Group 3 (Myers)

INSTRUCTIONS: Answer all the questions that apply to your assigned case study.
Discuss concisely and comprehensively to the point. When asked to provide
several answers, list them in order of priority. Do not assume information that
is not provided.

Case Scenario
You are a nurse at a freestanding cardiac prevention and rehabilitation center.
Your new patient in risk-factor modification is V.M., a 41-year-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 a 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 of 3 days a
week. V.M.'s wife comes along to help him with healthy lifestyle changes. You
take a nursing history, as indicated in the following.

Family History
Father died suddenly at age 42 of a myocardial infarction (MI)
Mother (still living) had a quadruple coronary artery bypass graft (CABG × 4) at
age 52
Past History and Current Medications
Metoprolol (Lopressor) 25 mg PO every 12 hours
Aspirin (ASA) 325 mg per day PO
Simvastatin (Zocor) 20 mg PO every evening
Lifestyle Habits
Smokes an average of 1½ packs of cigarettes per day (PPD) for the past 20
years
Drinks an “occasional” beer, and “a 6-pack every weekend when watching
football”
Dietary history: High in fried and fast foods because of his traveling
Exercise: “I don't have time to take walks.”
General Assessment
White Male
Weight 235 lb
Height 5 ft, 8 in.
Waist circumference 48 in.
Blood pressure 148/88 mm Hg
Pulse 82 beats/min
Respiratory rate 18 breaths/min
Temperature 98.4 °F (36.9 °C)
1. Calculate V.M.'s smoking history in terms of pack-years.

1.5 packs x 365 days per year = 547.5 x 20 = 10,950 packs or 219,000 stick of
cigarettes smoked in 20 years.

2. There are several risk factors for coronary artery disease (CAD). For each
risk factor listed, mark whether it is nonmodifiable or modifiable.
a. Age – nonmodifiable
b. Smoking – modifiable
c. Family history of CAD – nonmodifiable
d. Obesity – modifiable
e. Physical inactivity – modifiable
f. Gender – nonmodifiable
g. Hypertension – modifiable
h. Diabetes mellitus - modifiable
i. Hyperlipidemia – modifiable
j. Ethnic background – nonmodifiable
k. Stress – modifiable
l. Excessive alcohol use – modifiable

3. Identify the nonmodifiable and modifiable risk factors that apply to V.M.
Nonmodifiable
a. Age
b. Family history of CAD
c. Gender
d. Ethnic background

Modifiable
a. Smoking
b. Obesity
c. Physical inactivity
d. Hypertension
e. Diabetes mellitus
f. Hyperlipidemia
g. Stress
h. Excessive alcohol use
4. You review V.M ‘s most recent lab results. Which lab values are of concern
at this time? Explain your answers.

Laboratory Testing (Fasting)

Total cholesterol 240 mg/dL –

A reading between 200 and 239 mg/dL is considered borderline high and
a reading of 240 mg/dL and above is considered high.

HDL 35 mg/dL
Desirable if 60 mg/dL (1.6 mmol/L) or above

LDL 112 mg/dL

Optimal: Less than 100 mg/dL. Near optimal: 100-129 mg/dL. Borderline
high: 130-159 mg/dL.

Triglycerides 178 mg/dL

Normal — Less than 150 milligrams per deciliter (mg/dL), or less than 1.7
millimoles per liter (mmol/L) Borderline high — 150 to 199 mg/dL (1.8 to
2.2 mmol/L)

M.V’s laboratory test shows that he is at high risk of heart disease. His total
cholesterol reading is 240 mg/dL considered high. His LDL level of 112 mg/dL is
near to the boundary line of risk of heart disease. His HDL level of 35 mg/dL is
low. His triglycerides level of 178 mg/dL is in borderline high. High
triglycerides might raise his risk of heart disease and may be a sign of
metabolic syndrome. Metabolic syndrome is the combination of high blood
pressure, high blood sugar, too much fat around his waist.
CASE STUDY PROGRESS
V.M. laughingly 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.

a) Angina Pectoris: Patient has been diagnosed with Angina pectoris, which is
a medical condition that arises when the heart muscle doesn't get as much
blood as it needs. This is a life threating condition that usually happens when
one or more of the heart's arteries is narrowed or blocked.
b) Patient V.M has hypertension which currently controlled by nifedipine
medication. It has been found that hypertensive has been the primary cause of
cardiac deaths over the years around the world.

c) Family history of patient V.M also suggests that cardiac disease runs in the
family, which makes him more prone to heart disease than a normal person.

7. Of all of his behaviors, which one is the most significant in promoting

cardiac disease?

All of V.M’s behaviors are promoting cardiac disease, but the most significant
factor is the continuous smoking.

8. What is the highest priority problem that you need to address with V.M.?
How will you determine this? Identify the teaching strategy you would use with
him.

The highest priority problem that V.M. should be addressed is about coronary
heart disease as he has complaints of chest pain. He also has a family history of
heart diseases. He is also a chain smoker from past 20 years and alcoholic too.
His diet includes oily, fried and fast foods. He should be concerned for his
weight too. He is overweight. His blood pressure is also high. These are all signs
of heart diseases in later stage of life.

9. What is the second problem you would work with V.M. to change? Identify an
appropriate strategy to resolve the problem.

The second problem I would address with V.M. would be his hypertension. His
blood pressure is always above the normal level. His pulse rate is also not
normal. His high blood pressure leads to major problems like heart failure,
stroke, heart attack and kidney failure. His unbalanced diet leads to these
problems which he is facing now. Excess intake of salt and sugar leads to
hypertension.

V.M. should be concerned about his smoking and drinking habits. These lead to
blockage of arteries.

 He should get treatment for quitting smoke and alcohol.

 He should learn about the relaxation techniques which he can do to
normalize his blood pressure.
 He should intake less caffeine because high amount of caffeine will lead
to high blood pressure. For his own overall well-being, he must modify
his lifestyle.
10. V.M.'s wife takes you aside and tells you, “I'm so worried for V. I grew up in
a really dysfunctional family where there was a lot of violence. V. has been so
good to the kids and me. I'm so worried I'll lose him that I have nightmares
about his heart stopping. I find myself suddenly awakening at night just to see
if he's breathing.” How are you going to respond?

I would ask V.M’s wife to tell me more about her fears and encourage her to
help her husband with the lifestyle changes he will need to make moving
forward. She should be advised not to over think and feel relaxed. Heart
diseases can be cured by changing lots of things in eating and other day to day
habits. She only can do this change in V.M’s life. She should take care of his
healthy and nutritious diet. She should not think negative as this will also
affect V.M’s condition. Positive thinking leads to positive outcome in life.

V.M’s wife should also be advised to practice stress management techniques

with V.M as this will help both of them to lead a happy and relaxed life.
Modifications do not change everything at a glance. Little modifications in their
life will change a lot of things later on. She should be advised to give her best
care to her husband and to love and support him.

STUDY PROGRESS
Six weeks after you start working with V.M., 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 note that his
skin is slightly diaphoretic and that he is agitated and appears to be anxious.

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

The first action would be to assess the patient’s readiness to learn about
lifestyle changes he will need to adhere to going forward. Then I would
educate the patient about his condition and what lifestyle changes he should
make, and these are the following:

1. Smoking cessation
2. Increase exercise
3. Dietitian or nutritionist
4. Medication adherence
5. Education about lifestyle
12. V.M. is still uncomfortable, and he has an unopened bottle of sublingual
nitroglycerin (SL NTG) tablets. You decide to give him one tablet. After 5
minutes, which is the appropriate action to take?

a. If the chest discomfort is relieved, call 911.

b. If the chest discomfort is not relieved, give another SL NTG tablet, and wait
5 minutes more.
c. If the chest discomfort is not relieved, have someone else call 911, while you
give V.M. another SL NTG tablet.
d. If the chest discomfort is not relieved, do a 12-lead electrocardiogram (ECG)
to look for ischemic changes, and call 911.

13. What other actions will you take at this time?

At this time, I should call 911 immediately according to the current guidelines.
One more tablet can be administered to the patient while waiting for
emergency care. However, more than 3 tablets in total should not be
administered.
14. Five minutes after the first NTG tablet, V.M. states that the discomfort is
still there and only slightly relieved. Explain what you can expect to be doing
while waiting for emergency medical system (EMS) to arrive.
During this time, V.M’s vital signs should be monitored continuously. If 12-led
ECG (electrocardiogram) is available, then it should be checked for ischemic
changes. I should keep him quiet and provide him assurance that I would stay
with him.
CASE STUDY OUTCOME
V.M. is transported to the ED of a local hospital and undergoes another cardiac
catheterization with coronary stent placement.

15. Identify three (3) nursing diagnoses (actual and potential/at risk)
applicable in the case of V.M. Prioritize according to Maslow’s hierarchy of
need.

1. Acute (chest) pain related to decreased myocardial blood flow as evidenced

by reports of pain scale 8/10 and distraction behaviors.

2. Anxiety related to change in health status and situational crisis as

manifested by expressed concerns due to change in lifestyle.

3. Risk for ineffective cardiac tissue perfusion

16. Identify three (3) to five (5) nursing interventions with rationales.
17. Make a drug study of the medications administered to V.M.

Expected Output: Mini Case Presentation (Oral and Written) with NCP and
Drug Study