Question

Case Study Coronary Heart Disease

Assignment:  16 points

Resources needed to completed assignment:

            1. Lewis Text Book

            2. Nurses Drug Guide

            3. Core Concepts of Pharmacology 5^thedition

SITE YOUR RESOURCES AFTER EACH QUESTION.  May work in groups.

Scenario:

You are a nurse at a freestanding cardiac prevention and rehabilitation center. Your new patient in risk-factor modification is B.T., a 41-year-old old traveling salesman, who is married and has three children. He tells you that his work does not let him slow down. During a recent evaluation for chest pain, he underwent a cardiac catheterization procedure that showed moderate single-vessel disease with 50% stenosis in the mid right coronary artery (RCA). He was given a prescription for sublingual (SL) nitroglycerin (NTG), told how to use it, and referred to your cardiac rehabilitation program for sessions 3 days a week.  B.T.’s wife comes along to help him with healthy lifestyle changes. You take a nursing history, as indicated in the following.

Chart Review

Family History

            Father died suddenly at age 42 of a myocardial infarction (MI)

            Mother (still living) had a quadruple coronary artery bypass graft (CABG x 4) at age 52

Past History and Current Medications

            Metoprolol (Lopressor) 25mg PO every 12 hours

            Aspirin (ASA) 325mg per day PO

            Simvastatin ((Zocor) 20mg PO every evening

Lifestyle Habits

Has smoked an average of 1 ½ packets of cigarettes per day (PPD) for the past 20 years.  Drinks an “occasional” beer and “a six-pack every weekend when watching football”

Dietary history: High fried and fast foods because of his traveling.

            Exercise: “I don’t have time to take walks.”

General Assessment

            White Male

            Weight     235lb

            Height      5 foot 8 inches

            Waist Circumference 48 inches

            Blood Pressure 148/88mm Hg

            Pulse 82 beats/minute

            Respiratory Rate 18 breaths/minute

            Temperature 98.4 degrees F

                  

            

1. Calculate B.T.’s smoking history in terms of packs per years.

2. There are several risk factors for coronary artery disease (CAD). For each risk factor listed, mark whether it is nonmodifiable or modifiable.
   1. Age
   2. Smoking
   3. Family History of CAD
   4. Obesity
   5. Physical Inactivity
   6. Gender
   7. Hypertension
   8. Diabetes Mellitus
   1. Hyperlipidemia
   10. Ethnic Background
   11. Stress
   50. Excessive Alcohol Use

3. List the Nonmodifiable and modifiable risk factors that apply to B.T.

Case Study Progress

You review B.T.’s most recent laboratory results

Total Cholesterol 240mg/dl

HDL 35mg/dl

LDL 112mg/dl

Triglycerides 178mg/dl

4. Which laboratory values are of concern at this time? Explain your answers.

5. B.T. asks you, “So how is my “good cholesterol” doing today?” Which is considered the “good cholesterol,” and why? What do his HDL and LDL levels indicate to you?

Case Study Progress

B.T. is laughing tells you he believes in the five all-American food groups: salt, sugar, fat, chocolate, and caffeine.

6. Identify health-related problems in this case description; the problem that is potentially life threatening should be listed first.

7. Of all of B.T.’s behaviors, which one is the most significant in promoting cardiac disease?

8. What interventions would you recommend to assist B.T. in addressing this behavior?

9. Because B.T. has several other problems, how will you determine what the priorities are that you need to address with B.T.?

10. Name a second problem you would work with B.T. to change. Identify an appropriate strategy to resolve the problem.

11. B.T.’s wife takes you aside and tells you, “I am so worried for B. I grew up in a really dysfunctional family where there was a lot of violence. B. has been so good to the kids and me. I am so worried I will lose him that I have nightmares about his heart stopping. I find myself suddenly waking up at night just to see if he’s breathing.” How are you going to respond?

Case Study Progress  

Six weeks after you start working with B.T., he admits that he has been under a lot of stress.  He is walking on the treadmill and rubs his chest and says, “It feels really heavy on my chest right now.” You feel his pulse and not that his skin is slightly diaphoretic and that he is agitated and appears to be anxious.

12. What is the first action you are going to do? What other information will you obtain?

Explain.

13. B.T. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL NTG) tablets. His blood pressure is 158/98, and his pulse is 122. You decide to give him one more tablet after 5 minutes, which is the appropriate action to take?  
    1. If the chest discomfort is relieved, call 911.
    2. If the chest discomfort is not relieved, give another SL NTG tablet, and wait 5 minutes more.
    3. If the chest discomfort is not relieved, have someone else call 911 while you give B.T. another SL NTG tablet.
    4. If the chest discomfort is not relieved, obtain a 12 lead electrocardiogram (ECG) to look for ischemic changes.

14. What other action will you take at this time?

15. Five minutes later after the first NTG tablet, B.T. states that the discomfort is still there and only slightly relieved. Explain what you can expect to be doing while waiting for the emergency medical system (EMS) personnel to arrive.

16. After taking the second NTG SL tablet, B.T. complains of a “terrible headache” and worries that he is getting worse. What is happening, and what should you tell him?

Answer 1

Calculate B.T.’s smoking history in terms of packs per year.

B.T smokes an average of 1 1/2 packets of cigarettes per day.

That means 1.5 packs of cigarettes per day.

For a year totally of 365 days.

No.of packs of cigarettes per year = 1.5 X 365

= 547.5

= 548 (rounded off)

So B.T smokes 548 packs of cigarettes per year.

There are several risk factors for coronary artery disease (CAD). For each risk factor listed, mark whether it is nonmodifiable or modifiable.

Modifiable risk factor	Nonmodifiable risk factor
b. smoking	a. Age
d. obesity	c. Family history of CAD
e. physical inactivity	f. Gender
g.hypertension	J. Ethnic background
h. Diabetes mellitus
i. Hyperlipidemia
k. stress
ax. alcohol abuse

The modifiable risk factor is the one that can be changed and the nonmodifiable risk factor is the one that can't be changed. B.T has the modifiable risk factor of smoking, physical inactivity, stress, alcohol abuse. Non-modifiable risk factor for B.T is a family history and Gender.

Total cholesterol and triglycerides are too high for this patient. LDL should be lowered because it increases the risk of heart disease.

HDL is considered as good cholesterol. High levels of HDL reduces the risk of heart disease and low levels increase the risk of heart disease. The goal is to increase the HDL level greater than 45mg/dL and LDL less than 70mg/dL.