Download Case Study 3: Heart and Peripheral Vascular

University of North Carolina Wilmington
NSG 250
Christy Pope, Sarah Orial, Stephanie Carpico, Jennifer Feagan
Background Information
 Mr. Madison is a 69 year old
African American school teacher
who is brought to the E.R. for
evaluation of chest pain. While
shoveling snow Mr. Madison
suddenly felt short of breath and
dizzy. He described his chest pain
to be “crushing and heavy” and
radiating to his left arm. Mr.
Madison’s chest pain subsided to a
2/10 pain after taking two
Nitroglycerin tabs and resting on
the couch. His wife proceeded to
call the ambulance.
Background Information Cont.
 While Mr. Madison is having his EKG, his
wife pulls the nurse aside to tell her that
he has a medical history of hypertension,
high cholesterol and diabetes.
 However, he has not been taking his
medication for the last year, since he quit
smoking.
 Mrs. Madison also says her husband is
about 50 pounds overweight because he
eats whatever he wants and does not get
much exercise.
 Mr. Madison states he is very upset,
because his Dad died of a heart attack.
Subjective Data
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Chest pain “crushing, heavy and radiating down arm”
Chest pain now a 2/10 after two Nitro
Shortness of breath
Dizziness
Nausea
Family history of heart attack “father died at 52”
History of hypertension, high cholesterol and diabetes
Former smoker “quit last summer”
Medication non-compliance “hasn’t taken in a year”
No dietary restrictions “uses salt shaker freely”
Objective Data
 Heart Rate is 118
 Blood Pressure is 172/98 mm Hg
 Heart Rhythm is regular, S1 and S2 heard with
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murmurs of extra sounds
Diaphoretic skin
Appears anxious
Palpable apical impulse at the 5th intercostal space
No heaves, pulsations of lifts are evident over
precordium
Myocardial Infarction
 Based on the collected data it appears Mr. Madison may be
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having a myocardial infarction better known as a heart
attack.
Onset: Started this morning, lasted about 10-20 minuets
Location: Chest and radiating down his left arm
Character: Crushing and heavy
Pain brought on by: Exertion while shoveling the driveway
Associated symptoms: diaphoretic, nausea, shortness of
breath and dizziness
Relieved by: rest and 2 nitro tablets
Interventions: MONA
 Morphine- typically 2-4 mg IV
 Oxygen – 4 liter per min via nasal cannula
 Nitro – 1 sublingual tab every 5 min, up to 3 doses
 Aspirin – 325 mg by mouth
Diagnostics: EKG
 Once Mr. Madison’s EKG is complete, the doctor will
review it to look for EKG changes
 He will look for elevation of the ST segment, which
indicates a STEMI (ST Elevated Myocardial
Infarction).
 A STEMI, is a life threating emergency requiring
immediate intervention.
Diagnostics: Blood Work
 Mr. Madison will need a set of cardiac
enzymes typically drawn every 6 hours,
times 3 sets.
 Cardiac enzymes consist of Troponin,
CK and CKMB.
 An elevated Troponin level is most
indicative of cardiac muscle damage
and heart attack.
 Other blood work such as cholesterol
and glucose levels should also be drawn
because we know they play such a vital
role on the cardiovascular system.
Diagnostics: Stress Test
 Mr. Madison may be asked to participate in a stress test.
 Mr. Madison can only have a stress test if his cardiac
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enzymes were negative.
There are two types: traditional and nuclear.
During the stress test Mr. Madison will walk on a treadmill
while having his EKG and blood pressure monitored.
The nuclear stress test is most beneficial because a dye is
injected into the bloodstream and pictures are taken of the
heart that can show if there are any blockages.
Stress test is only for diagnostic purposes, no intervention
can be done during a stress test.
Intervention: Catheterization
 If blockages are seen during Mr. Madison’s stress test
he will need to have a cardiac catheterization.
 A cardiac catheterization is a invasive procedure done
under moderate sedation, a consent must be obtained.
 During a cardiac cath a thin flexible tube is inserted
into the femoral artery and dye is injected into the
blood stream.
 Pictures are then taken of the heart and blockages may
be seen. If a blockage is seen a angioplasty or stent my
be done to reopen the narrowed artery.
Modifiable Cardiac Risk Factors
 Weight
 Diet
 Smoking
 Exercise
 Stress
 Non-compliance
Non Modifiable Risk Factors
 Gender - Male
 Genetics – Family history
 Age – Greater then 50
 Race – African American
Cultural Considerations
 Heart disease is the number one killer for all Americans, but the
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chance is higher among African American’s.
High blood pressure, obesity and diabetes are the most common
conditions that increase the risk of heart disease. Mr. Madison has all
of these.
The prevalence of high blood pressure in African-Americans is the
highest in the world. Research suggests African-Americans may carry a
gene that makes them more salt sensitive, increasing the risk of high
blood pressure.
African-Americans are disproportionately affected by obesity. Among
non-Hispanic blacks age 20 and older, 63% of men and 77% of women
are overweight or obese.
African-Americans are nearly twice as likely to have diabetes as nonHispanic whites. In fact, about 15% of all African-Americans age 20 and
older have the disease.
In 2009, African Americans were 30% more likely to die from heart
disease, as compared to non-Hispanic white men.
Nursing Diagnosis
 Acute Pain related to ischemic tissue, secondary to
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clogged arteries.
Decreased Cardiac Output related to changes in power
factors, reduction of myocardial characteristics.
Activity Intolerance related to the imbalance between
oxygen supply and demand, the ischemic / necrotic tissue
Ineffective Tissue Perfusion related to ischemic heart
muscle damage, narrowing / blockage of coronary arteries.
Anxiety related to actual threats to biological integrity
Knowledge deficit related to sedentary lifestyle, poor diet
and medication non compliance
Patient Education
 For the first time, the American Heart Association has defined
what it means to have ideal cardiovascular health, identifying
seven health and behavior factors that impact health and quality
of life. We know that even simple, small changes can make a big
difference in living a better life. Known as “Life’s Simple 7,” these
steps can help add years to your life:
 don’t smoke
 maintain a healthy weight
 engage in regular physical activity
 eat a healthy diet
 manage blood pressure
 take charge of cholesterol
 keep blood sugar, or glucose, at healthy levels
Diet Education
 The American Heart Association’s Heart Healthy Diet
Recommendations are based on a 2,000 calorie diet and include:
 Limit saturated and trans fat and cholesterol by choosing lean
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meats, selecting fat-free (skim), 1 percent and low-fat dairy
products and avoiding hydrogenated fats (margarine, shortening,
cooking oils and the foods made from them).
Choose and prepare foods with little or no salt (sodium) to maintain
a healthy blood pressure. Keep sodium intake to 1,500 mg per day or
less.
Eat fish, especially oily fish like salmon or albacore tuna, twice a
week to get omega-3 fatty acids.
Make your diet rich in fruits and vegetables. A typical adult should
try for 9-10 servings (4.5 cups) of fruits and vegetables every day.
Limit or avoid alcohol
Exercise Education
 After a heart attack most doctors recommend
aerobic cardiovascular exercise. Aerobic exercise
includes activities such as walking, jogging, cycling,
and swimming. Mr. Madison’s doctor and the
cardiac rehabilitation staff will determine the exact
type and intensity of exercise he should do.
Although his initial workouts will likely be at a low
intensity level and later ones likely will be more
intense, a typical workout may include the
following:
 about 10 minutes of warm-up (that is, stretching or
light walking, jogging, or cycling)
 20 to 30 minutes of more intense cardiovascular
exercise
 5 minutes of cool-down (with activities similar to
the warm-up)
 Doctors usually request that heart attack patients
exercise at least three times a week
Medication Education
 Mr. Madison will be going home with new
prescription medications, it is very important that
he be educated and provided with patient handouts
about theses medications
 Because Mr. Madison has a history of medication
non compliance the importance of taking his
medication daily needs to be reiterated.
 One study showed that patients who do not take
their medications after their first heart attack
increase their chances of dying within a year by 80%
Best Place to Listen to Heart
 The examiner places the stethoscope
over 4 areas of the chest to listen to the
valves of the heart to pick up a possibility
of heart murmurs. To listen to the
pulmonary valve the stethoscope is
placed over the second intercostal space
(the space between the 2nd and 3rd rib)
on the left side of the patient’s sternum.
The aortic valve is heard over the 2nd
intercostal space on the right side of the
patient’s sternum. The tricuspid valve is
heard over the 5th intercostal space at
the left side of the patient’s chest. The
mitral valve is heard over the 5th
intercostal space inline with the middle
of the collar bone.
 First heart sound (S1) can be heard
loudest at the apex of the heart and
second heart sound (S2) can be heard
loudest at the base.
References
African Americans and Heart Disease . (2012, November 9). Retrieved from American Heart
Association:
http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/African Americans-and-Heart-Disease-Stroke_UCM_444863_Article.jsp
Cardiac Auscultation. (2012). Retrieved from Heart Disease and Prevention: http://www.heart-diseaseand-prevention.com/cardiac_auscultation.html
Healthy Diet Goals. (2012). Retrieved from American Heart Association:
http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/H ealthyDietGoals/HealthyDiet-Goals_UCM_310436_SubHomePage.jsp
Heart Disease and African Americans . (2012, August 9). Retrieved from Office of Minority Health:
http://minorityhealth.hhs.gov/templates/content.aspx?id=3018
Jarvis, C. (2012). Physical Examanation and Health Assessment. St Louis: Elsevier Saunders.
Johns Hopkins. (2007, April 20). Exercising Safely After a Heart Attack . Retrieved from Heart Health
Special Report: http://www.johnshopkinshealthalerts.com/reports/heart_health/261-1.html
Wascher, R. (2008, March 2). Medication Compliance & Risk of Death After Heart Attack. Retrieved from
Health Report: http://doctorwascher.com/Archives/3 -2-08