© 2018 International Journal of Nursing and Health Services

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REVIEW ARTICLES Umara. IJNHS. 1(2):120-128

The Model Theory Approach “Care, Core, Cure” for

Patients with Cardiovascular Disease
Annisaa Fitrah Umara

Faculty of Health Science, Nursing Program, University of Muhammadiyah Tangerang

Correspondence: nisaumara5@gmail.com

Abstract
The impact of cardiovascular disease was felt by individuals and global. By individual approach, prevention
and supervision are needed to reduce the burden. Nurses have an essential role in giving holistic standards of
nursing practice. The purpose of this study is to provide an overview of the case management of patients with
cardiovascular disease by using the theoretical approach "care, core, and cure" model theory. The method
used is a case study of 30 patients with Cardiovascular Diseases in Harapan Kita Jakarta National Heart
Center. Inform consent was obtained, the initial name and code were assigned to all participant. The results
are nine acute coronary syndrome patient, four heart failure patient, ten heart surgery patient, and seven
arrhythmia patient. The majority of patients were male, an average age more than 41 years old. Most risk
factors are caused by hypertension and smoking. In the acute phase, the "care" and "cure" aspects were more
prominent than the "core" aspect. In the non-acute phase, patients need rehabilitation and health education,
so the more prominent aspects are "care" and "core" than "cure." The aspect "care" provides an overview of
risk factors that result in cardiovascular disease. The "core" aspect shows the needed of education and the
"cure" aspects indicating the necessity for medical therapy in patients with cardiovascular disease. In the
"Care" aspect, independence nursing intervention can be identified and easily evaluated. In the “Core” aspect,
the nurse can recognize the patient's needs during the treatment and provided nursing care plans as needed.
In the “Cure” aspect, can be increased coordination among health care providers. Nurse need to develop the
model of nursing theory approach in providing nursing care for patients with Cardiovascular Diseases,
especially patients who have the opportunity to undergo rehabilitation.

Keywords: cardiovascular disease; “care-core-cure” model; nursing theory.

1. Introduction
The World Health Organization (WHO, 2016), defines cardiovascular diseases as
a set of disorders of the heart and blood vessels. These disorders may include Coronary
Artery Disease (CAD), cerebrovascular disease, congenital heart disease, rheumatic
heart disease, peripheral artery disease, and Deep Vein Thrombosis (DVT) and
pulmonary embolism. CAD is a condition in which the blood vessels are impaired in
supplying blood to the heart muscle.
The impact of cardiovascular disease is not only felt by individuals but also
global. WHO undertakes prevention and supervision to reduce the burden faced by
cardiovascular disease with population and individual approaches. Population
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 approaches such as controlling policies about cigarettes, while individual approaches
through primary and secondary prevention. Also, surgical intervention is also needed to
treat cardiovascular disease with coronary artery bypass, balloon angioplasty, and valve
repair or replacement (1).
In North America, Coronary Artery Bypass Graft (CABG) or Percutaneous
Coronary Intervention (PCI) is a widely performed medical procedure for coronary
revascularization (2). At the Harapan Kita Jakarta National Heart Center, on average in
the last three years, as many as 612 patients underwent CABG. By 2016, as many as 625
patients undergo CABG and show a success. A study was conducted to determine
survival in 5 years in CAD patients with three diabetes mellitus who underwent CABG,
PCI, or medical. The results show that survival is better in patients undergoing CABG
(3). Various studies were conducted to look at CABG outcomes regarding mortality and
morbidity. Nevertheless, the impact of CABG also needs to be viewed
multidimensionally from the physical, psychological, and social (4).
Nurses have an essential role in it, by giving holistic standards of nursing
practice. The American Holistic Nurses Association (AHNA) describes holistic nursing
as the interrelation of the bio-psycho-socio-spiritual dimension and views the
individual as a unity in the process along with the environment (5). Holistic concepts
are used in nursing plans, self-care, self-responsibility, and reflection to help patients to
be healthy (6). One theory and model of holistic nursing from Lydia Eloise Hall is "Care,
Core, and Cure" theory was used in this study as an approach in giving nursing care to
patients with CVD in Harapan Kita Jakarta National Heart Center. The application of
nursing care use the “Care, Core, and Cure” model theory approach was based on Lydia
E Hall's career centered on cardiovascular care, long-term disease care, and towards
rehabilitation.

2. Objectives
The purpose of this study is to provide an overview of case management of
patients with cardiovascular disease by using the theoretical approach "care, core, and
cure" model theory

3. Methods
The study method was the case study of 30 patients with cardiovascular diseases
that consist of Acute Coronary Syndrome (ACS), heart failure, cardiac surgery, and
arrhythmia. This study was conducted from January to May 2017 in Harapan Kita
Jakarta National Heart Center. Participation was voluntary, and informed consent was
obtained from all participants. An initial name and code were assigned to all participant
materials to ensure confidentiality.








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121

4. Results
In general, 30 cases of management were grouped into cases of cardiac surgery,
ACS, heart failure, and arrhythmias. Thirty cases were managed using the “care, core,
and cure” model theory approach developed by Lydia Eloise Hall.

Table 1. Distribution Based on Medical Diagnosis (n=30)

Case Amount % Medical Amount %
Diagnosis
STEMI 7 23,3
ACS 9 30 UAP 1 3,3
SAP 1 3,3
Heart CHF 2 6,7
4 13,3
Failure ADHF 2 6,7
CABG 6 20
Cardiac
10 33,3 Valve Surgery 3 10
Surgery
Vascular 1 3,3
Atrial 3 10
Fibrillation 1 3,3
Atrial Flutter 1 3,3
Arrhythmia 7 23,3 Junctional 2 6,7
Rythm
Ventricular
Tachycardia

Based on table 1, the majority of patients who managed the case of cardiac
surgery with CABG action is 6 cases or 20%. Furthermore, case management with ACS
diagnosis with STEMI diagnosis is 7 cases or 23.3%. Cases of arrhythmias with atrial
fibrillation in 3 cases or 10% and heart failure as many as 4 cases or 13.3%.

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Table 2 Distribution Based on Sex and Age (n= 30)

Age Sex
Case
Criteria Amount % Criteria Amount %
< 20 - - Male 7 23,2
21-40 1 3,3 Female 2 6,7
ACS
41-60 6 20
>60 2 6,7
< 20 - - Male 3 10
21-40 - - Female 1 3,3
Heart Failure
41-60 2 6,7
>60 2 6,7
< 20 - - Male 6 20
Cardiac 21-40 1 3,3 Female 4 13,3
Surgery 41-60 6 20
>60 3 10
< 20 1 3,3 Male 5 16,7
21-40 - - Female 2 6,7
Arrhyithmia
41-60 1 3,3
>60 5 16,7

Table 2 shows that the majority of patients aged under the age range 41-60
years in the ACS and cardiac surgery cases were 20%. Based on the evidence, the
majority of the age in ACS cases ranged from 41-60 years, heart failure cases> 41 years,
heart surgery cases 41-60 years old, and arrhythmia cases aged >60 years. While based
on sex, the majority of cardiovascular handling is experienced by men from each case
group.

Diagram 1. Distribution Based on Modifiable Risk Factors (n=30)

18
16 4
14
12 4
10 Smoking
2 1
8 5
3 Diabetes
6 3 0
1
4 7 2 3 Dyslipidemia
2 1 4
1 2
0 Hypertension

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 Based on Diagram 1, the highest risk factors in ACS cases were hypertension as
many as seven findings, dyslipidemia as much as two findings, then smoking and
diabetes Mellitus each of 4 findings. The most risk factors in cases of heart failure due to
hypertension and dyslipidemia each of 1 results, diabetes two outcomes, and smoking
as many as three findings. The most risk factors in the surgical case group were
diabetes mellitus and dyslipidemia every three findings, hypertension two results, and
smoking one finding while the most risk factors in cases of arrhythmia are due to
smoking as much as five findings and subsequent hypertension as much as four findings
and dyslipidemia as much as two findings, nevertheless, each patient in the case group
may have more than one risk factor.

Diagram 2 Distribution Based on Unmodifiable Risk Factors (n=30)

4
3 0 0
3 1
2 2
History of Stroke
1 0 2
1 1
0 0 Menopause
Family History

Based on diagram 2, the most unmodified risk factors from 30 cases of

management were stroke history in the group of cardiac surgery cases of 3 findings.
Whereas according to the case group, the highest risk factor in ACS cases associated
with menopause as much as two findings and in the case of arrhythmia associated with
family history of 2 results.

5. Discussion
Some of Hall's career concerns are centered around cardiovascular care and
long-term illness treatments (7). According to the Australian Institute of Health and
Welfare (2017), CVD is one of a group of long-term illness or chronic disease. Types of
long-term diseases related to CVD include CHF, arrhythmias, especially atrial
fibrillation, hypertension, angina, CHD, and peripheral vascular disease (8). This
suggests that all of the cases belonging to chronic diseases require long-term care.
Therefore, the use of the theory developed by Hall in providing nursing care in 30 cases
under management is expected to have a positive impact and benefits.
Groups of heart failure, arrhythmia, and CAD may experience acute conditions.
For example ACS in CAD. In the acute phase, the use of "care" model theory, "core," and
"cure" is more prominent in "care" and "cure" aspects than "core." While in the non-
acute phase, patients need rehabilitation through learning so that the more prominent
aspects of "care" and "core" than "cure." Hall developed his theory at the Loeb Center to
deal with non-acute patients who need learning and rehabilitation (7).

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 Care Aspects
The concept of theory adopted by Hall is the function of nurses in health care is
prevention or preventive and health care (7). Therefore, one of the nurse's roles in
providing nursing care using Hall theoretical "care" approach is the management of risk
factors.
Based on the results of management in 30 cases of patients with CVD, found six
risk factors that often arise that is hypertension, dyslipidemia, diabetes, family history,
smoking, and menopause. The most risk factor that was found in 30 cases under
management was hypertension as many as seven findings, followed by smoking as
many as five findings — the risk factors that can be modified in 30 instances of
management such as hypertension, dyslipidemia, diabetes, and smoking. Meanwhile,
risk factors that can not be changed such as family history, menopause, and history of
stroke. Also, age is also a risk factor for CVD that cannot be modified.
Heart failure, arrhythmia, and ACS can be preceded by the presence of CAD
disease. In general, The Framingham risk scoring system presents ten risk factors for
CAD such as age, gender, High-Density Lipoproteins (HDL) cholesterol, total cholesterol,
systolic blood pressure, smoking history, diabetes, family history, ventricular
hypertrophy (9). Other important risk factors such as obesity, psychological factors
such as stress, lack of vegetable and fruit consumption, and lack of physical activity.
The condition of coronary atherosclerosis results in decreased oxygen supply to
the myocardium, leading to myocardial ischemia. Acute myocardial ischemia conditions
can lead to various states of the disease such as ACS and arrhythmias. As with atrial
arrhythmias conditions that have an automaticity disorder and re-entry are often
caused by myocardial ischemia. While in the state of chronic, myocardial ischemia
becomes the most common cause and the presence of coronary heart disease,
hypertension, and diabetes increases the risk of heart failure (10).
Management of coronary heart disease begins with identifying modifiable risk
factors for coronary heart disease. According to Loscalzo (2014), several risk factors for
coronary heart disease that can be modified are hyperlipidemia, hypertension and
diabetes mellitus while risk factors cannot be adjusted such as age, family history,
gender, and history of stroke (11). Increased risk factors for cardiovascular disease
with age. Before the age of 60 years, men have a higher risk factor than women, but at
the age above 60 years, women or those who have menopause have a higher risk factor
than men. Besides, strokes at age less than 55 years in men and 65 years in women may
increase risk factors (11).

Core Aspects
In the “core” aspect, the nurse provides explanations and treatment goals to
facilitate the process of increasing self-awareness or patient awareness (7). A person
who has self-awareness will be able to control himself. Therefore, in this aspect, the
patient needs less medical treatment and requires professional care and education
handling. Through education, the patient can achieve maximum potential and through
rehabilitation becomes a learning process to live with its limitations.
In general, rehabilitation programs include modification of risk factors,
supervised practice, and education and counseling (9). According to The British
Association for Cardiac Rehabilitation, several essential components that must be
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 present in the rehabilitation phase include advice on healthy lifestyles, education, risk
factor management, psychosocial counseling, cardioprotective drug therapy, and long-
term management strategies (12).
After passing through the acute phase and getting educated and undergoing
rehabilitation, the patient is expected to prevent recurrence of problems in
cardiovascular diseases. As an effort to avoid the occurrence of CAD can be done
primary, secondary, and tertiary prevention (9). Primary prevention can be done such
as maintaining a healthy lifestyle by controlling weight, physical activity, and quitting
smoking. The two most important risk factors that contribute to two-thirds CAD events
are smoking and abnormal blood pressure. Smoking can accelerate atherosclerosis in
men and women of all ages and increase the risk of thrombosis, plaque instability,
myocardial infarction, and death. Also, smoking leads to increased myocardial oxygen
demand and reduces the supply of oxygen so that it can trigger angina.
The facts show that quitting smoking, controlling blood pressure and cholesterol
and campaigning for prevention and managing it well is important (13). A study was
conducted to determine differences in risk factors ACS with Stable Angina Pectoris
(SAP) in Japan. The results showed that smoking was an independent predictor of ACS
among the risk factors studied. Patients who returned smoking after CAD had a five
times more high risk of patients who quit smoking (14).
Secondary prevention such as screening or controlling risk factors such as
cholesterol, diabetes, and blood pressure (9) (Humphreys, 2011). Diabetes mellitus
accelerates coronary and peripheral atherosclerosis. Also, diabetes is also often
associated with dyslipidemia that increases the risk of developing angina, myocardial
infarction, and sudden coronary death. The target of cholesterol control is Low-Density
Lipoprotein (LDL) <70 mg / dL and hypertension <120/80 mmHg in diabetic patients.
On tertiary prevention such as management of CAD post-acute attacks and management
of heart failure or postabloker consumption post-acute attacks.

Cure Aspects
Treatment and medical management were given to the patient is a form of "cure"
aspect. In this aspect, the nurse collaborates with the doctor in providing nursing care.
When patients are acute, "cure" and "care" aspects are more prominent or dominant
than "core" ones. In patients with arrhythmias, one of the major management points is
with antiarrhythmic drugs and medical intervention. Therefore, the "Cure" aspect
becomes dominant in patients with acute arrhythmias. However, when the patient is in
a non-acute phase, the "cure" aspect becomes non-dominant. The shape of the "Cure"
aspect of the non-acute phase may be the administration of drugs that need to be taken
in the long term as in patients with heart failure or postoperative valve replacement.

6. Conclusion
In the "Care" aspect, independence nursing intervention can be identified so the
nurse can be easily evaluated. In the “Core” aspect, the nurse can recognize the patient's
needs during the treatment. Thus, nursing care may be provided as needed or focused
on the patient. Similarly, in the "Cure" aspect, nurse collaboration actions with other
professions can be identified thus increasing coordination among health care providers.

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7. Acknowledgments
This study was supported by Prof. Dra. Elly Nurachmah, M.App.Sc., D.N.Sc.;
Ns.Muhamad Adam, S.Kep., M.Kep., Sp.KMB; and Tuti Herawati, S.Kp., M.N. from the
University of Indonesia and Dr. Rita Sekarsari, S.Kp., Sp.KV., MHSM. From Harapan Kita
Jakarta National Heart Center who provide insight and expertise that greatly assisted
the study and give some advice.



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