The given scenario revolves around a 54-year-old man who has a history of hypertension and reports that he is experiencing chest tightness issues due to mild physical activity. In the case of cardiovascular risk factors, it is stated that: “hypertension is the strongest or one of the strongest risk factors for almost all different cardiovascular diseases acquired during life, including coronary disease, left ventricular hypertrophy and valvular heart diseases, cardiac arrhythmias including atrial fibrillation, cerebral stroke, and renal failure” (Kjeldsen, 2018, p. 95). In other words, there is a real danger in regards to cardiovascular diseases (CVD), which can be life-threatening. The pathophysiology of hypertension is rooted in the fact that there is severe impairment in renal pressure of the natriuretic mechanism, where high pressure in the blood leads to elevated water and sodium excretion (Fuster et al., 2017). Thus, there is a disturbance which both causes and impacts renal function.
In addition, the reported chest tightness is a major concern because it can signify the occurrence of a heart attack. The cardiovascular risk factors include increasing age because the majority of heart attacks take place among people who are older than 65 (“Understand your risks to prevent a heart attack,” 2021). Males are also more prone to heart attacks than females, and it remains so even after women reach menopause when there is a sudden increase in the occurrence rates (“Understand your risks to prevent a heart attack,” 2021). The heredity factor needs to be also considered because the family history can be an indicator of the probability of having similar issues. It also includes race, where African Americans and Mexican Americans are more likely to have heart attacks compared to Caucasians (“Understand your risks to prevent a heart attack,” 2021). Smoking is also a cardiovascular risk factor because substances in tobacco can severely damage the blood vessels in one’s body, which can also be accompanied by the narrowing of the vessels, which inevitably leads to hypertension and high blood pressure (“Cardiovascular disease,” 2018). In other words, these risks cumulatively and collectively cause cardiovascular disturbances and dysfunctions, which lead to further complications.
Pathophysiology of hypertension is a complex topic, which revolves around a wide range of issues. These include the renin-angiotensin aldosterone system, the sympathetic nervous system, genetic factors, hypercoagulability, endothelial dysfunction, and insulin sensitivity (Saxena et al., 2018). In the case of the renin-angiotensin aldosterone system, angiotensin II is known to be a major vasoconstrictor, which leads to hypertension (Di Giosia et al., 2018). In addition, the sympathetic nervous system is directly involved in the “fight-or-flight” response, where noradrenaline and adrenaline are released, which cause vasoconstriction. Endothelial dysfunction can also be the cause of the issue, where vascular endothelial cells do not respond properly to the relaxation signals, which leave the vessels narrowed (Saxena et al., 2018). In addition, genetic factors can be accounted for almost 30-50% of all blood pressure variations within the population, which means that the patient is likely to be impacted by his family history (Patel et al., 2017). In regards to the patient, this factor can be considered as one of the most critical and prominent ones because he has a family history of heart attacks during a similar age range. Therefore, the pathophysiology of hypertension includes a wide range of elements, which can be contributing either individually or cumulatively.
Pathophysiology of myocardial infarction or heart failure (HF) also includes an array of bodily issues. A coronary vessel’s thrombotic occlusion is one of the main causes of myocardial infarction. One fundamental link is the renin-angiotensin-aldosterone system. This system is activated in response to decreased renal perfusion. The production of renin and, consequently, angiotensin II increases, which leads to vasoconstriction of efferent arterioles, increases the filtration function, and maintains a minimum glomerular filtration rate (Zipes et al., 2018). At the same time, there is a simultaneous increase in the concentration of aldosterone, which causes the retention of sodium and water. This system is a compensatory reaction of the body and, despite its effectiveness, increases myocardial dysfunction in the early stages and mortality during long-term observation. Aldosterone plays an equally important role in fluid retention. It acts on metal-proteinases, thereby affecting fibrosis and remodeling of the LV myocardium.
The classical theory explains the congestion of sodium and water retention, which leads to the accumulation of extracellular fluid, weight gain and effective volume, and the development of renal dysfunction. The second, more recent, theory explains the overload as a result of a sudden shift in the balance of the circulating fluid volume in the venous system due to an increase in sympathetic stimulation during HF decompensation (Zipes et al., 2018). As a result of tissue hypo-perfusion, constant stimulation of the sympathetic nervous system is accompanied by a decrease in the stimulation of carotid baroreceptors. As a result of a slight increase in sympathetic tone at the beginning of HF decompensation, the volume of fluid in the body is redistributed, which explains the volume overload and symptoms of stagnation (Zipes et al., 2018). Therefore, there is no exogenous fluid retention and weight gain preceding HF decompensation.
Cardiogenic shock can be defined as a state of systemic tissue hypo-perfusion in response to an acute inability of the heart muscle to provide an output adequate to the body’s needs. The most common cause of shock is damage to the heart muscle in acute myocardial infarction (Zipes et al., 2018). Slightly less common are ventricular or supraventricular arrhythmias that cause a decrease in cardiac output, myocardial insufficiency with sepsis, rupture of tendon chords or valves with endocarditis, acute myocarditis, rupture or thrombosis of a valve prosthesis, severe, acute aortic or mitral stenosis, severe or acute aortic stenosis mitral insufficiency, rupture of the interventricular septum. In other words, the case presents how complex the pathophysiology of heart failure can be due to the restricted blood flow to the heart.
The second scenario is centered around a 33-year-old woman who is exhibiting substance abuse behavior, where she is becoming more and more non-compliant with the medications. Since she is actively using opioid drugs to overcome her pain issues, it is evident that substance abuse might be taking place in this case. I would approach by adhering to the principles and ethical considerations of patient-centered care, where I am only in a position to lead an individual rather than commanding her. It is ethically problematic that she is abusing her medications, but as an advanced practice nurse, who puts a great deal of emphasis on a patient’s autonomy, I would make an attempt to lead the patient through the educational approach. The main reason is that it is stated: “a patient-centered approach involves transferring power and authority away from health care professionals and towards patients” (Russell et al., 2003, p. 281). In other words, the patient-centered approach gives patients autonomy but also makes them responsible for their actions. Therefore, the only ethical measure that I can utilize is to educate the patient. Under such a power dynamic, where patients are in charge of the decision, the most plausible action is to equip the patient with all necessary tools for making better choices (Whittaker, 2016). It is important for the patient to understand that there are major and serious consequences of her substance abuse problem, which can lead to further complications in regards to her health and well-being.
My approach would vary on the basis of the substance being abused because some drugs are well-known to be harmful and lead to major illnesses, whereas others are not as evident. For example, I would not use an educational approach for a patient, who abuses alcohol, because it is well-known to be harmful to the overall well-being of an alcoholic. In this case, I would refer to specific organizations, which deal with alcoholics. However, as in the given case, patients might not be well-informed on prescription drug abuse, which is why I would be more proactive at utilizing an educational approach and leading the patient to make the necessary changes.
I do not come from a background with a high socioeconomic status, which is why I understand the social and economic reasons that could lead to substance abuse. I experienced the harsh realities of being a person with low socioeconomic status, where the lack of capital and sufficient income can make life stressful. In addition, the lack of money can affect one’s ability to make the necessary changes, such as eating healthy, performing regular exercises, and reducing the general stress levels. I would be able to provide an educational approach for the patient by taking into account her financial and socioeconomic struggles because I will focus on the things, which she will be able to integrate into her life without major resource investments.
The primary care techniques and tools to identify substance abuse involve treatments, which are office-based. The categorizations include three major groups, which are substance dependence, substance abuse, and hazardous use. The latter can be managed by the use of a short counseling procedure with a competent physician. However, substance dependence and substance abuse require additional measures on top of the counseling, such as pharmacotherapy, monitoring, and reevaluations (Schulz, 2020). In other words, the patient requires a brief counseling session with her physician as well as extensive follow-up monitoring in conjunction with a strict evaluation of her compliance.
One of the most urgent ethical and legal dilemmas of modern nursing is preserving and protecting patients’ autonomy. The dilemma is centered around keeping a patient autonomous or act with the intent of beneficence. I would suggest my APRN/APN colleagues adhere to the essentials of patient-centered care, where decisions should be made by a patient or people representing his or her interests. In other words, nurses should not act without informed consent because it will be both an ethical and legal violation. Therefore, it is important to constantly preserve and protect the patient’s right to autonomy over her or his treatment.
References
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Fuster, V., Harrington, R., Narula, J., & Eapen, Z. (2017). Hurst’s the heart (14th ed.). McGraw-Hill Education.
Kjeldsen, S. E. (2018). Hypertension and cardiovascular risk: General aspects.Pharmacological Research, 129, 95-99. Web.
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Schulz, R. (2020). Patient compliance with medications: Issues and opportunities. CRC Press.
Understand your risks to prevent a heart attack. (2021). Web.
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Zipes, D. P., Libby, P., Bonow, R. O., Mann, D. L., & Tomaselli, G. F. (2018). Braunwald’s heart disease e-book: A textbook of cardiovascular medicine (11th ed.). Elsevier.