A full assessment of Jane was carried out which showed that she was tachycardic, with a pulse rate per minute of 118, and hypertensive with a blood pressure of 182 systolic over 102 diastolic. However, the tachycardia Jane was experiencing may have been due to the pain, or stress and anxiety of the situation (Lippincott Williams and Wilkins 2007). An electrocardiogram (ECG) test was then carried out which is used to show the electrical activity of the heart including heart rhythm and rate (Handler and Coghlan 2007). The reading from the ECG showed ST segment elevation which signifies that injury to the myocardium has taken place (Thaler 2006). Jane was then treated with thrombolytic therapy which works to dissolve the clot causing the MI (Kroll 2001). The sooner this thrombolytic drug can be administered, the better the chance there is of avoiding the death of the heart muscle as the blood flow to the heart can be restored (National Institute for Clinical Excellence 2002). In health, the main functions of the cardiovascular system are to deliver nutrients and O2 to tissues in the body and carry waste materials like CO2 to organs such as the lungs to be eliminated from the body (Fuster et al. 2004).
After Jane’s condition was under control she was moved to a cardiac unit for closer monitoring and so a Troponin T blood test could be carried out, which is used to confirm that damage to the myocardium has taken place, but has to be done 12 hours after the first onset of chest pain (Lippincott Williams and Wilkins et al. 2002). The main risk factors that can be identified from Jane’s assessment for the development of CHD are smoking, her poor diet and her lack of exercise (Carlson et al. 2004). High blood cholesterol is a major cause of cardiovascular illness because high levels can promote the formation of atherosclerosis thus causing the hardening and narrowing of the arteries (Insel et al. 2009). Cigarette smoking has major implications on the heart also as the chemicals found in cigarettes can cause plaque build-up on blood vessel walls (Dulmus and Rapp-Paglicci 2005). It is the sticky substance of nicotine which can cause platelets to build up in the arteries, thus, causing a clot (Rosdahl and Kowalski 2007). Nicotine also has other adverse affects on the cardiovascular system including peripheral vasoconstriction, tachycardia (Aschenbrenner and Venable 2008) and hypertension because it stimulates the sympathetic nervous system (Hand 2001).
Smoking has been known to be a significant factor towards the development of CHD for a long time (Hand 2001) and so it has been targeted for many years. In 1980, a study called the Black Report was conducted to look at inequalities in health (Macionis and Plummer 2008). This report, headed by Sir Douglas Black, looked at mortality rates among five different social classes (Roemer 1992), and found that people from higher social classes were healthier and lived longer than individuals in lower social classes (Giddens and Griffiths 2006). The report blamed this difference between social classes on socioeconomic factors such as smoking and poor living conditions (Cockerham 2007). The stress and anxiety that lower social classes suffer means they are five times more likely to smoke according to MacDonald (2004) and in Jane’s case she would have been suffering the stress of her mother and father arguing and struggling financially as a child and then later on in life, the stress of her husband and herself struggling financially. From the findings of this report came 37 recommendations which included phasing out the advertising of cigarettes and providing smoke free areas in public places (Hatchett and Thompson 2002). Figures show that the difference in smoking and social class had the same trend back in 1973 as it had in 2004 (See appendix 2), even though the prevalence had dropped (Parliament UK 2009).
Though the Black Report did make important changes, it is evident that smoking is still more prevalent in poorer individuals than wealthy individuals. Figures on the prevalence of cigarette smoking among adults by socio-economic groups in England (see appendix 3), show that in 2006, 28,000 manual workers were smokers opposed to 17,000 non-manual workers who were smokers (NHS 2008). However, figures from The Office for National Statistics (2006) (See appendix 4) show that even though the trend in social class remains similar, the actual number of people over the age of 16 that smoke has decreased from 45% in 1974 to 24% in 2005. The above figures show that the chances that Jane would go on to be a smoker were higher than if she came from a wealthy background, and from the information Jane disclosed in the assessment, it is clear she did come from a low social class family.
In recent years, smoking has been the target of another government scheme which was to ban smoking in all enclosed public places by July 1st 2007 in England (Thomas 2007), and 2nd April 2007 in Wales (Welsh Assembly Government 2007a). The main aims of the ban were to reduce smoking related harm, ill health and premature death by making smoking illegal in public places and work places (Welsh Assembly Government 2007b). However, because of this ban, the amount people accessing help and support who wanted to give up smoking increased, and since the introduction of the smoking ban, Stop Smoking Wales reported a 20 per cent increase in people contacting the service (Welsh Assembly Government 2008). The main purpose of smoking services are to provide advice and treatment to smokers who are planning to or making an attempt to quit smoking (McEwen et al. 2006). Figures show that the legislation has been beneficial as 30 per cent of smokers interviewed in a Welsh Omnibus Survey in 2008, said that they were smoking fewer cigarettes since the introduction of the ban (Welsh Assembly Government 2008). When Jane was asked if the smoking ban in public places had motivated her to give up, she unfortunately stated that the ban had not really given her any motivation to give up, as it did not affect her that much as she only went to the local pub once a week and could smoke anyway when at home, or outside at work. She stated that had never really given much consideration to giving up even though she said she knew of the risks associated with smoking, but always thought that ‘it would never happen to her’, meaning cancer or heart disease.
As CHD is the biggest cause of death world wide (see appendix 5) according to the World Health Organisation (2009), England and Wales both put a NSF together for CHD. The purpose of NSF’s is to bring together the best evidence based, cost effective care as possible for major illnesses and diseases (Leathard 2003). The National Assembly for Wales published a NSF in March 2001 for Coronary Heart Disease in order to improve and modernise services in Wales, stop variations in care and access, and decrease the number of people developing CHD (National Assembly for Wales 2000). The framework, Tackling CHD in Wales: Implementing Through Evidence, identified the major risk factors of developing CHD such as lack of exercise, a poor diet and smoking and targeted many of these in the plan. The framework detailed a plan of how it would achieve these aims such as placing emphasis on all local authorities that they have to have policies on smoking and support programmes for people wanting to quit smoking like targeting people who are at risk of developing or worsening CHD (National Assembly for Wales 2000). Procedures of care were also laid out in the framework such as ensuring all patients who are suspected of suffering a cardiac arrest; see a paramedic or first response team within 8 minutes of the initial call (National Assembly for Wales 2000). Some of the initiatives laid out in the framework may benefit Jane as she is at risk of worsening CHD now that she has suffered a MI, because she will receive increased support and advice especially regarding her risk factors. Subsequent to the NSF for CHD and the smoking ban been implemented, Plaid Cymru released figures for Wales in July 2008, showing that there had been a decrease in the amount of cardiac admissions into hospital (Hairon 2008).
Another factor that may have contributed to Jane starting to smoke is the influence her father smoking himself may have had on her, since Jacobson et al. (2001) suggests, adolescents are more likely to try smoking if either one of their parents smoke. Shumaker et al. (2008) also suggests that parents who smoke could be sending unintentional signals to their children that it is socially acceptable to smoke. Part of this is because smoking became popular and socially acceptable in the early 1920’s (Lock et al. 2001), which is when Jane’s father would have grown up, and so he will have had a positive attitude towards smoking which may have carried on down through Jane’s generation. However, Jane did state that she didn’t start smoking until she moved to Manchester when she was 16, and lived with two other girls who were also smokers. Smoking usually starts in adolescent years because peer pressure and role modelling are strong psychosocial factors that have an influence among this age group (Sarafino 2006) mainly because they find it hard to resist these pressures (Ayers et al. 2007). Also, adults and peers who smoke around the adolescent can send out the indication that smoking is advantageous (Elders 1997) such as gaining new friends or been perceived as mature. There is a strong possibility that Jane started smoking to fit into the new social network and her new housemates when she moved to Manchester, and as Marks et al. (2000) states, smoking may be perceived as a way of initiating and strengthening social networks and also, non-smokers could be frowned upon.
Jane was asked about her smoking habit in the days following her MI, and she said that she had been craving for a cigarette, but was not going to have one. She stated that having a MI had scared her and had made her realise that what she was doing was bad and that she needed to take action. Jane said that she did want to give up smoking, but knew it was going to be hard. However, Jane stated that she had other worries apart from smoking such as how her life will be affected by having a MI. Her main worries were that she could not go back to work, would struggle getting back in to her old routine and also the risk of another MI. Jane was assured that she would receive cardiac rehabilitation, and would have support and advice following her discharge from hospital.
Through Jane suffering a MI and been admitted to hospital, she has been deemed to have taken on the sick role. The sick role concept was developed by Talcott Parsons, a sociologist who believed that individuals adopt a socially defined role when they become sick, in which there are privileges and obligations attached to it (Denny and Earle 2005). Parsons believed that sickness was a social phenomenon, in which rules about been sick had to be strict in order to prevent a strain on society (Porter 1998). It is a deviant state from society in which persons take to depart form normal activity and behaviour, but in order to fit legitimately into this role, there is certain criteria that must be fulfilled (Williams et al. 1998). The person is expected to be motivated to get better as soon as possible, seek help from a professional and comply with the treatment, otherwise the privileges that come with been sick, of been exempt from everyday responsibilities and not been held accountable for their illness, will be taken away (Taylor and Field 2007). In Jane’s illness, it can be seen that she has legitimately fitted the criteria of the sick role as she has sought professional help, complied with the treatment given to her when she was admitted to the accident and emergency unit and she has so far, been motivated to get better. This means that Jane has been entitled to the rights that come with being ill and so she can withdraw from her job as a health care worker, her normal role at home and any other responsibilities she may have until she is deemed to be better.
However, there are some criticisms of the sick role concept, as Turner and Samson (1995) suggests, such as the concept simply applying to those who are acutely ill and giving no consideration to those people who have chronic illnesses or who may never fully recover from their illness. One of the obligations for entering the sick role is to get better as soon as possible, but for people who have long term or permanent illnesses such as diabetes or chronic leg ulcers, it may be the case that they do not fit into the criteria of the sick role or it may be unclear when the person is accepted to be in the sick role (Moon and Gillespie 1995). For instance, a person with diabetes may usually be able to lead a normal life, fulfilling all their social roles, but if they were to become hypoglycaemic, could they then enter the sick role until back to normal functioning? Henderson et al. (2009) suggests that people with chronic illnesses must learn to adapt and live with their illness, however, variability between individuals and their illness can vary as some people may not want to give up their normal social roles, whereas others may be forced to carry on by the un-acceptance of family and friends (Roy 2004)
Another criticism of the concept is that Parson’s assumes that every one will adhere to the rights and obligations of the role, but this may not always be the case (Kirby 2000). How people behave when they are ill can largely depend on how they were brought up and what they have learned (Sarafino 2006). Jane has been co-operative with her treatment since admission; however, problems may be encountered when Jane is discharged from hospital and rehabilitation at home begins. Rehabilitation involves the individual making necessary life changes and risk factor modification (Tod 2008). Jane will have to change her lifestyle and adhere to medication regimes since ACE inhibitors, beta blockers, statins and aspirin are usually prescribed (Loue et al. 2008) to reduce the chance of having another MI. Jane is going to have to radically change her lifestyle in order to reduce other risk of suffering from another MI, and so her adherence to treatment is essential. However, if Jane stops adhering to treatment, she may be frowned upon be seen to be self inflicting her illness which may lead to the privileges of the sick role been revoked. Depression and anxiety are common in individuals in the months following a MI due to social and psychological adjustments (Steptoe 2007). These negative emotions can contribute to harmful lifestyle choices such as smoking (Woods et al. 2004) and so it can be a vicious circle that Jane may smoke if she suffers from anxiety or stress due to her worries about her illness, and look like she is self inflicting illness on her self leading to a loss of privileges.
Whether Jane gives up smoking and changes her lifestyle on the whole for the better will largely depend on whether she has an internal or external locus of control and knows that her health depends on her actions. The locus of control theory, which was developed by Julian Rotter, is concerned with the extent to which people perceive themselves to have control over events in their lives (Quinn and Hughes 2000). If a person believes outcomes in their life occur because of their own actions or behaviour then they have an internal locus of control, but if they believe these outcomes occur because of external factors and influences, then they have an external locus of control (Hughes 2004). Jane, for instance, seems like she is adopting an internal locus of control as she can see that her smoking habit is harming her health and knows she has to do something about it. However, if Jane was to say that giving up smoking will not make any difference as outcomes in life depend on fate, then she would have an external locus of control as she believes we cannot stop what is going to happen to us regardless of lifestyle factors. A patient’s ability to cope with a change in health depends on his or her social wellbeing (Lloyd and Craig 2007) as recovery can be an enduring process that involves a person learning to live with the difference an illness makes to their life (Todd 2008). Jane must realise that changing her lifestyle and behaviour is going to benefit her health, and if not, she must be informed of the consequences of not changing her behaviour in respect to smoking (Kozier 2007). Jane will have to have an internal locus of control in order to change her lifestyle, otherwise she will continue with her poor lifestyle behaviour. However, looking at Jane’s health behaviour in the past, it seems that she has had an external locus of control as she stated she knew the risks of smoking but never thought the risks would happen to her, so hopefully, suffering a MI will give her the notion that she has to do something about her health behaviour.
To conclude, this assignment looked at how biopyschosocial factors of a persons life influences and impacts upon their health. It was carried out by looking at Jane, who had suffered a MI and identifying her risk factors which were her smoking habit, poor diet, and also the fact she is and has always been in a low social economic household. The reasons why these risk factors contribute towards the development of CHD were explored, and because smoking was identified to be a major risk factor of the development of CHD, it has been at the heart of many initiatives and legislation. Through the implementation of phasing out the advertising of cigarettes in the 1980’s through recommendations of the Black report, to more recently, the smoking ban, the incidence of smoking and related CHD has started to reduce. This is enabling a healthier nation as well as reducing the stress the high numbers of CHD patients have on the NHS. It is important that support is readily available to assist those who do want to quit smoking and figures show that more and more smokers have been accessing these services for advice. However, recent figures show that even though the incidence of smoking is reducing on the whole, there is still a definite difference in the amount of people smoking in lower social economic classes then in wealthy classes, but hopefully, when the smoking ban has been in force for a while longer, this gap will start to close and inequalities in health will diminish.
The assessment that was carried out on Jane included information about not only her present and past medical history, but other aspects of her life both socially and psychologically. The psychosocial part of the assessment allowed for consideration of any future needs that Jane may have had, such as planning how she will cope socially and integrate back into the community or how she may cope with new medication routines (Haas 2004), whereas the biological element involved issues such as to whether Jane already had any health issues or illnesses (Burke and Laramie 2003). This BPS approach to assessing means that as well as the nurse understanding the medical treatment of the illness, the nurse will have an understanding of the psychosocial issues the patience faces and the relevance they have to the manifestation of the illness (Haas 2004). A thorough understanding of the patient’s culture and life experiences allows for holistic and competent care to be delivered (White 2004).
Following the assessment of Jane, an actual and a potential care problem were identified that will be carried through to the next assignment. The actual problem that will be looked at will be Jane’s smoking habit and how Jane can be helped to give up. The potential problem that was identified was how Jane will cope with a medication regime after discharge from hospital as she will have to take aspirin, beta blockers, ACE inhibitors and statins (Loue et al. 2008) for the foreseeable future. These problems were identified party through carrying out the BPS assessment, as the problem of smoking was identified early on in Jane’s care and a better understanding of the reason’s Jane smoke were better understood allowing for better planning of the health promotion approach.
Reflection
Through the completion of this assignment, I have learnt a great amount on the importance of carrying out a full bio-psycho-social assessment. In order to expand my knowledge, i have had to look at research and statistics in great depth and critically analyse them and having examined how much of an impact smoking has on an individuals health, I feel more confident in approaching patients about their smoking habits and offering advice to them. This is partly due to my increased knowledge on the effects of smoking, especially how nicotine harms the cardiovascular system, and partly due to me having increased knowledge on the services available to individuals who want to give up smoking. Roberts (2002) suggests that if we do not offer our patients help and support to help quit smoking, then we are failing them as health professionals, and this is not what I want to do in my future career as a nurse.
I have also significantly improved my skills in not only assessing patients, but communicating and interacting with patients as I have improved on my ability to make the most of different communication tools such as using open and closed questions at the appropriate time or asking leading questions to encourage the patient to disclose key information. Lloyd and Craig (2007) suggest that to ensure nothing is missed when taking patient history, it is important to use appropriate questioning techniques. I feel that through the assessment of Jane, I managed to build a better rapport with her as it enabled me to gain a better understanding of Jane and her needs, whilst giving Jane the time and chance to talk about any fears she may have about her illness or worries about her discharge home. The assessment with a patient provides an opportunity to establish a therapeutic relationship with them and listen to their problems and feelings (Kaufman 2008).
Having this increased understanding will facilitate me in planning a smooth discharge of the patient as I will be able to plan better for the patients needs and understand what is important and essential for the patient after discharge. The understanding of a patient’s strengths and limitations allows for the planning of realistic, individualised expectations of care (White 2004). Encompassing this knowledge is important to me as a developing practitioner as it has given me good foundations on which I can build more knowledge on, and improve and enhance my practice.
As a next step, I feel i now need to carry what I have learnt out into practice so I can improve my assessment of patients, which will in turn help me have a better understanding of my patient’s needs and more insight into their lifestyle, the reasons why they do certain things, and the effects of their lifestyle choices. Nurses need a better understanding of how self-efficiency, compliance and locus of control effect individual patients (Hughes 2004).
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Appendix
Appendix 1
Body Mass Index
BBC (2009) Calculate your body mass index (Accessed on 28th May 2009)
Appendix 2
Smoking prevalence and socio-economic disadvantage
CIGARETTE SMOKING BY DEPRIVATION IN GREAT BRITAIN: GHS 1973 & 2004
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(Accessed on 12th June 2009)
Appendix 3
Figures on smoking by social economic group taken from the Office for National Statistics General Household Survey
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Appendix 4
Percentage of adults who smoke cigarettes by sex: Great Britain 1974 to 2005
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Appendix 5
Chart to show main causes of death globally
World Health Organisation (2009) Cardiovascular diseases http://www.who.int/cardiovascular_diseases/en/ (Accessed on 11th June 2009)
