Case Study 3: Heart and Peripheral Vascular

University of North Carolina WilmingtonNSG 250

Christy Pope, Sarah Orial, Stephanie Carpico, Jennifer Feagan

Background InformationMr. 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 DataChest pain “crushing, heavy and radiating down arm”Chest pain now a 2/10 after two Nitro Shortness of breath DizzinessNauseaFamily history of heart attack “father died at 52”History of hypertension, high cholesterol and diabetesFormer smoker “quit last summer”Medication non-compliance “hasn’t taken in a year”No dietary restrictions “uses salt shaker freely”

Objective DataHeart Rate is 118Blood Pressure is 172/98 mm HgHeart Rhythm is regular, S1 and S2 heard

with murmurs of extra soundsDiaphoretic skinAppears anxiousPalpable apical impulse at the 5th intercostal

spaceNo heaves, pulsations of lifts are evident over

precordium

Myocardial InfarctionBased on the collected data it appears Mr. Madison

may be 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 armCharacter: Crushing and heavyPain brought on by: Exertion while shoveling the

drivewayAssociated symptoms: diaphoretic, nausea, shortness

of breath and dizzinessRelieved by: rest and 2 nitro tablets

Interventions: MONAMorphine- typically 2-4 mg IVOxygen – 4 liter per min via nasal cannulaNitro – 1 sublingual tab every 5 min, up to 3

dosesAspirin – 325 mg by mouth

Diagnostics: EKGOnce Mr. Madison’s EKG is complete, the

doctor will review it to look for EKG changesHe 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 WorkMr. 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 TestMr. Madison may be asked to participate in a stress

test. Mr. Madison can only have a stress test if his cardiac

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: CatheterizationIf 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 FactorsWeightDietSmokingExerciseStressNon-compliance

Non Modifiable Risk FactorsGender - MaleGenetics – Family historyAge – Greater then 50Race – African American

Cultural ConsiderationsHeart disease is the number one killer for all Americans, but the

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 non-Hispanic 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 DiagnosisAcute Pain related to ischemic tissue, secondary to

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 integrityKnowledge deficit related to sedentary lifestyle, poor

diet and medication non compliance

Patient EducationFor 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 EducationThe 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

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 EducationAfter 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 EducationMr. 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.

ReferencesAfrican 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-disease-and-prevention.com/cardiac_auscultation.html

Healthy Diet Goals . (2012). Retrieved from American Heart Association: http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Healthy -Diet-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