Introduction
The purpose of this paper is to provide an overall assessment of a patient’s case and discuss some aspects of overall care. According to Lamar University (2018), the goal of nursing has always been the healing of not only the physical symptoms but also the mind and soul of an individual. Therefore, a holistic assessment is a process under which a patient’s health state is analyzed from the viewpoint of not only their physical symptoms but also their mental state and their environment’s impact on their wellbeing. Holistic assessment allows nurses to gain a better comprehension of the patient’s physical and psychological state and the factors that can help or hinder the process of healing.
Summary of the Patient Case
The patient in question is a 57 years old male admitted to the emergency care department. The symptoms are chest pains that radiate to the back of his neck and arm and a short breath. Mr. Vlog’s family history shows that his father has died from a heart attack, which is the first factor of the holistic assessment of the patient’s family history. Secondly, Mr. Vlog’s lifestyle predisposes him to a heart attack since he admits to smoking 15 cigarettes per day since he was 20 years old. According to Better Health Chanel (n.d.), heavy smoking is among the primary risk factors for the development of severe issues linked to one’s cardiovascular system. FDA (n.d., para. 1) states that “when breathed in, the toxic mix of more than 7,000 chemicals1 in cigarette smoke can interfere with important processes in your body that keep it functioning normally.” As a result, this brief assessment shows that Mr. Vlog’s current environment, genetics, and habits affect his health adversely and put him at risk of having a heart attack. The following sections will address the assessment methodologies and tools that can be used to communicate to Mr. Vlog the importance of a healthy lifestyle.
The Importance of Holistic Assessment
Holistic assessment of patient cases is a relatively new approach to working with individuals. That is why one should pay careful attention to the critic of this method to be able to critically appraise its benefits and downsides. This practice was first introduced by Florence Nightingale in the 19th century since Nightingale was the first nurse to draw attention to the interrelationships between the person, their environment, and their wellbeing (Lamar University, 2018). The goal of a holistic assessment is disease prevention, which is achieved by analyzing the impact of the family and community on the person’s wellbeing (Weiss, 2017). Thus, patients become more aware of the factors that may affect their health and are more likely to engage in self-care practices.
The importance of a holistic assessment is linked to patient-centered care and mutual goal setting, both of which allow achieving the best possible results for the patient. The University of Texas Arlington (2018, para. 5) defines a holistic assessment as a method under which “a nurse typically dives deeper into a patient’s health history.” Wellness goals are the end result of a holistic health assessment, which allows a nurse to draw a patient’s attention to the specific changes. It targets health-related markers that will indicate that these changes were successful.
Hence, for example, with Mr. Vlog, it is evident that his history of heavy smoking has an impact on his health and his heart’s function. Therefore, a nurse and a patient can set a goal to reduce the number of cigarettes this patient smokes per day and to eventually quit smoking to help him address his heart-related problems (Darawshy et al., 2021; Kwong et al., 2019). Next, heart failure is also associated with issues such as food and physical activity, and the nurse should set a goal to address these as well (FDA, n.d.). Moderate physical activity several times per week can serve as an adequate measure to help this patient reduce his risk of developing further heart problems.
A holistic assessment is important because it allows reviewing the patient’s history fully and references the different aspects of their lifestyle or genetics that may impact the way these patients manage their health. According to Mills (2017) and Turley et al. (2021), this method is what allows a nurse to employ a patient-centered approach to nursing. It gains a full comprehension of the person’s health state, values, religious attributes, and everything else that might matter in relation to their health and wellbeing. Moreover, Mills (2017, p. 1) states that a “holistic assessment is an important aspect of providing high-quality care focused on meeting a patient’s individual needs.” Therefore, it allows a nurse to collect more details about the patient’s state of health and address their concerns better and more comprehensively, for example, by recommending changes to the lifestyle or some non-traditional therapeutic methods that may relieve the patient’s symptoms.
Additionally, to interpret the patient’s information adequately, an assessment model will be used. The Calgary-Cambridge (C-CG) model is “is a well-known approach to teaching and training clinical communication skills,” as defined by Iverson et al. (2020, p. 140). When developing this method, the authors aimed to create a cohesive teaching methodology that would allow medical professionals to advance their communication skills and improve collaboration with patients (Keifenheim et al., 2019). The current version of the C-CG was updated in 2013. This version includes an assessment tool used to determine the quality of communication skills a person has (Iversen et al., 2020). Moreover, C-CG can help improve inter-team collaboration as a nurse’s work often involves a need to communicate with other professionals as well, for example, to order lab tests or to interpret results.
The C-CG model is also consistent with the patient-centered approach, which is also important for contemporary diagnosing and treatment plan practices. The C-CG “values patients’ ideas and compliments the traditional holistic approach used by nurses” (Munson and Wilcox, 2007, para. 10). In total, there are six steps in the C-CG model, and the conversation with a patient has to end with a closing statement. Hence, an important benefit of using a model such as C-CG when working with Mr. Vlog is the fact that it provides the structure for the assessment. When a holistic approach is employed, the nurse has to ask many questions relating to the areas outside of a person’s physical health. Hence, the use of communication tools such as the C-CG is a useful method when working with patients and implementing a holistic strategy. It allows the nurse to address all the requirements of a holistic methodology in a structured and practical manner.
Analysis
This section of the paper will present the analysis of Mr. Vlog’s symptoms. Next, it will discuss how the application of the holistic assessment and the C-CG model is helpful for diagnosing conditions and creating a treatment plan. According to Lamar University (2018), the following are the steps one must complete under a holistic assessment: physiological, physical, sociological, developmental, cultural, and spiritual. Hence, in contrast to a traditional type of health examination, where physiological health markers are central for determining the health state of a person, with a holistic assessment. Even the individual’s culture and spiritual values are viewed as essential contributors to the well-being (Ross et al., 2018). Although the factors apart from the physiological health do not impact the health state directly, they might affect the recovery and either aid it or exacerbate the condition (Lamar University, 2018). The symptoms presented by Mr. Vlog correspond to myocardial infarction.
A typical treatment for the myocardial infraction is a combination of aspirin and infusion that will help dissolve the clots in the patient’s blood. Lu et al. (2015) recommend combining aspirin with nitroglycerin for several reasons. The first medication targets the blood clots and does not allow further clots to form, while the second element is needed to restore the flow of oxygen to the heart muscle. Additionally, painkillers such as morphine can be administered to address chest pain (Lu et al., 2015; Feng et al., 2019). The tissue plasminogen activator, which addresses the blood clots, has to be issued within three hours from the onset of the symptoms (Wang et al., 2020). These recommendations are consistent with the acute coronary syndrome protocol that is titled MONA (Nikolaou and Vrints, 2012; Schwartz et al., 2018). MONA is an acronym for morphine, oxygen, nitrate, aspirin, which are all of the elements required to restore adequate oxygen flow and relieve the patient from their pain if they have a myocardial infarction.
There is another treatment method which is called antifibrinolytic treatment. This method is needed to prevent a patient from losing large quantities of blood, which is typically employed during surgeries (Hemophilia News Today, n.d.). This medication is used to stop bleeding through the process of clotting, which does not obstruct the normal blood flow. Next, cardiac catheterization is “an invasive diagnostic procedure that provides important information about the structure and function of the heart” (NHS, n.d., para. 1). After a heart attack, catheterization is used if the blood flow continues to be blocked by blood clots (Chowdhury et al., 2019). However, since this is an invasive technique, it is used only in emergency cases or when the MONA protocol did not produce the expected results.
Once the acute symptoms of Mr. Vlog are addressed, the nurse practitioner has to focus on managing his health state and the factors that contributed to the cardiac malfunction. However, Lu et al. (2015, p. 302) note that it is vital to take measures for preventing a heart attack as it is the only way of ensuring a patient’s wellbeing. A positive outcome can be achieved by “taking an earlier action to lower those risks by controlling diet, fat, cholesterol, salt, smoking, nicotine, alcohol, drugs, monitoring of blood pressure every week” (Lu et al., 2015, p. 302). Hence, under the holistic approach and the C-CG, the nurse will have to discuss the ways in which Mr. Vlog can make changes to his lifestyle. It is important in order to address the health concerns and prevent the potential heart attack in the future.
Differential Diagnosis
A differential diagnosis is a list of potential causes of the illness that a patient has, which is a necessary element of diagnostics as a nurse has to determine all the possibilities that cause disease and use laboratory analysis and tests to determine the final diagnosis. Apart from the conditions described above, there are other causes of the elevated Tropin T levels. For Mr. Vlog, the differential diagnosis includes myocarditis, pericarditis, congestive heart failure, takotsubo cardiomyopathy, arrhythmias, pulmonary embolism, sepsis. Myocarditis is a result of the inflammation that occurs within the heart’s muscles that reduces the organ’s ability to pump blood (Myrick and Karosas, 2021). Pericarditis is the swelling of the pericardium, which is the sacklike tissue of the heart (Myrick and Karosas, 2021).
A congestive heart failure happens when the person’s heart seizes to pump blood, causing the build-up of fluids in the lungs and blood blockage (Myrick and Karosas, 2021). Takotsubo cardiomyopathy is also referred to as a “broken heart syndrome” and is caused by extreme emotions, although sometimes it is a result of a physical illness or surgery, which causes chest pains (Myrick and Karosas, 2021). Although the symptoms are similar to those of a heart attack, the disruption of the organ’s functioning is temporary. Next, arrhythmias is an unusual rhythm of one’s heartbeat, which can be either too slow or too fast (Myrick and Karosas, 2021). A pulmonary embolism is the blockage of one of the heart’s arteries, which is typically a result of a clot (Myrick and Karosas, 2021). Finally, sepsis is one’s body’s response to infection, which leads to the damage of the tissues (Myrick and Karosas, 2021).
For chest pain, in particular, the differential diagnosis includes the following options: aortic dissection, pericarditis, pericardial effusion. Aortic dissection is a tear in the inner layer of the aorta, while pericarditis, as was discussed, is an inflammation of the pericardium (Myrick and Karosas, 2021). Pericardial effusion occurs when liquid is accumulated around one’s heart, which can put pressure on this organ (Myrick and Karosas, 2021). Gastrointestinal differential diagnosis is based on these conditions: heartburn or gastro-oesophageal reflux disease and pancreatitis. Heartburn is a pain caused by stomach acid moving up towards one’s throat, while pancreatitis is simply an inflammation of the pancreas (Myrick and Karosas, 2021).
The pulmonary causes are pulmonary embolism, pleurisy, and pulmonary hypertension. A pulmonary embolism is a blockage of the lung’s arteries, while pleurisy is the inflammation of the pleura, a tissue that separates the heart from the lungs (Myrick and Karosas, 2021). Pulmonary hypertension occurs when the vessels supplying blood to the lungs have high pressure (Myrick and Karosas, 2021). Finally, psychogenic reasons can cause chest pains, although “psychogenic” is not an official medical term. However, Myrick and Karosas (2021) note that strong emotions or beliefs can cause or prolong a person’s physical pain, and the treatment of such pain would involve a consultation with a therapist or psychiatry specialist.
Tropin T is the most specific and sensitive marker for acute myocardial infarction because this marker is sensitive and is indicative of a myocardial injury (Myrick and Karosas, 2021). This enzyme is specific for the cardiac muscle. Therefore, the lab test for Tropin T allows a nurse to recognize that the muscle has been damaged. An echocardiogram and ECG are important for diagnosing acute myocardial infarction or acute coronary syndromes because these diagnostic tools allow medical professionals to measure the heart’s electrical activity (Myrick and Karosas, 2021). Therefore, if one can stop inconsistencies in this activity, one can suspect that this muscle is not functioning properly, and therefore, there is a need to subject the patient to further tests.
Clinical Decision-Making
The clinical decision-making in the case of Mr. Vlog is guided by two factors. The first one is the need to address the myocardial infusion immediately, as it poses a threat to his life. The second is the need to discuss prevention strategies with this patient to ensure that he is capable of maintaining his health at an optimal state in the future. According to Lamar University (2018), a holistic approach allows nurses to combine traditional medicine with alternative treatment methods. Such methods as aromatherapy, meditation, and others could be combined.
The first step that a nurse should take when Mr. Vlog is admitted to the emergency department is to order a set of blood tests that would allow confirming a diagnosis in the future. These blood tests include Troponin T, Full blood count, Renal Profile, C-Reactive Protein, D-Dimer. Additionally, one of the following should be performed: ECG, echocardiogram, or a chest x-ray. The symptoms that Mr. Vlog presents are consistent with a potentially deadly condition such as heart failure. Therefore, it is essential to ensure that the team collaborates and performs the tests and analysis of the results as quickly as possible.
Effective Collaboration and Communication
An effective holistic assessment begins with open communication with the patient. Therefore, the first goal of the contact between a nurse and a patient is the ability to create a welcoming environment. The latter can freely express their concerns and discuss habits or environmental factors that might adversely affect their health (Abrams et al., 2020). The goal, as with any type of medical assessment, is to preserve the patient’s dignity and consider their preferences when developing the health improvement plan.
In this particular case, a nurse has to cooperate with a cardiologist, radiologist, pathologist, fellow staff nurses, discuss referral to a specialized cardiac center. Namely, the cardiologist’s consultation is required to confirm the final diagnosis, which is the myocardial infarction, and to begin the treatment immediately. The radiologists and pathologists are required to perform procedures that will help confirm the diagnosis and analyze the severity of Mr. Vlog’s heart’s state.
Synthesis, Interpretation, and Conclusion
The cardiac diagnosis that is consistent with Mr. Vlog’s symptoms is myocarditis infraction. This diagnosis is commonly known as heart failure, and it occurs when a person’s cardiac muscles do not receive enough oxygen; and therefore, this organ fails to perform its vital function (Martin-Isla et al., 2020). One critic that a nurse must consider before diagnosing the myocardial infraction is the elevation of the ST levels (Miranda et al., 2018). According to Ahmad and Ali (2019, p. 1), the “Non-ST elevation myocardial infarction (NSTEMI) which denote cardiomyocyte necrosis and death by a rise in serum troponin levels.” This is a specific case of a heart attack that is more complex and, therefore, difficult to diagnose and treat in a timely manner (Mohan, Thirumalai, and Srivastava, 2019). Hence, the elevation of the ST levels is not always a good indicator of myocardial infarction. A mnemonic for memorizing the ST levels elevation is ELEVATIONS (ESC cases 17, n.d.). During a myocardial infarction, a patient develops sensitivity to Troponin T since troponins proteins are released after damage occurs, for example, to a heart muscle tissue (Ahmad and Ali, 2019; Thygesen et al., 2019). Hence, troponin is a good indicator of heart muscle damage that can be used to diagnose a heart attack.
However, apart from the cardiac diagnosis, a nurse should also consider the non-cardiac alternatives that can cause similar symptoms. For example, renal failure can also cause elevated levels of Troponin T (Lan et al., 2020). This marker is a part of the troponin complex that forms some of the skeletal structures and heart muscles. That is why a cardiac diagnosis is the first option to consider when Troponin T levels are elevated (Kidney failure, n.d.). Renal failure means that one or both of the kidneys have seized to function normally, which therefore affects the levels of Troponin T. According to Chesnaye et al. (2020, p. e013091), chronic kidney conditions result in the elevated levels of this marker, and the authors report that “CKD patients, hs‐cTnT increases over time as renal function decreases.” However, the acute symptoms that Mr. Vlog communicated, such as chest pains that radiate to other parts of the body, indicate that this case is not a renal failure.
In summary, this paper reviewed the basics of a holistic health assessment and offered strategies for communicating the changes that a patient needs to implement into his lifestyle to facilitate improvements in his health state. This paper discusses the importance of a holistic assessment using the example of Mr. Vlog. Additionally, using the information from the case study, this paper presents an analysis and synthesis of evidence-based on which this patient is diagnosed with myocardial infarction. The C-CG model should be used to communicate the health-related information to Mr. Vlog. From this case study, I have learned the importance of implementing holistic assessment in patient care. In order to make my future practice safe and effective, I will consider the application of this type of assessment. It will help me to explore the probable diagnoses better and thus improve the patient care and treatment quality.
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Appendix
- Short introduction of patient: 57 year old man admitted via emergency department due to central chest pain radiating to the back of neck and left arm and with short of breath.
- Past medical history: Patient’s father died at 50 due to heart attack; the patient smokes 15 per day since 20 years old; works as a finance manager.
The patient’s cardiac enzyme levels were slightly elevated. Acute myocardial infarction without ST elevation was the reason for the patient’s hospitalization. Echocardiography did not show apical dyskinesia, ejection fraction 0.45, or intraventricular pressure gradient. Due to the patient’s persistent chest pain, an emergency coronary angiography was performed using an intra-aortic balloon pump. During systole, angiography showed apical balloon formation with increased contractility of the basal region. LVSF (LV contraction function) was moderately reduced overall. The patient’s symptoms improved after treatment.
Creatine kinase MB and troponin T levels were both slightly higher. A 1 mm.
ST rise was seen on the lead V1 to V3 electrocardiogram (EKG). Significant precordial T-wave inversion suggestive of acute chest pain and acute myocardial ischemia required urgent coronary angiography.