Holistic Care Plan
Patient Initials: n/a Age: 52 Sex: Male.
Client Complaints: The client has chronic stable angina with a documented spasm. After the stent placement, the client is asymptomatic; however, he is worried that symptoms may return at some point in the future. The patient seeks help to discuss the risks of blockages reforming after stent placement.
HPI (History of Present Illness): The patient sought medical help with angina symptoms, such as crushing chest pain and shortage of breath. Symptoms were present 6 months before admission but were relieved with rest. There was a change in the usual pattern before admission: the symptoms lasted for four days and were more severe. The client was hospitalized with coronary artery spasm and underwent a stent placement surgery to open up a blocked artery. The patient remained hospitalized for four days after the surgery. No angina symptoms are present at this point.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): The patient was not previously diagnosed with angina. The patient is not allergic to any medicine and is currently taking Tenormin XL 50 mg, Lipitor 10 mg, Glucophage 500mg, and baby ASA daily. No major traumas were reported. The patient has been diagnosed with hypertension and high cholesterol levels in the past. The patient underwent cholecystectomy in 2006 without any complications.
Significant Family History: The patient has two brothers diagnosed with high blood pressure and diabetes. The patient’s parents are deceased: the father from cardiovascular disease, the mother from breast cancer. The positive parental history of heart disease is of particular concern for future assessments since it is a traditional risk factor (Jugdutt, 2014, p. 22).
Social/Personal History (occupation, lifestyle—diet, exercise, substance use): The patient is a high-school graduate, occupied, with an average yearly income of $50,000. The patient’s wife is disabled with type 2 diabetes. The patient is under a lot of stress due to financial issues and the lack of social support. The patient has no relatives in the city and lives in a disadvantaged neighborhood, not safe for exercise.
No alcohol or illicit drug use was reported. However, the client is a heavy smoker and has been smoking for 30 years. It is a risk factor since cigarette smoking increases the risks of coronary artery disease (Huxley & Woodward, 2011, p. 1297). The client’s diet is unbalanced and is mainly comprised of meat and pasta, with little vegetables and fruits. Such diet is likely to contribute to the risk of heart disease and poor health in general (Gray, 2016, p. 41).
Description of Client’s Support System: The patient has little to no support due to a lack of friends or relatives in the city.
Behavioral or Nonverbal Messages: The patient shows signs of depression and stress.
Client Awareness of Abilities, Disease Process, Health Care Needs: The client seems unaware of the risks his lifestyle has on the development of the disease, and his ability to affect the course of its progress. The client’s health care needs include controlling the progression of coronary disease.
Vital Signs including BMI:
Blood pressure is high, and the patient’s BMI is 31. Such BMI is considered obese (Nguyen, Nguyen, Lane & Wang, 2011, p. 351).
Physical Assessment Findings: HEENT within normal limits. EKG showed no change from baseline. No problems were detected except for decreased breath sounds and signs of android obesity. Waist circumference is 44 inches.
Lab Tests and Results: Lab tests suggest that the patient’s current cholesterol levels are very high at 210 mg/dL. High cholesterol levels are well-recognized as a risk factor for coronary artery disease.
Client’s Support System: See above.
Client’s Locus of Control and Readiness to Learn: The patient has shown to be incompliant with prescribed medication in the past, but is compliant now. The fact that the patient wants to discuss risk factors suggests that he is interested in learning more about his condition and treatment.
ICD-10 Diagnoses/Client Problems: ICD-10-CM Code I201 (I20.1) Angina pectoris with documented spasm
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources, and follow-up plans): To prevent further development of the condition and the episodes of angina in the future, it is important to consider a holistic approach to treatment. While the client should be strongly encouraged to take the prescribed medications to control his cholesterol levels, a lifestyle change is necessary to minimize the risk of future angina episodes. The risk of coronary disease is largely influenced by the presence of risk factors, such as:
- obesity and high cholesterol levels;
- unbalanced diet;
- the lack of physical activity;
These are the areas of concern. The focus of holistic care is, therefore, on eliminating or minimizing unhealthy habits and encouraging physical activity. The patient should be provided with information on the benefits of a balanced diet with plant sources of fats and protein, whole grain, fish, fruits, and vegetables (Willett & Stampfer, 2013, p. 77). The dietitian should provide the client with a diet and exercise plan to help the client lose weight.
The patient should be educated on the negative effects of smoking and encouraged to stop this unhealthy practice (Huxley & Woodward, 2011, p. 1297). While the neighborhood is not safe for exercising, the client should be encouraged to exercise in other, safer parts of the city. Follow-up plans should include assessing the client’s progress on weight loss, diet improvement, and lifestyle change.
Gray, J. (2016). The balanced diet – why so difficult to achieve? Nutrition Bulletin, 41, 100–103. Web.
Huxley, R., & Woodward, M. (2011). Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. The Lancet, 378(9799), 1297-1305. Web.
Jugdutt, B. (2014). Aging and Heart Failure: Mechanisms and Management. Berlin, Germany: Springer Science & Business Media.
Nguyen, N., Nguyen, X., Lane, J., & Wang, P. (2011). Relationship Between Obesity and Diabetes in a US Adult Population: Findings from the National Health and Nutrition Examination Survey, 1999–2006. Obesity Surgery, 21(3), 351-355. Web.
Willet, C. & Stampfer, M. (2013). Current Evidence on Healthy Eating. Annu Rev Public Health, 34, 77-95. Web.