Psychological factors and the person’s perception of their own illness/condition

• 74 year old male, multiple ongoing cardiovascular health conditions

• Is Incarcerated – has been for prolonged period and not for release anytime soon

• Resides within a challenging and sometimes frightening environment, has expressed physical trauma from fellow inmates in the yards.

• However, has been coping well mentally, nil history noted of mental health conditions or depression considering his surrounding environment and sentence. Has some stress noted from younger inmates causing trouble for him but he isn’t medicated for it.

• Has a fairly sound, realistic & validated conception of his ongoing health concerns

• PMHX
diagnoses of arthritis in 2011 which has ultimately affected his mobility
Asthma & coronary artery stenosis diagnosis 2013
Hypertension & atherosclerosis diagnosis in 2015 followed by myocardial infarction 2016.

• Never looked after his health, knew his blood pressure was a bit high but never saw GP in community before being imprisoned

• managed now within a primary health clinic setting by primary health clinic nurses & GP.

• BP in clinic was 188/92 – on antihypertensives, previous day 175/89
Pathophysiology of the person’s key condition – Hypertension & associated atherosclerosis
• Pt has many risk factors for hypertension including being male (higher risk), family history of hypertension on fathers side, environmental stressors (jail activation of SNS fight or flight response), lack of physical activity due to arthritis use of wheelchair.

• Blood pressure is the lateral force on the walls of an artery as blood is pumped out by the heart

• Blood pressure is determined by cardiac output, blood viscosity and presence of total peripheral resistance.

• In this case study his previously uncontrolled hypertension in the community combined with risk factors such as family history, smoking, poor diet and aging has led to vascular damage and arterial remodelling through permanent damage of the tunica intima & media layers of his arteries from prolonged increased workload of the heart.

• The damage of the inner layer of the arteries at this level can attract plaque to form which is where atherosclerosis formation begins, overtime eventually hardening and causing a narrowing of arteries which increases blood pressure and risk for rupture of that plaque

• Rupture of this plaque can result in platelet formation and thrombosis at the plaque site which combined with increased arterial pressure can cause it to break off and form an embolism which can cause myocardial infarction if circulated to the heart (which he has suffered from previously) or a stroke if it is circulated to the brain.

Nursing management and rationale
Daily observation checks – monitor vital signs and BP status and monitoring therapeutic affect of antihypertensive medication. This also allows to monitor for any side effects on antihypertensive therapy – which he had suffered orthostatic hypotension increasing his falls risk from cell bed to wheelchair.

Through this the patient was started on additional antihypertensives when his norm was not working which helped bring his BP down within 24 hours to normal parameters.

Morning and nighttime medication dispensed at medication window – to ensure medication compliance, as its within a jail environment a lot of inmates are stood over for their medications regardless of its action as they can be traded and sold within the jail system.
Referral onto GP if present in clinic during acute hypertensive events, if GP is not present then transfer of care via ambulance to tertiary hospital setting.

Education :
regarding exercise, referral to primary clinic physio to help with exercise regimes suitable from a wheelchair perspective.
Reducing stress: meditation techniques
Regarding diet: advised to stop consuming processed sodium rich foods in buy ups
Regarding symptoms: signs such as blurred or vision disturbances, headaches to present or inform nurses immediately.

Pharmacological interventions and management
Metoprolol (Lopressor) 2.5mg BD – Beta 1 selective blocker – works by blocking effects of epinephrine which reduces cardiac output which in turn reduces arterial blood pressure and strain on the heart. Also helps to prevents chest pain.
Nicorandil 10mg BD – Potassium-channel activator – works to promote vasodilation through relaxation of vascular smooth muscle which helps vasodilation of arteries in turn decreasing diastolic pressure and systemic resistance. Also helps with angina
Irbesartan 300mg daily – angiontensin II antagonist
Prazosin 0.5mg BD – alpha-adrenoreceptor antagonists, peripherally-acting antiadrenergic agents

Hydrochlorothiazide added additionally as regular treatment was not working.