Cardiovascular Risk

This case study of George, age 48, presents a classic Type A personality. George operates under a consistently high level of emotional and physical stress. While some of this stress is the result of his work, part of it is also self-imposed and is the product of a personality type who often refuses to seek help unless in a crisis. George works two demanding high-stress jobs. One is as a machinist with a construction company, which is very physically stressful. The other is as a cab driver, which can place physical stress on the patient due to long hours of driving. Although only middle-aged, George has suffered three heart attacks.
There is empirical evidence to suggest that there is an association between personality and susceptibility to suffering cardiac conditions: “The hypothalamic-pituitary-adrenal (HPA) axis and the stress hormone cortisol provide key links between emotions and the heart. The HPA axis controls various body functions by releasing hormones into the bloodstream” (“Type D Personality,” 2018, par.7). Genetics, smoking and poor lifestyle decisions can likewise increase a patient’s susceptibility to heart attacks. Although it is not stated, working long hours and shift work in general often can reduce the likelihood a patient has time to exercise and eat healthy meals. Thus irregular work and sleeping patterns are likewise associated with increased cardiovascular risk (Mosendane, Mosendane, & Raal, 2008). George’s patriarchal cultural attitudes about women working and the need to be a breadwinner clearly intensify his emotional stress, as does one of his children’s learning disabilities. George is very resistant to the idea of his wife working and shouldering some of the financial burden of the family.
Crisis Paradigm
Although George may not feel as though he is living in a state of crisis, his youthful age combined with the risks posed by his heart attacks indicates that he warrants a crisis-based approach in terms of his treatment. His unwillingness to seek help likewise suggests that such an approach may be needed. One helpful model for emotional crisis intervention is the transtheoretical model of change, which suggests pre-contemplation, contemplation, readiness, action, maintenance are the steps involved in any change process (“Transtheoretical Model,” 2018). Currently, George is in the pre-contemplation stage, in which he denies the need for change entirely. Pre-contemplation is characterized by a lack of awareness and a lack of the ability to connect behaviors like smoking, stress, and working long hours with negative consequences. There is no indication that George has made any lifestyle changes since his previous heart attacks. In fact, his views about his need to work hard have appeared to become even more entrenched.
Given this fact, an important part of the nurse’s job is to convince George about the need for change. This means laying before George the statistics that his health status is not normal. Going over George’s lifestyle, including his diet, exercise, and sleep habits, would also be useful as a wakeup call. Lifestyle changes can be challenging even for motivated patients, and George does not appear to be motivated to change at present. Only then can the nurse move forward into readiness and constructing a plan of action.
Rationale for Crisis Status
George’s health status is not normal for an individual of his relatively youthful age and the space between his attacks are of very short duration. His lack of proactive action in the past, the continued stresses placed upon him in his work and personal life, and his resistance to availing himself of a support system all suggest a crisis status is warranted. George’s anger and stubbornness also suggests that approaching this as a crisis is the only way to communicate to him the severity of his problems. He has already been advised by his physician of his vulnerability to future heart attacks and of the need to reduce his stress levels.
Nursing Interventions
George must develop an effective stress reduction strategy he is willing to follow and will be feasible for him. Evidence-based research indicates that meditation, deep breathing, and yoga can all be helpful to reduce stress (“Reduce Your Stress to Protect Your Heart,” 2018). As noted previously, George’s Type A personality may make him resistant to accepting assistance, much less engaging in what he might consider New Age approaches to health. A number of new, accessible stress reduction methods and psychological interventions are more available to patients, including apps which instruct them in meditation techniques and deep breathing. The multifaceted nature of George’s problems, which are both physical and emotional, suggests an intraprofessional team of health providers is likely to be most effective, even if the nurse assumes primary responsibility for directing them.
According to Rees (et al. 2004), no single counseling approach has been shown to be superior in assisting cardiac patients. The important thing is to win George’s willingness to go along with a plan, and to construct one which reduces rather than increases his financial stress. Connecting George to a social worker may be helpful in reducing the perceived financial crisis which is driving him to work such long hours, and may help direct him to financially feasible ways to help his struggling child in school (such as tutoring through the school or other community-based programs). Seeing the financial benefits to his household of allowing his wife to work without protest may also be useful.
A nutritionist can help George construct a diet which works within his work schedule and budget and is recommended for cardiac patients, as well as suggest exercise interventions to both reduce stress and improve cardiac health. Even if the nurse solicits assistance from outside healthcare professionals, the nurse can still fundamentally reinforce the patient-centric nursing paradigm which stresses that such interventions must be workable within George’s lifestyle, social situation, and culture.


References
Mosendane, T., Mosendane, T., & Raal, F. J. (2008). Shift work and its effects on the
cardiovascular system. Cardiovascular Journal of Africa, 19(4), 210–215. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3971766/
Reduce your stress to protect your heart. (2018). Harvard Medical School. Retrieved from:
https://www.health.harvard.edu/healthbeat/reduce-your-stress-to-protect-your-heart
Rees, K., Bennett, P., West, R., Smith, G. D., & Ebrahim, S. (2004). Psychological interventions
for coronary heart disease. The Cochrane Database of Systematic Reviews, (2), CD002902. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170898/
The transtheoretical model. (2018). Prochange. Retrieved from:
https://www.prochange.com/transtheoretical-model-of-behavior-change
Type D personality and cardiovascular risk. (2014). Harvard Medical School. Retrieved from:
https://www.health.harvard.edu/newsletter_article/Type_D_personality_and_cardiovascu lar_risk