SU_NSG4055_W5_Project_Tanner_W

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Feb 20, 2024

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1 Coronary Heart Disease Windy L. Tanner South University NSG 4055 Illness and Disease Management across Lifespan CP02 Professor Kara Bral MSN, RN April 25, 2022

2 Coronary Heart Disease Heart disease is the number one cause of death in the United States (U.S.). People are at higher risk of developing heart disease due to dietary habits and lifestyles. Smoking, hypertension, diabetes, and obesity are risk factors associated with poor diet and a sedentary lifestyle. Heart disease affects the cardiac output and can cause shortness of breath, edema, congestive heart failure, atrial fibrillation, angina, myocardial infarction, and peripheral artery disease. It has a significant bearing on someone's quality of life and impacts the family or caregiver. Heart disease is a chronic illness that has contributed to 17.6 million deaths globally (Benjamin et al., 2019). Heart disease has a massive impact on my community. According to the CC, 4.6% of adults have been diagnosed with coronary heart disease (CDC/National Center for Health Statistics [CDC], 2022). The participants chosen for this project is dear to my heart, and I want to learn more and help create a healthy environment and behavior changes for people living with heart disease. Holistic Plan of Care Participant J. L. Has been diagnosed with coronary artery disease for several years. It was discovered after a short hospitalization for chest pain and an irregular heart rate. Her ejection fraction on the echo was > 55%. However, it did reveal large thrombus clots in the left atrium. During the interview portion of the project, it was identified that J. L. did not fully understand the importance of medication adherence. She occasionally had difficulty in affording her medicine when she fell into the doughnut gap with Medicare Part D. Items J. L. expressed to improve in her health include seeking more information on exercise to strengthen her ability to perform activities of daily living (ADLs), the ability to walk around in the grocery store and have the endurance to complete light yard. Cardiac rehabilitation is an excellent program to help

3 improve physical endurance. Healthy lifestyle choices include smoking cessation education and encouragement to support a reduction plan in smoking, diet changes to lower fried foods in the diet, increase in fresh fruits and vegetables, and decrease in foods high in fat. J. L. has a vast support system with a healthy husband, and three children are involved with her health care plan. Her daughters can express the need for medication compliance, and both demonstrate a strong understanding of the increased risk of stroke with smoking and stopping her direct oral anticoagulant. J. L. verbalizes that walking around the house isn't active enough to qualify as therapeutic cardiac therapy. Each member of the family is effectively coping with the diagnosis. Practical coping skills are validated by verbalizing risk factors of hypertension, smoking, and dietary habits for coronary heart disease, peripheral artery disease, and stroke. The plan of care is determined by the needs identified by the participant and goals that she felt were essential for her to accomplish. Holistic care methods involve the patient and family or caregiver to devise objectives that can be measured and patient-centered goals collaboratively. Summary Week 1 Week 1 project, a complete discussion of coronary artery disease (CAD) was conducted. Hypertension narrows the arteries, and smoking increases the risk of developing it (Mohan et al., 2019). Hypercholesteremia is when deposits of a sticky substance called plaque buildup in the arteries causing partial or total blockage of blood flow. Modifiable health factors for increasing the risk of developing CAD are obesity, unhealthy diets, smoking, and decreased physical activity. Risk factors that cannot be altered include gender, ethnicity, age, and genetics. Hypertension, diabetes, obesity, and an elevated cholesterol level are comorbidities seen with

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4 CAD (Benjamin et al., 2019). Different types of heart disease were reviewed, including heart failure, atrial fibrillation, and peripheral artery disease. Heart Healthy goals include reducing hospitalizations, improving medication adherence, complying with diet changes, and adapting to healthy behavior changes. Depression and ineffective coping mechanisms are frequently seen in this chronic illness. Education to the patient and family or caregiver must include the disease progress, trajectory, and treatment options, including medications used for treatment (Sidney et al., 2022). Reducing hospitalizations, readmissions, disabilities, and the mortality rate is vital in improving the quality of life of any individual learning to live with CAD. Week 2 In week 2, the benefits of individualized care plans were researched after a complete analysis of the questionnaire administered in week 1. The health assessment included a health history and a family support system. The impact of the chronic illness was included in the discussion with an understanding of how to incorporate patient objectives and goals instead of medically therapeutic interventions and goals (Bayliss et al., 2014). Shared decision-making with the entire health team is vital to devise a workable plan of care to improve the quality of life that the patient or caregiver gauges (Park et al., 2018). Knowledge gaps were identified in week two concerning medication adherence and how to seek help for medical assistance. Preventive health and the identification of medical issues are ways to manage CAD and increase the health quality and must include the patient and family or caregiver to positively impact the lifestyles of patients learning to live with chronic illnesses. Week 3

5 Patient-centered care plans, education, and nursing advocacy are indispensable activities for nursing objectives. In week three, information was obtained on the hierarchy of needs. Maslow identified that until the basic needs were met of food, shelter, clothing, and sleep, no progress could be seen in a higher category (Taormina & Gao, 2013) . A deeper analysis of the participants' needs was evaluated and included the financial impact of the illness. Objectives identified on the Healthy People 2030 website have vast information on heart disease. Strategies to improve cardiovascular health include dietary changes, increasing physical activity, and smoking cessation. One Healthy People 2030 objective for improving the health of this population consists of the reduction of risk factors for heart disease by controlling hypertension and lowering cholesterol levels. Excellent topics on pharmacy-based adherence intervention programs identified by the Community Preventive Services Task Force (CPSTF) were evaluated this week. Barriers were identified to specific patient populations that could not follow their prescribed medication plan (Guide to Community Preventive Services, 2019). Social and environmental factors play a huge role in outcomes for chronic illnesses. Support systems, insurance programs, community resources, access to health care, and transportation back and forth are considerations during the planning phase to properly manage health outcomes (Graffigna & Barello, 2018). Objectives and goals must be centered around items that motivate change behaviors in the patient. Advocating, educating, and being a change agent is the role nurses play in developing patient-centered plans of care using a holistic approach. Week 4 Week 4 cardiac rehabilitation, smoking cessation, and medication adherence focused on the week four project. A complete analysis and discussion of objectives and goals for each topic for the participant were conducted. The benefits of cardiac rehab include behavior changes,

6 improving activity tolerance, socialization, connection with a support system, and diet modifications. Factors that affect participation include costs, transportation, availability, scheduling, physical ability, and motivation (January et al., 2019). There are varieties of smoking cessation education, including websites, informational literature, apps, and hotline numbers. It is a public service that is available to all free of cost (US Department of Health and Human Services, National Institutes of Health, n.d.). Tailored pharmacy-based medication programs help identify issues that may result in noncompliance. The CPSTF recommends that this program improves adherence to medication for people with chronic illnesses (Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, Million Hearts [CDC], 2022). An evaluation of health equity in society in specific populations was researched with the disadvantages and advantages of complying with exercise, medicine, and smoking education. Resources within the community offer some benefits to changing outcomes for people with chronic illnesses. Individual needs and desires are the focus of holistic care plans. They are developing assessment tools, using verbal and nonverbal cues during interviews, while including the family or caregiver allows for well-managed care plans to be implemented. Educating about resources in the community and addressing barriers that may be present is essential in nursing care plans. Identifying barriers allows work through to occur and aids in goal attainment (Mc Namara et al., 2019). Nurses must be well-rounded in insurance benefits and qualifications or be able to direct the questions that a patient or family may have to the case manager. All goals and objectives must remain centered around what the patient feels is essential to accomplish healthy living with chronic decisions. Nursing Diagnosis

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7 The participant will be able to verbalize how to take her medications as prescribed and list two risk factors for nonadherence to medication compliance. The participant will be able to perform simple daily activities and experience no leg pain with the exercise by the end of month one. The family will be able to identify risk factors associated with smoking and atrial fibrillation after one education session. Assessment Objective Data Participant J. L. is an advanced-age female. Her heart rate is irregular when radial pulses are palpated. She is accompanied to the interview by her husband and two daughters. They all answer questions appropriately and are good historians. She has an unpalatable pulse in the left dorsal pedis. It was obtained by doppler, skin color is pink, with capillary refill 3 seconds, the foot is warm, with solid movement in the extremity with flexion and extension. She currently takes a DOA for atrial fibrillation, a beta-blocker for rate control, and a calcium channel blocker for pressure and rate control. She drinks more than three beers daily and lives with her husband of greater than 50 years. She has insurance with Medicare B and part D and has a primary care provider. Subjective Data J. L. reports pain when walking short distances in the house or doing light home or yard work. She states that she must take frequent breaks during the day due to fatigue, which bothers her emotionally. During the interview, she says that she misses medication doses and smokes a pack a day. She worries about affording the DOA later in the year after she is capped on her Medicare

8 part D plan. She also states that she sometimes feels a fluttering feeling in her chest, and it worsens with activity. She reports only attending medical appointments when she is sick. Interview Results J. L. has excellent verbal skills and does not shy away from answering any questions. She laughs frequently and makes jokes with a variety of questions. She has concerns over her health and loves spending time with her family. She does not express a desire to stop smoking currently. She does want to be able to complete household tasks and ADLs without being fatigued. She is older than 65 years of age and smokes, takes medications, and occasionally cannot afford them. She has frequent meals with her family and is not overweight. She reports being tired more than usual and does not have a history of heart disease. She expresses a desire to improve her health and ability to complete ADLs. Desired Outcomes J. L. will be able to walk around the home without calf pain. J. L. and her family will verbalize the associated risk factors for heart disease and stroke. J. L. and her family will verbalize the understanding of medication adherence and taking her DOA as prescribed. J. L. will be able to state how to obtain medications when she is running low and cannot afford her refills. J. L. will participate in an exercise program and report a decrease in fatigue. Evaluation Criteria On observation, J. L. will be able to walk around the house three times without taking a break by the end of month one in the exercise program.

9 J. L. and her family, at the end of the first education session, can cite three risk factors associated with CAD. J. L. will be able to identify a means of obtaining medications and how to access the Medicare part D web portal to review her medication purchase history. J. L. and her family will recite the importance of not missing a dose of DOA and the risks associated with nonadherence. J. L. enrolls and completes a cardiac rehab program attending 28 out of the 36 required sessions. Actions and Interventions Consult completed for cardiac rehab. Cardiac rehab interviews the patient and discusses the program's schedule, fees, and benefits. Barriers are identified after the interview if any, and an action plan is made to address them by consulting with needed departments. Education pamphlets on DOA are provided, and a consult with the pharmacy is scheduled to review medication adherence concerns. Education literature and web links will be provided to the patient and family, covering the following topics, atrial fibrillation, CAD, hypertension, smoking cessation, healthy eating habits, low sodium substitutes, and risk factors for stroke. Discount coupons for DOA prescription medications are provided. Literature on Medicaid QMB programs is provided in written format. After one month enrolled in the cardiac rehab program, an evaluation of her activity level will be obtained to mark the improvements in endurance. Evaluation of Patient Outcomes The patient can participate in moderate exercise with minimal calf pain.

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10 If pain is experienced, the patient will take a 10-minute rest and attempt exercise again. The patient takes her medication as prescribed without missing a dose 95% of the time. The patient can verbalize two healthy options for a meal and one low salt substitute. Inclusion of the Family in the Plan of Care The support system in any illness is critical to emotional well-being. Interviews conducted with the family and patient allow them time to discuss the disease, ask any questions, and state their priorities are vital to the patient-centered approach to care. Collaborating with healthcare team members, caregivers, and patients' goals and objectives can be aligned with exact precision for measurement. A holistic team approach is healthy for all members and supports the physical, emotional, economic, and psychosocial aspects of care. Evaluation of family dynamics helps the healthcare professional identify potential spiritual needs or economic disadvantages. All involved members' inclusion in the plan allows ownership and accountability for all. The quality of life can be modified if a team approach is utilized (Healthy People 2030, n.d.). Understanding the motivating factors enables the plan to have a driving force for success. Advocating for your patient and family has a significant impact on chronic diseases, and the quality of life improves for people struggling to live in their new normal. Conclusion Chronic conditions impact the lives of millions daily. Nursing plans must include the healthcare team, patient, and family, focusing on goals and objectives driven by the patient. Behavior changes will not occur if motivation is not listed as a reason to change. Development of care plans must be measurable and timed, with allowances for modifications when barriers are identified. A holistic, patient-centered approach is a key to successful strategies. Nurses must utilize the advocacy, change agent, and the educator skills to promote management of living with

11 a chronic condition. The nurse can have a major impact on the quality of living for individuals and families that are managing living a chronic condition by addressing the physical, emotional, financial, and psychosocial aspects of care. Heart disease is a chronic illness that needs global attention by the healthcare community to educate on preventive and screening measures to reduce the incidence of heart disease. Strategies to effectively manage the condition requires behavior modification, medication therapy adherence, and access to care to improve the quality of life for people with CAD.

12 References Bayliss, E. A., Balasubramianian, B. A., Gill, J. M., & Stange, K. C. (2014). Perspectives in primary care: Implementing patient-centered care coordination for individuals with multiple chronic medical conditions. The Annals of Family Medicine , 12 (6), 500–503. https://doi.org/10.1370/afm.1725 Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Das, S. R., Delling, F. N., Djousse, L., Elkind, M. S., Ferguson, J. F., Fornage, M., Jordan, L., Khan, S. S., Kissela, B. M., Knutson, K. L.,...Virani, S. S. (2019). Heart disease and stroke statistics—2019 update: A report from the American Heart Association. Circulation , 139 (10), e56–e528. https://doi.org/10.1161/cir.0000000000000659 CDC/National Center for Health Statistics. (2022). Heart disease . https://www.cdc.gov/nchs/fastats/heart-disease.htm Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, Million Hearts. (2022). Appropriate aspirin or anticoagulant use (January 27, 2022). https://millionhearts.hhs.gov/about-million-hearts/optimizing-care/aspirin-anticoagulant- use.html Graffigna, G., & Barello, S. (2018). Spotlight on the patient health engagement model (PHE model): A psychosocial theory to understand people’s meaningful engagement in their own health care. Patient Preference and Adherence , Volume 12 , 1261–1271. https://doi.org/10.2147/ppa.s145646 Guide to Community Preventive Services. (2019). Heart disease and stroke prevention: Tailored pharmacy-based interventions to improve medication adherence.

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13 https://www.thecommunityguide.org/findings/cardiovascular-disease-tailored-pharmacy- based-interventions-improve-medication-adherence Healthy People 2030. (n.d.). Health equity in healthy people 2030 . Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. https://doi.org/https://health.gov/healthypeople/priority-areas/health-equity-healthy- people-2030 January, C. T., Wann, L., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., & Yancy, C. W. (2019). 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation , 140 (2). https://doi.org/10.1161/cir.0000000000000665 Mc Namara, K., Alzubaidi, H., & Jackson, J. (2019). Cardiovascular disease as a leading cause of death: How are pharmacists getting involved? Integrated Pharmacy Research and Practice , Volume 8 , 1–11. https://doi.org/10.2147/iprp.s133088 Mohan, S., Thirumalai, C., & Srivastava, G. (2019). Effective heart disease prediction using hybrid machine learning techniques. IEEE Access , 7 , 81542–81554. https://doi.org/10.1109/access.2019.2923707 Park, M., Giap, T.-T., Lee, M., Jeong, H., Jeong, M., & Go, Y. (2018). Patient- and family- centered care interventions for improving the quality of health care: A review of

14 systematic reviews. International Journal of Nursing Studies , 87 , 69–83. https://doi.org/10.1016/j.ijnurstu.2018.07.006 Sidney, S., Lee, C., Liu, J., Khan, S. S., Lloyd-Jones, D. M., & Rana, J. S. (2022). Age-adjusted mortality rates and age and risk–associated contributions to change in heart disease and stroke mortality, 2011-2019 and 2019-2020. JAMA Network Open , 5 (3), e223872. https://doi.org/10.1001/jamanetworkopen.2022.3872 Taormina, R. J., & Gao, J. H. (2013). Maslow and the motivation hierarchy: Measuring satisfaction of the needs. The American Journal of Psychology , 126 (2), 155–177. https://doi.org/10.5406/amerjpsyc.126.2.0155 US Department of Health and Human Services, National Institutes of Health. (n.d.). Explore the smoke free family . https://doi.org/https://smokefree.gov/tools-tips/get-extra-help

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