Smoking and Risk of Myocardial Infarction
Question:
Discuss about the Oxygen Supplementation in Acute Myocardial.
The essay examines the case scenario of Mr. Sipos, a 52 year old Hungarian man who comes to the emergency department with central chest pain. Central chest pain is a presenting complaint most commonly found in patients with acute myocardial infarction (MI). Such patient experience heavy chest pressure and difficulty in breathing (Malik et al. 2013). However, present of this symptom is unusual in Mr. Sipos because he has no history of coronary heart disease or myocardial infarction. No family risk factor for development of myocardial infarction has been found too. Hence, there is a possibility that his social history and lifestyle has contributed to myocardial infarction in patient currently. This can be said because Mr. Sipos has been found to be heavy smoker and engaging in little exercise. The manner in which these factors can increase the risk of myocardial infarction is explained in more detail below.
Mr. Sipos has been found to be an active smoker as she smokers about 15 cigarettes per day. Evidence has shown smoking as an independent risk factor for MI and the risk increases particularly for older adults. Cigarette smoking leads to impairment of vascular endothelial function and activation of sympathetic nervous system. This in turn leads to reduced coronary blood flow compared to increased myocardial demand. This kind of dysfunction increases the risk of cardiovascular event in smokers Centers for (Disease Control and Prevention 2010). Smoking has been recognized as an undertreated risk factor contributing to vascular damage and decreased myocardial infarction delivery. However, the positive aspect is that effects of smoking are reversible and cardiovascular risk can be minimized in patient (Erhardt 2009). This discussion implies that smoking habits is one of the major risk factor for MI in case of Mr. Sipos. Mr. Sipos also did very little exercise and his sedentary lifestyle might also have contributed to his current symptom. Inverse relationship between physical activity and cardiovascular disease risk has been found (Cheng et al. 2014).
Based on the identification of risk factors of MI in case of Mr. Sipos, it is necessary to make Mr. Sipos aware about the risk and the need to change his lifestyle. The approach that can be taken to provide health promotion message to client is to engage in therapeutic communication with patient. Instead of just making patient aware about the risk factor, the patient will be supported and motivated to make healthy changes in his lifestyle. For this, it is necessary to develop a positive relationship with patient so that he trusts the nurse and actively respond to the health promotion message (Pham and Ziegert 2016). After building rapport with client, the nurse can inform Mr. Sipos regarding how heavy smoking impairs vascular function and creates risk of cardiac event. After this, the patient will be referred to smoking cessation programs so that he can get nicotine replacement therapy and reduce smoking rate gradually. Such health promotion intervention can significantly reduce risk of adverse cardiac event like chest pain in patient (Mons et al. 2015). The nurse can also motivate Mr. Sipos to engage in moderate level of exercise after making him aware about the harmful effect of sedentary lifestyle on his cardiovascular health. He can be referred to a physical activity trainer who can educate him regarding types of exercise and dose of exercise that he can do in his leisure time to reduce risk of cardiovascular disease. Even low level of activity like walking can also help client to improve his health (Carnethon 2009).
Sedentary Lifestyle and Cardiovascular Disease Risk
The ECG report of Mr. Sipos revealed an acute ST Elevated Myocardial Infarction (STEMI). It is one of the type of heart attack during which the arteries that supplies oxygen rich blood to the heart muscle is blocked. Patients with STEMI experience symptoms of chest pain, breathlessness, vomiting, diaphoresis and anxiety. Mr. Sipos also had symptoms of chest pain, nausea and diaphoresis. The pathophysiology behind STEMI is the sudden rupture of the atherosclerotic plaque within the wall of coronary artery. Atherosclerotic plaque is the build up of plaque inside the arteries and arteries are the blood vessels that transport oxygen rich blood to different parts of the body and the heart. These plaques consist of fat, cholesterol and calcium. The plaque buildup narrows the arteries and thus limits the flow of oxygen rich blood to the heart muscle. This event of obstruction of blood flow is also known as coronary occlusion. The damage is higher if the blood supply is disrupted for longer time (Montecucco, Carbone and Schindler 2015). Hence, time is an important clinical priority for restoration of symptoms in patient. The patient condition is restored by cardiac resuscitation therapy and by restoring coronary blood flow as soon as possible (National 2013).
Non STEMI (Non ST-elevation myocardial infarction) is also another type of heart attack. The difference between NSTEMI and STEMI is that NSTEMI is a less severe condition compared to STEMI. This can be said because STEMI leads to complete blockage of coronary artery, whereas in case of NSTEMI, partial blockage takes place. Partial blockage results in unstable angina and ischemia that only affects the subendocardium (Bajraktari and Henei 2016). Subendocardium is an area beneath the endocardium and this area is at higher risk during partial blockage (Algranati, Kassab and Lanir 2010). Hence, NSTEMI causes unstable ischemia whereas STEMI causes extensive myocardial ischemia.
The nursing assessment of Mr. Sipos revealed that patient had symptoms of radiation of pain to shoulders and left arm, pallor and clamminess. The review of homeostatic mechanism for all three symptoms can give good idea about how the mechanism behind such symptom in patient. The symptom of radiating pain from shoulder to the left hand is also known as cervical radiculopathy and nearby mechanical structure like shoulder or cervical spine is involved in such kind of symptom. Such radiating pain arises because of inadequate blood flow in the coronary artery and loss of oxygen rich blood to the heart tissue. Cigarette smoking may also predispose patient to such type of pain. The nerve roots C6 and C7 are affected and radiation of pains is seen due to the role of inflammatory mediators and changes in vascular response of patient (Leach and Fisher 2013). Hence, it can be said that central nervous system is the main player behind such radiating pain.
The convergence of visceral and sensory input and the complex pattern of interaction between the visceral and somatic information lead to varying pain sensation in coronary heart disease patient. The erosion of atherosclerotic plaques during myocardial infarction contributes to the release of many chemical mediators such as serotonin, histamine and bradykinin. These chemical mediatory interacts with specific receptors leading to the depolarization of spinal afferent fibers (Foreman et al. 2015). Hence, interaction between somatic and visceral afferent pathway results in radiating pain in patient. Poor localization of pain is also seen due to the diffused nature of convergence and inability of spinal routes to classify autonomic information as nociceptibe. For this reason, variation in intensity as well as location is seen in patient (Leach and Fisher 2013).
Health Promotion for Mr. Sipos
Mr. Sipos was also found to have symptoms of pallor meaning a pale appearance. Pale skin color is seene because of illness, shock and anemia. All such condition reduces amount of oxyhemaoglobin which is present in mucous membrane and skin conjuctiva and leads to pale appearance in patient. The symptom is more evident in arm and palms. Oxygenated hemoglobin present in blood has a red pink color and due loss of such oxygenated hemoglobin, the skin takes on the color of connective tissue (which is white) (Ramm et al. 2017). This homeostatic mechanism explains why Mr. Sipos displayed symptom of pallor. In case of patient, this might have occurred due to cardiogenic shock.
Mr. Sipos was also found to exhibit symptom of clamminess. This is linked to the homeostatic regulation of the vascular system. Hypovolemic shock might be one of the causes of clamminess as fluid loss results in restricted peripheral blood flow and clinical manifestation of cool and clammy skin in patient. Hence, it can be said that insufficient circulating blood volume leads to clammy skin in patient. The condition of MI might have affected circulating blood volume and led to weak pulse and vasoconstriction in patient (Thiele and Zeymer 2015). Therefore, the mechanism behind cool and clammy skin is understood from this explanation.
The main diagnosis for Mr. Sipos is acute STEMI and symptoms of acute cardiac condition. He also had associated cardiac symptom of nausea, diaphoresis and radiating pain and clammy appearance. The most importance care plan for Mr. Sipos in terms of clinical priority is management of chest pain in patient as he gave a pain score of 10 out of 10. This mean that immediate nursing intervention is needed to provide pain relief to patient. This can be done by assessment of pain level and then consulting physician for appropriate pharmacological drug for patient. As chest pain increases the severity of MI, the symptom can be minimized in patient by providing morphine medication to patient. Persistence pain may increase the workload of patients heart due to sympathetic activation. Hence, this aspect can be controlled by giving morphine to patient. Morphine is an opioid analagesic that has hemodynamic effect. It stimulates histamine mediated process and reduces pain in patient (Atar and Agewall 2015). It also decreases heart rate and blood pressure. Study done on STEMI patient has also proved the effectiveness of morphine for pain relief (Parodi 2016). Nitroglycerin cal also be provided to patient to facilitate arterial dilatation and reduce myocardial oxygen demand. However, it will be important for nurse to monitor side-effect of drug in patient and assess pain score to understand level of relief from pain.
Reduction in myocardial oxygen demand due to STEMI may also lead to shortlessness of breath in patient. Hence, the second care priority is to provide complete relief from pain and discomfort to patient. To fulfill this care priority, it will be necessary for nurse to provide bed rest to patient in a semi-fowler position. It is a position in which nurses place patient in upright sitting position up to 45-60 degrees. The advantage of this position is that it alleviates chest compression and improves severity of chest pain in patient (CortÃ, DiCenso and McKelvie 2015).
Positive Relationship with the Patient for Health Promotion
The condition of STEMI also deprives heart of oxygen. Hence, another nursing care priority is to provide supplemental oxygen to patient. This intervention can improve oxygenation of the heart tissue and lead to reversal of ischemia too. Evidence suggest that Oxygen is one of the standard treatment for patient with acute MI. It reduces the extent of damage and increases oxygen delivery to the ischemic myocardium (Hofmann et al. 2017). Hence, pace of recovery for patient can be enhanced by the use of oxygen therapy.
The next care plan is to educate patient about the pathophysiology of the condition and risk factors that exacerbate symptoms in patient. By providing health education intervention to Mr. Sipos, he is most likely to engage in proper management of any complication at home. To improve the quality of life of patient, educating patient about the harmful effect of smoking and physical activity is also critical to help patient understand the need for change. As the diagnosis of STEMI has occurred because of risk factor of smoking, quitting smoking is extremely important for him. Evidence proves that cigarette smoking accelerates atherosclerosis and process of developing plaque (Schlyter et al. 2016). Hence, to promote long-term health of patient, making patient aware about the need to quit smoking is necessary. The advantage of this education care plan is that it can motivate patient to make changes in his lifestyle. The involvement of patient in smoking cessation programme can decrease the likelihood of recurrent myocardial infarction and need for stent in the future. The quality of diet and level of physical activity also needs to be assessed to improve quality of life and reduce risk of mortality in patient (Li et al. 2013).
The main activities of living mentioned in the Roper-Logan-Tierney Model of nursing are communication, breathing, eating and drinking, elimination, maintaining a safe environment, controlling temperature, mobilization, working and playing, sleeping, death and sexuality. From this list, the activities that might be altered for Mr. Sipos post admission include breathing, mobilization, controlling temperature and work and play. Mr. Sipos breathing ability might be affected due to central chest pain and diagnosis of STEMI. Dyspnea is a high risk symptom in patients with myocardial infarction as higher mortality from chest pain has been found than chest pain (Bøtker et al. 2016). Hence, a registered nurse can manage breathing problem in patient by providing supplemental oxygen therapy to patient and evaluating the skin color and temperature of patient. Evaluating skin color is important because lack of oxygen leads to cyanosis. In addition, oxygen therapy can decrease ischemic pain and promote effective breathing (Raut and Maheshwari 2016).
Due to chronic pain and STEMI, Mr. Sipos has poor ability to regulated body temperature. This is understood from the symptom of clamminess in patient. A registered can improved patient’s ability to control body temperature by means of fluid replacement therapy. Clamminess is seen due to hypovolemic shock and fluid replacement therapy can balance the circulating blood volume and reduce symptoms of clamminess. Another important responsibility of a registered nurse will be to assess room temperature of patient.
Smoking Cessation Programs to Reduce Risk
Another vital parameters that will is affected after admission is Mr. Sipos’s mobilizing ability. The persistence of chronic chest pain may affect patient ability to mobilize. A registered nurse can address mobilizing issues in patient by providing optimal rest position to patient. Placing the patient to a semi-fowler position is an effective nursing intervention as it can restore oxygenation level and hemodynamic status of patient. Due to impact on mobilization ability, the nurse also needs to consider patient’s need for assistive device or assistance during walking and going to washroom too (Voldby and Brandstrup 2016).
Patient’s ability to work and play will be affected because of pain and anxiety. The persistence of adverse symptom of patient may further reduce patient’s motivation to fully engage in work and leisure. A registered nurse can improve the patient’s motivation level and his interest in work and pleasure by giving him educational support and health promotion message. Once the patient develops clear understanding about the disease process of STEMI and its risk factors, he will become clear about the health behavioral factors that he need to change (Butcher et al. 2018). Secondly, when a registered nurse will make Mr. Sipos aware about important health care services and physical activity program that he can avail to improve his lifestyle, the patient feel more confident. Improved knowledge related to health promotion will also reduce symptom of anxiety in patient and increase his interest in work and play. Being physically active and taking appropriate steps to mitigate risk factors can also reduce adverse symptoms that affect daily life activities of patient (Nakajima et al. 2016).
Reference:
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