Case Study 13 - Angina Difficulty: Advanced Setting: Hospital, intensive care unit Index Words: angina, anxiety, rule out myocardial infarction, assessment, electrocardiogram (ECG) strip Giddens Concepts: Anxiety, Care Coordination, Pain, Patient Education, Perfusion HESI Concepts: Anxiety, Assessment, Care Coordination, Pain, Patient Education, Perfusion Name _________________________________ Class/Group _______________ Date _______________ Scenario R.K. is an 85-year-old woman who lives with her husband, who is 87. Two nights before her admission to your cardiac unit, she awoke with heavy substernal pressure accompanied by epigastric distress. The pain was reduced somewhat when she rolled onto her side but did not completely subside for about 6 hours. The next night, she experienced the same chest pressure. The following morning, R.K.’s husband took her to the physician, and she was subsequently hospitalized to rule out myocardial infarction (MI). Lab specimens were drawn in the emergency department. She was given 325 mg chewable, non–enteric-coated aspirin, and an IV line was started. She was placed on oxygen (O2) at 2 L via nasal cannula. You obtain the following information from your history and physical examination: R.K. has no history of smoking or alcohol use, and she has been in good general health, with the exception of osteoarthritis of her hands and knees and some osteoarthritis of the spine. Her only medications are simvastatin (Zocor), ibuprofen as needed for bone and joint pain, and “herbs.” Her admission vital signs (VS) are blood pressure 132/84, pulse 88, respirations 18 breaths/min, and oral temperature 99 ° F (37.2 ° C). Her weight is 114 pounds (51.7 kg) and height is 5 ft, 4 in. (163 cm). Moderate edema of both ankles is present; capillary refill is brisk, and peripheral pulses are 1+. You hear a soft systolic murmur. She denies any discomfort at present. You place her on telemetry, which shows the rhythm in the following figure. Ape to Man 1. Identify her cardiac rhythm. (Modified from Huszar R. Basic Dysrhythmias: Interpretation and Management—Revised Reprint. ed. 3, St. Louis, MO: Mosby; 2007.) Anginal equivalent = Non-traditional S/S. A: Sinus Rhythm with premature atrial contraction. PAC = Usually harmless 2. Give at least 2 reasons for inserting an IV line. 1. Fluids 2. Meds. 3. Explain the purpose of the aspirin tablet. Why is “non–enteric-coated” aspirin specified? What would be a contraindication to administering aspirin? Faster absorbing. 4. What additional history and physical information should you obtain related to her admitting diagnosis? Name at least 4 for each. Accustomed diet Family Hx Co-morbidities Medication allergies Pain Hx Sleep patterns 5. List 7 laboratory or diagnostic tests you would expect to be performed; suggest what each might contribute. 1. Cardiac markers 2. EKG 3. CBC (Hemoglobin – not enough.) 4. CMP 5. BNP (CHF) 6. Chest X-ray (Crackles/congestion) 7. PTT, PTINR. 8. D-Dimer 6. What other sources, in addition to cardiac ischemia, might be responsible for her chest and abdominal discomfort? - PE -GERD SO much 7. Define the concept of differential diagnosis and explain how the concept applies to R.K.’s symptoms. wtf CASE STUDY PROGRESS After some rest, R.K.’s chest pain has subsided, and she tells you she feels much better now. You review her lab results. Chart View Laboratory Results 12-Lead ECG: Light left-axis deviation, normal sinus rhythm, with no ventricular ectopy Cardiac troponin T is less than 0.03 ng/mL (0.03 mcg/L) (at admission) and the same 4 hours after admission Serial CPK tests are 30 units/L at admission, 32 units/L 4 hours after admission Copeptin 5 pmol/L at admission, 5.1 pmol/L 4 hours after admission d-Dimer test result less than 250 ng/mL (250 mcg/L) 8. On the basis of the information presented so far, do you believe she had an MI? What is your rationale? No. 9. Do you think she may have a pulmonary embolus? no 10. While you care for R.K., you carefully observe her. Identify 2 possible complications of coronary artery disease (CAD) and the signs and symptoms associated with each. 1. Cardiac ischemia 2. Dysthymia 11. R.K. rings her call bell. When you arrive, she has her hand placed over her heart and tells you she is “having that heavy feeling again.” She is not diaphoretic or nauseated, but states she is short of breath. Use the PQRST Assessment of Angina to assess her episode of chest pain. What questions would you ask for each factor? Holy fuck. No thanks. 12. What else do you assess, and what priority actions does the nurse need to take right now? CASE STUDY PROGRESS During the episode of chest pain, R.K.’s vital signs were as follows: BP 140/92, P 110; R 20. The rhythm strip shows sinus tachycardia, and she was very anxious. Her chest discomfort subsided in 3 minutes after 1 nitroglycerin (NTG) dose, and she is resting quietly with O2 per nasal cannula at 2 L/min. R.K.’s physician is making rounds. 13. Using SBAR (Situation, Background, Assessment, Recommendation), how would you communicate this episode to R.K.’s physician? CASE STUDY PROGRESS R.K.’s husband is upset. He tells you they have been married for 62 years and he does not know what he would do without his wife. One way to help people deal with their anxieties is to help them focus on concrete issues. 14. What information would be useful to get from him? What other health care professional might be able to help with some of these issues? CASE STUDY PROGRESS The cardiologist diagnosed R.K. with angina associated with coronary artery disease. She has had no further episodes of chest pain and is discharged to home the next day. She is to see a cardiologist this week and set up an appointment for outpatient testing. As you present the discharge instructions, you review the proper technique for taking sublingual NTG for chest pain. 15. Using the teach-back method, you ask R.K. what to do if she experiences chest pain. Which statement by R.K. indicates that further teaching is needed? Explain your answer. a. “If I have chest pain, I will place 1 nitroglycerin tablet under my tongue.” b. “At the first sign of chest discomfort, I will stop what I’m doing and sit down.” c. “If the chest pain does not stop or ease up, I can take another tablet in 5 minutes.” d. “My husband will need to call 911 if the chest pain does not stop after 3 nitroglycerin tablets.” 16. R.K. tells you that she hates the headache that happens after she takes a nitroglycerin tablet. What can you suggest to her for this problem? 17. What essential safety point will you emphasize when discussing sublingual nitroglycerin with R.K.? CASE STUDY OUTCOME R.K.’s outpatient testing showed coronary artery disease, and the cardiologist recommended medical treatment at this time. She has not experienced an increased number of episodes of angina.
