds of fat and eat the right kinds (Napoli et al. 2006). If John had known about appropriate health measures and led a healthy lifestyle, this might have prevented heart disease. Secondary Prevention: Cigarette smoking is associated with many risk factors for disease and high social costs (Collins & Lapsley, 2002; Heart Foundation 2002; Kaleta et al. 2007; Ministerial Council on Drug Strategy, 2004). The WHO (2008) warns that smoking may cause up to a billion deaths by 2100. Smoking cessation is a good preventive measure because it is almost 100% certain that giving up smoking improves health factors and reduces risk of some fatal or chronic illnesses (Heart Foundation, 2002). The WHO recommends telling people about the risks and helping them to quit in its MPOWER program (WHO 2008). This is one important thing I could do for John. I could register him for an appropriate smoking cessation intervention in our area and follow-up with measure that can help him stay quit (self-help groups, stress management, etc.). John might benefit from secondary prevention, in terms of trying to find ways to prevent the heart disease from getting worse. Medication regimes and therapeutic interventions can be supplemented by cardiac rehabilitation, appropriate exercise regimes and diet (Deaton & Namasivayan, 2004). Self-help groups and angina diaries are also helpful to reduce symptoms (JBI, 2005). I would offer John help in finding groups and be available to advise him in case of problems and questions. Legal and Ethical Issues Legal and ethical considerations are dealt with extensively by the Ministerial Council on Drug Strategy (2004) and the WHO (2008). The issue of corporate responsibility of the tobacco companies, the role of taxes and the fact that tax revenues from tobacco products by far exceed spending on smoking prevention (WHO) are tantalizing questions. The rights of smokers to "free choice" (Ministerial Council on Drug Strategy 2004) and their marginalisation by prohibition measures is also another issue that inspires debate and will require ethical consideration and practical measures (Barblett et al. 2005) regarding appropriate interventions in health promotion. Conclusion The measure of the success of a management plan is whether or not there are positive outcomes for the patient. Has John understood the educative measures Has this understanding led to behavioural change, and ultimately, have the interventions served to increase the health and well-being of the patient, or at least hindered further deterioration With appropriate feedback from the patient corrective measures can be taken and successes can be used to inspire and motivate both the patient and the case management team. John's illness is an opportunity for him to heed the warning and change to a healthier lifestyle. Appropriate exercise, dietary measures, smoking cessation and good management of his symptoms either through medication or invasive measures can help to reduce John's suffering and improve his quality of life. The measure of good nursing care is just how well one manages to address the patient's needs, even those about which he may not himself be aware, to increase the level of knowledge and competency in managing one's own health and reduce morbidity and mortality, as far as possible. If we succeed that will make our efforts worthwhile. And for John that may mean living longer with a better quality of life than he would have enjoyed without nursing care. References Australian Bureau of Statistics, 2006. Tobacco Smoking in Australia: A Snapshot, 2004-05 Available at [Accessed 23 April, 2008] Australian Institute for Health and Welfare, 2006. Coronary Heart Disease. Available at [Accessed on 24 April 2008] Barblett, A., Bayly, L., Hansen, J., Poole, A., 2005. Advocating for Accredited Population Health Training as Part of a Workforce Development Strategy. Presented at the 15th National Health Promotion Conference. Australian Health Promotion Association. [Online] Available at > [Accessed 27 April 2008] Better Health Channel, 2002. Smoking and Heart Disease. Available at >[Accessed March 24, 2008] The Cancer Council NSW, 2007. Smoking in Australia-Statistics [Accessed March 21, 2008] Collins, D.J., Lapsley, H.M., 2002. Counting the cost: Estimates of the social costs of drug abuse in Australia in 1998-99. Canberra: Commonwealth Department of Health and Ageing, National Drug Strategy Monograph Series, No. 49. Deaton, C., Namasivayam, S., 2004. Nursing Outcomes in Coronary Heart Disease Journal of Cardiovascular Nursing Vol. 19, No. 5, pp 308-315 Heart Foundation, 2002. Cigarette Smoking: Information from the Heart Foundation, Available at. [Accessed March 24, 2008] JBI, 2005. Nurse-led cardiac clinics for adults with Coronary Heart Disease, Best Practice 9(1) Blackwell Publishing Asia, Australia. Kaleta,D., Polanska,K., Jegier,A., 2007. Smoking predictors among economically active individuals. International Journal of Occupational Medicine and Environmental Health, 20 (4), pp. 357-363. Ministerial Council on Drug Strategy, 2004. National Tobacco Strategy 2004-2009: The Strategy. Available at [Accessed 24 April 2007] Mooney, J., Boxer, E., 2003. Keeping Heart Failure Patients at Home. Australian Journal of Advanced Nursing 21 (1), pp.8-13 Napoli,C., Lerman, L.O., de Nigris, F., Gossl, M., Balestrieri, M.L., Lerman, A., 2006. Rethinking Primary Prevention of Atherosclerosis-Related Diseases. Circulation. 114:2517-2527. Available at [Accessed on 23 April 2008] Philpot, T.K., The ethics of smoke-free zones: an exploration of the implications and effectiveness of a non-smoking policy as a health-promotion strategy in the context of an orthopaedic trauma ward. Journal of Clinical Nursing 3 (5) 307-311. Tan N, Wakefield M, and Freeman J., 2000. Changes associated with the National Tobacco Campaign: results of the second follow-up survey, in Australia's National Tobacco Campaign. Evaluation Report Volume Two, Hassard K, Editor. 2000, Commonwealth Department of Health and Aged Care: Canberra. p. 21- 75. Available at [Accessed 24 April 2008] World Health Organization (2008, February 11). Tobacco Could Kill One Billion By 2100, WHO Report Warns. ScienceDaily. Retrieved April 24, 2008, from Read More