National Assembly for Wales

This assignment is going to explore how biological, psychological and social factors of a person's life may impact upon their health status. This will be done by including a detailed patient profile of Jane, a 55 year old patient, who suffered a myocardial infarction (MI) and was nursed in an acute hospital setting. The altered physiology that occurred as a result of the MI will be looked at with consideration to psychosocial factors that may have contributed to the patient's illness.

MI is one of the most common manifestations of CHD according to Todd (2008) and so Jane's main risk factors for the development of coronary heart disease (CHD) will be identified, with particular attention on the issue of smoking. How smoking may have contributed to the cause of an MI will then be explored, with an analysis of the factors that may have influenced Jane taking up smoking. The main factors that will be looked at will be how living in a low social economic household gives more chance of becoming a smoker, and how influences from family and peers may trigger smoking behaviour.

Government interventions such as the smoking ban will then be looked at, and how National Service Frameworks (NSF) have been put in place to tackle the high numbers of CHD, as the disease accounts for almost a third of all smoking related deaths in Britain (Royal College of Physicians 2000). Confidentiality will be respected throughout the assignment since the Nursing and Midwifery Council (NMC) (2008) states that a persons right to confidentiality must be respected at all times and so for this reason, any names used will be changed and the location of the care provided will not be recognisable.

The concept locus of control and the sick role model will be looked at in relation to Jane's health behaviour and beliefs and brief descriptions will be given of the two. How Jane has taken on the sick role during her illness will be identified, and the problems that may arise because of this will be explored such as Jane adhering to treatment and adapting her lifestyle. A conclusion will then follow which will review the main points that have been explored through the assignment, including an analysis of how the bio-psycho-social (BPS) model has assisted with the assessment of Jane and enabled transition to part B of the care study.

Therefore, two care problems will be identified that will be critically analysed in part B. Lastly, a personal reflection will be given that will demonstrate what has been learnt through the completion of this assignment and how this new knowledge will be used to improve practice. First of all however, the full patient profile on Jane will be looked at. To begin with, Jane was asked about her childhood and she stated that she came from a poor background as she lived in a cramped, three bed roomed house with her mother, father and four siblings.

She said the house was clean, but it was difficult living on top of one another and having to share a room with her two sisters. As Maynard and Thomas (2004) state, housing is an important element in a child's life, as poor housing or overcrowding can seriously affect a child's physical and mental health. Jane stated that she was quite unhappy at home as her parents often used to argue, mainly over money, as they used to struggle financially which used to be very upsetting for her and her siblings.

It is often external factors such as poor housing or financial hardship that cause depression and marital conflict, which can in turn affect children psychologically (Golombok 2000). This was the main reason Jane moved away from home when she was 16, and went to live in Manchester where she found a place to live with two girls and work as a shop assistant. She said she loved this time of her life as she had her own independence and didn't really get homesick as she was glad to be away from the cramped lifestyle and the arguing of her parents.

After living in Manchester for two years, Jane decided to move on and moved to Wales where she stayed with her auntie and gained work in a factory. She said that this was hard work and long hours, but was the only work she could find and do at the time, having only school education and no other qualifications or experience then shop work. It is often only the poorly paid, manual work that people can gain who have no qualifications as Skelton et al. (2006) states. When Jane was 23 she got married to Tom, her boyfriend of two years, and had three children very close together, so Jane stayed at home whilst Tom went out and worked as a mechanic.

Jane stated that it was difficult having to look after three young children with no family support, whilst Tom went out and worked, only earning enough to pay the bills and rent. However, when their youngest child started in full time school, Jane decided to go back to work part time. She found work in the local shop just whilst the children were in school. Jane states that this helped out with the bills and took some of the strain off Tom who was bringing the only money into the household.

As the children became a little older, Jane decided to find another job with better prospects, but longer hours to earn more money, so she looked around and found work as a care assistant in a nursing home nearby. She said she was lucky to get the job with no experience, but was taken on because of here maturity and willingness to work, as her last employer had giver her an excellent reference. Jane stated she loved this job and felt like she was doing something worthwhile with her life and more fulfilling whilst Tom continued to work as a mechanic.

Jane still works as a care assistant and says she works full time now that her children have all moved away from home. Jane was then asked if she was a smoker and she stated that she started smoking when she moved to Manchester when she was 16. As Esmond (2001) states, most smokers take up the habit when they are teenagers where it may signify they are maturing and becoming independent. Jane stated that she gave up smoking when she had her children, but unfortunately, started smoking again when she was 35 and has done to this day.

However, she stated that she usually only smokes 10 cigarettes a day as she does not smoke in the house and so finds she smokes less. When Jane was asked whether she consumes alcohol and if so how much, she said that she only occasionally drinks alcohol when she meets her friends in the local pub maybe once per week. Jane was then asked about her diet and exercise habits and she stated that she has a reasonably healthy diet, but when asked what she would typically eat in a day, it became clear that Jane did not really have a true understanding of what a healthy diet included.

She stated that a typical day's food included a sandwich, a packet of crisps and a yoghurt for lunch and a curry or chinese for tea. When Jane was then asked about her past diet she stated that it used to be difficult to eat healthy because of money and time looking after the children and home. People's perception of healthy eating does vary, but some have the perception that it cheaper to buy convenience foods and tinned food than to buy the ingredients to make their own food (Hitchman et al. 2002).

Jane then stated that she didn't really have time for sports activities, but said she felt she was active because of her job and the fact she didn't drive so walked to work when the weather was nice. However, Jane's weight of 13 stone 9 pounds and her height of 5 feet 2 inches show that there has to be a problem with her diet and /or the amount of exercise she undertakes as she states she has been overweight since she had her children and stopped working. People with a low level of education, and/or are on low incomes, are prone to having weight management problems according to Pearson (2003).

From Jane's weight and height, a body mass index (BMI) (See appendix 1) of 35 shows that Jane is classed as obese. The World Health Organisation (WHO) (2005) states that CHD is one of the main consequences of obesity in Europe. One afternoon, Jane was brought into the accident and emergency unit by her husband complaining of chest pain. She stated that she had never suffered anything like this before and was normally always fit and healthy apart from suffering from occasional back pain. Jane stated that the pain was in the middle of her chest and was radiating down her left arm.

She was seen by the nurse and doctor immediately because she also appeared clammy, was profusely sweating and short of breathe. The doctor quickly assessed Jane and treated her condition as an MI. An MI occurs when a blood vessel supplying the heart with O2 becomes blocked by an atherosclerosis or a coronary thrombosis and causes a region of the heart muscle to die (Nelson and Cox 2005). The affected tissue degenerates, causing a non-functional area known as an infarct (Gillespie and Melby 2003).

When this occurs it can be accompanied by symptoms of sweating, tiredness, weakness, pallor and dyspnoea; the difficulty or shortness of breathe (Thompson and Webster 1992). 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.

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