Unfolding cardiac case study

1. Unfolding cardiac case study With live role play

2. The patient • Mr. Smith • 55 years old • CC: blurry vision that started several months ago and has worsened recently • PMH: no medical history. Has not seen a PCP in years because he feels fine and doesn’t think there is a need. He came to the clinic last week and had high BP, but was told to return this week for a recheck.

3. The Patient • Smoker for 30 years • Denies alcohol or recreational drug use • No home medications • Family Hx: • Mother: HTN • Father: HTN, high cholesterol, heart disease

4. Assessment • What do you want to know? • What should you assess?

5. Assessment • Vitals: • BP 172/98. HR 94. RR 20. T 98.8F. O2 sat 98% on RA. Weight: 280lbs (BMI 38 kg/m2) • Labs: • BUN high. Creatinine high. Creatinine clearance decreased. Lipids (LDL, TG, TC) high. Glucose normal • ECG normal • Retinal exam shows small hemorrhages • No symptoms except for blurry vision

6. Assessment • Which risk factors for HTN does Mr. Smith have? • Age • Male gender • Obesity, esp central obesity • Family History • Smoker • Dyslipidemia • Are any complications of HTN present? • Renal Insufficiency (High BUN and creatinine, decreased creatinine clearance) • Retinal damage (blurry vision and retinal hemorrhages seen on exam)

7. Diagnosis (medical, not nursing) • Physician diagnoses Mr. Smith with HTN and prescribes hydrochlorothiazide (a thiazide diuretic) and lisinopril (an ACE inhibitor). He is also diagnosed with hyperlipidemia, but a conservative approach is initiated via lifestyle modifications.

8. Interventions • Teach lifestyle modifications • Teach medication knowledge • Teach signs of HTN complications and when to seek medication attention.

9. Interventions • Teach lifestyle modifications • Weight reduction • Smoking cessation • Regular checkups • DASH diet • Teach medication knowledge • check BP daily • Know s/s of orthostatic HTN and teach ways to avoid (slow position changes) • Teach signs of HTN complications and when to seek medication attention. • Hypertensive Heart Disease- development of chest pain • CVA and TIAs • PVD

10. Evaluation • performed at follow up appoints. • Evaluate BP, weight, smoking status, etc), follow up labs, etc

11. Mr. Smith Returns • CC: “I am here to follow up on my BP and to get my lab results. Last time they said my cholesterol was high but I didn’t start new medication because they wanted to give me a chance to eat better.”

12. Assessment • What do you want to know? • What should you assess?

13. Assessment • Vitals • BP 140/80. HR 82. RR 20. T 98.6F. O2 sat 98% on RA. Weight: 280lbs (BMI 38 kg/m2) • Labs • LDL high, Triglycerides high, Total Cholesterol high, Glucose normal. BUN, Creatinine, and creatinine clearance all unchanged from the last visit • Lifestyle Modifications • tried to stop smoking after the last visit, but just couldn’t do it. Began walking for exercise, but only gets 20min once a week. Did not make changes to his diet, so still eats lots of fast food, red meats, does like fruit but does not eat many veggies.

14. Assessment • Assessment of Pain (OLD CARTS) • Onset: walking up stairs • Location: middle of chest • Duration: 5 minutes • Characteristics: tight, heavy sensation • Alleviating/Aggravating: alleviated by rest, aggravated by exercise • Radiation: none • Time: not specific to time of day • Symptoms: no other symptoms like dizziness, SOB, etc

15. Assessment • Which non- modifiable risk factors does Mr. Smith have for developing CAD? • Age • Male gender • Family history • Which modifiable risk factors does Mr. Smith have? • Smoker • Obesity • HTN • Physical Inactivity

16. Diagnosis(Medical, not nursing) • Physician diagnoses Mr. Smith with CAD and Angina Pectoris and prescribes nitroglycerin (short-acting nitrate), aspirin (antiplatelet), and clopidogrel (antiplatelet), and simvastatin (a statin).

17. Interventions • Teach medication knowledge • NTG • Aspirin and Clopidogrel • Simvastatin • Teach disease process, lifestyle modifications, when to seek medical help

18. Interventions • Teach medication knowledge • NTG • Aspirin and Clopidogrel • Simvastatin • Teach disease process, lifestyle modifications, when to seek medical help

19. Evaluation • Evaluation: performed at follow up appoints • assessing if nitro has relieved pain • lack of further progression of chest pain

20. Time for a BREAK 

21. Mr. Smith has Surgery • CC: “I am here to have a stent placed in my heart. I am very nervous about the procedure and don’t remember much about what the doctor said the procedure was for ” • Preop vitals: • BP 130/80. HR 86. RR 20. T 98.6F. O2 sat 98% on RA. Weight: 275lbs (BMI 38 kg/m2)

22. Percutaneous Coronary Intervention • Teach the patient about the procedure preop

23. Pre-PTCA and Post-PTCA with Stent Placement

24. Interventions • Post-op • Bed rest and lie flat • Assess site • Pressure dressing stays on for 24 hrs • Assess pulses distal to access site. Neurovascular checks distal to access site • Assess for recurrent chest pain. Assess for general postop pain and medicate as needed • Ambulate after bed rest • Discharge home with medication instructions, signs of complications

25. Mr. Smith gets worse • CC: “My chest is hurting really bad and my nitroglycerin did not work this time. I feel like I can’t breathe and like I am going to pass out.” • Further investigation: unstable angina

26. Assessment • Vitals: • BP 182/90. HR 112. RR 26. T 98.6F. O2 sat 86% on RA. Weight: 280lbs (BMI 38 kg/m2). • Appearance: • Pale and diaphoretic, SOB • What do you do??

27. Interventions • First priority: • Oxygen (O2 sat is 86%) • Second priority: • 12 lead ECG (must be done within 10 minutes) • Shows ST-segment elevation • Other interventions: • IV access • NTG • Morphine (when nitro does not relieve pain and BP is stable) • Aspirin • Statin (within 24hrs) • Prepare for PTCA! (must be done within 90 minutes of arrival)

28. Interventions (cont) • after STEMI, patients are transferred to ICU after treatment and invasive procedures. Once the patient is transferred back to the floor, teaching and further interventions begin: • Diet • Cardiac Rehab • Physical Activity • Instruct on body awareness • Teach pulse and BP monitoring • Discuss exercise and sexual activity