CASE STUDY

Coronary Artery Disease

Patient Profile
H.C., a 47-year-old Navajo woman, comes to the emergency department with a burning sensation in her
epigastric area extending into her sternum.

Subjective Data

• Has had chest pain with activity that is relieved with rest for the past 3 months

• Has had type 2 diabetes mellitus since she was age 35

• Has a smoking history of one pack a day for 27 years

• Is more than 30% over her ideal body weight

• Has no regular exercise program

• Expresses frustration with physical problems

• Is reluctant to get medical therapy because it will interfere with her life

• Has no health insurance

Objective Data

Physical Examination

• Anxious, clutching fists

• Appears overweight and withdrawn

Diagnostic Studies

• 12-lead ECG

• Cholesterol: 248 mg/dL (6.41 mmol/L)

• LDL: 160 mg/dL (4.14 mmol/L)

• Glucose: 210 mg/dL (11.7 mmol/L)

Collaborative Care

• Metoprolol (Toprol) XL 100 mg PO daily

• Nifedipine (Procardia) 10 mg tid

• Nitroglycerin 0.4 mg sublingual PRN for chest pain

• Exercise treadmill testing

Questions

1. What are H.C.’s risk factors for CAD?

2. What symptoms should lead the nurse to suspect the pain may be angina?

3. What nursing actions should be taken for H.C.’s discomfort?

4. What kind of ECG changes would indicate myocardial ischemia?

5. What information should the nurse provide for H.C. before the treadmill testing?

6. Priority Decision: What are the priority nursing measures that should be instituted to help H.C.
decrease her risk factors?

7. Should H.C.’s angina become chronic stable angina, explain the treatment that would be used using
the mnemonic A, B, C, D, E, and F.

8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses?

ANSWERS

1. Diabetes mellitus, smoking history, obesity, physical inactivity, and stress response.

2. Anxiousness with fist clutching; radiation of the burning from epigastric area into the sternum; and
prior episodes of chest pain with activity, relieved by rest.

3. Provide emotional support and explain all interventions and procedures. As well, position her in an
upright position, administer oxygen per nasal cannula, obtain vital signs, initiate continuous ECG
monitoring, auscultate heart and breath sounds, assess pain using PQRST, medicate as ordered, and
obtain baseline laboratory values and a chest x-ray.

4. Depressed ST segment and T wave inversion would indicate myocardial ischemia.

5. The nurse should inform H.C. that she will have continuous cardiac monitoring while she walks on a
treadmill with increasing speed and elevation to evaluate the effects of exercise on the blood supply to
her heart. Her pulse, respiration, BP, and heart rhythm will be measured while she walks and after the
test until they return to normal and the cardiac monitor will be used after the test until any changes
return to normal.

6. This patient does not seem motivated to assume responsibility for her health and, in the absence of
symptoms, has not had a desire to make lifestyle changes. First, the nurse should assist her to clarify her
personal values. Then, by explaining the symptoms related to her risk factors and having her identify her
personal vulnerability to various risks, the nurse may help her to recognize her susceptibility to CAD.
Help the patient to set realistic goals and allow her to choose which risk factor to change first.

7. A: Antiplatelet, antianginal, and ACE inhibitor or ARB therapy

B: β-adrenergic blocker and blood pressure control

 C: Cigarette smoking cessation, cholesterol management, calcium channel blockers, and cardiac
rehabilitation

D: Diet for weight management, diabetes management, and depression screening

E: Education and exercise

F: Flu vaccination

Many of these measures can be used now to help the

patient better manage her current health if she is motivated

to do so.

8. Nursing diagnoses:

• Acute pain related to imbalance between myocardial oxygen supply and demand

• Anxiety related to possible diagnosis and uncertain future

• Ineffective denial related to reluctance to receive medical care or change lifestyle

• Ineffective coping related to lack of effective coping skills

• Imbalanced nutrition: more than body requirements related to intake of calories in excess of calorie

expenditure

• Ineffective health maintenance related to lack of health insurance and motivation