Clinical Module #2

The Heart: A Case Study Approach to Patient Care

Student Name _________________________________ Date _________________ Module Objectives: 1. Apply cardiac assessment findings to the nursing plan of care. 2. Apply teaching strategies for a patient with risk factors for a CAD. 3. Integrate knowledge of the concepts relative to chest pain and tissue ischemia. Case Study Reference Text: Nursing Health Assessment: A Critical Thinking Case Studies Approach, Patricia M. Dillon, Edition 2

About the Heart: The cardiovascular system is the lifeline of the body. Its primary function is too act as a transport system, delivering oxygen by way of the red blood cells, and delivering nutrients, metabolites, and hormones to every cell in the in the body. At the same time, it transports metabolic wastes for detoxification and excretion. Before we begin the case study, lets review the cardiac structures and their primary functions. This will be accomplished by completion of the table provided: Anatomy and Physiology of the Heart Structure Heart Right Side Right Atrium Primary Function Circulate blood throughout the body.

Receives de-oxygenated blood and pumps it into the right ventricle Prevents blood from flowing back into the atrium. Only allows blood to flow in one direction. Pumps blood into the pulmonary artery. Prevents blood from back flowing into the right ventricle. Carry blood away from the heart to the lungs. Carry oxygenated blood from the lungs to the left atrium.

Tricuspid valve

Right ventricle Pulmonary semilunar valve

Main pulmonary artery Pulmonary veins

Left Side Left atrium Mitral valve Left ventricle Aortic Valve

Passes oxygenated blood from the pulmonary veins into the left ventricle. Allows the blood to only flow in one direction, preventing back flow. Pumps blood into the aorta. Prevents back flow into the left ventricle allowing the blood to only flow in one direction
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Interventricular septum

This separates the left and right ventricles.

*Anything that affects the valves, the hemodynamic events, or the conduction system may affect what you hear when you auscultate the heart!

Introducing the Case Study: Marcus Bloomberg is a 72 year old Caucasian male who is married and was in relatively good health until 3 weeks ago. At that time, he visited the ER with the complaint of, just not feeling right. His B/P on admission was 180/112 so he was admitted to the coronary care unit with a diagnosis of uncontrolled hypertension. His B/P was controlled with medication and he was discharged several days later. He is now being seen for follow-up care and management of his HTN.

Assessment Alert: If your patient presents with chest pain, be sure to determine the time of onset because this may influence the course of treatment. Thrombolytic agents must be given within 6 hours of onset of pain to be effective. H & P Database for Mr. Bloomfield Biographical data 72 year old white male Married, father of 4 grown children Retired banker Born and raised in the U. S., Jewish BCBS Insurance Current Health Status No rheumatic fever or heart murmurs No chest pain, palpitations, edema
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Review of Systems General Health Survey: Fatigue, weight gain of 40 lbs. over the past 5 years Integumentary Feet cold, thick nails, tight shoes Head, Eyes, Ears, Nose, and Throat (HEENT) 2 dizzy spells over the past 6 months Wears glasses, yearly eye exam

Complains of fatigue, loss of energy and occasional dizzy spells Past Health History No history of injuries Appendectomy at 24 yrs of age Left ventricular hypertrophy revealed by echocardiogram Family History Positive family H/O HTN and CVA Mother had HTN and died of a CVA Paternal uncle died at 72 of MI

Respiratory Short winded with activity Gastrointestinal Indigestion 1-2 times/week Genitourinary Awakes x1/PM to void Reproductive Little sexual activity because he is, too tired Musculoskeletal/Neurological General weakness, cramps in legs with walking Lymphatic- WNL Endocrine - WNL

Critical Thinking Activity #1 From the subjective information you have obtained from Mr. Bloomfields history, what are his identifiable risk factors for heart disease? Dizzy spells 6 months ago, generalized weakness before arrival, family history of HTN, CVA, and MIs, age, weight gain What risk factors are modifiable and which are unmodifiable? Age, family history

Critical Thinking Activity #2 What key points in his history will help you plan his educational needs? Please explain. His age is a huge factor so you have to keep in mind that they need to be within his limits. First off you have to remind him how important it is to maintain his blood pressure within reasonable limits and that he needs to have a digital blood pressure cuff at home so that he can keep a daily log. Also you want to recommend that he get a pill container to put his medication in so that he doesnt forget to take it each morning. When you teach this patient you want to make sure that he can read and provide him with written information to take home with him and if at all possible see if a family member, hopefully the wife
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can be present to assure that they understand the risks and the dangers of uncontrolled blood pressures. Teaching him the signs and symptoms of a MI or stroke are upmost importance because he needs to be aware that if he doesnt get control of his blood pressure he is putting himself at risk. Exercise is important for every individual, even as much as ROM exercises will help. You want to encourage if he is overweight to lose weight and to take a look at specific dietary issues if they are present. And teach him extensively about his medications and the adverse reactions that could be seen with them.

Assessment Alert: If you get an irregular radial pulse on a patient who is not on telemetry and does not have an H/O A Fib, take an apical pulse for 1 full minute. If the apical pulse is also irregular, report these findings to the physician!

*If the patients B/P is high, serial readings of elevated B/P will help confirm a diagnosis of HTN

Your general assessment is documented as follows: General Health Survey Well developed, well-groomed 72 year old white male Cardiac Assessment Neck Vessels Positive, large carotid pulsation x3, negative for thrills and bruits JVP at 30 degrees <3 cm No striae, bruises, or hernias noted; scar from previous hysterectomy Precordium
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Sits upright during interview, relaxed and answers questions appropriately A&Ox4

Positive sustained pulsations, displaced lateral to apex 3 cm with increased amplitude Heart sounds S1 S2, regular Negative for murmurs and rubs

Affect is pleasant and appropriate Vital Signs Temperature 98 F HR 87, strong and reg. Respirations, 18, nonlabored B/P 160/92 Ht. 6 Wt. 245 lbs.

Critical Thinking Activity #3 What effect would HTN have on Mr. Bloomfields heart? It prevents the heart from getting enough oxygen and ischemia starts occurring. It makes the heart work much harder than it has to. Critical Thinking Activity #4 Considering the relationship of the cardiovascular system to the respiratory system, why does Mr. Bloomfield feel short of breath with increased activity? The heart supplies blood to the lungs and it carries it back up into the heart, so if the blood pressure is elevated and the heart cant pump blood to provide oxygen efficiently it is going to make it more difficult to breath because of the lack of oxygenated blood to the lungs. If the heart is having a difficult time perfusing blood to the lungs to oxygenate the blood it would result in difficulty breathing and shortness of breath with increased activity. This is all a result in inadequate perfusion.

When using the diaphragm of the stethoscope, use firm pressure. When using the bell, use light pressure.

Critical Thinking Activity #5 Now that you have completed the review of your documented assessment findings: Document your key assessment findings that will help you to formulate nursing diagnoses. HTN, weight gain, poor circulation, generalized weakness, fatigue, and SOB upon activity Formulate 2 nursing diagnoses relative to your key findings Ineffective perfusion related to HTN as evidenced by SOB, fatigue, generalized weakness, poor circulation. Risk for injury related to ineffective perfusion as evidenced by dizzy spells.

The Ongoing Case Study: Two months after his initial diagnosis of HTN, Mr. Bloomfield presents to the ER complaining of chest discomfort. He says it started 2 hours ago after he finished dinner and then awakened from a nap. An EKG and Troponin level indicate that Mr. Bloomfield has had an MI. He asks you, Am I going to die? Critical Thinking Activity #6 What assessment data would you expect to find for the following nursing diagnoses? Pain related to cardiac tissue ischemia: Bradycardia, tachypenia, HTN Anxiety related to threat of dying: Bradycardia, tachypenia, HTN Ineffective tissue perfusion related to decreased blood flow.: Decreased ejection fraction, Increased troponin levels, bradycardia, tachypneia, HTN Decreased cardiac output related to altered myocardial contractility: Decreased ejection fraction, abnormal EKG
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Critical Thinking Activity #7 Which of the above diagnoses would be of highest priority? Why? Decreased cardiac output related to altered myocardial contractility because it effects the rest of the nursing diagnoses such as the ineffective perfusion and pain.

Critical Thinking Activity #8 What EKG pattern would you expect to see when an MI is occurring? Why? A change in the q wave and ST segment elevation, depending on the location of the MI. V tach is also commonly seen. The EKG strip is indicative of change in perfusion to the heart and ischemia that is occurring. If there are abnormal changes such as the ones above it can indicate an MI.

Critical Thinking Activity #9 What is a Troponin level? Explain the meaning of its elevation. It refers to three proteins in the body classified as I, C, and T. They are present in cardiac muscles and skeletal muscles. They are at a very low level and sometimes arent even measurable. But any elevation in these indicates damage to the heart.

Congratulations! You have completed Module #2. Please answer the NCLEX-Style questions that accompany this module.

1. A client reports symptoms of morning headache that extends into the neck that goes away as the day wears on. The nurse realizes this client is describing: 1. Spinal stenosis 2. A migraine headache
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3. A sinus headache 4. A symptom of HTN 2. The nurse is teaching a client about lifestyle modifications to help manage hypertension. The nurse determines that teaching has been effective when the client makes which statement? 1. I need to get started on my medications right away. 2. "I know I need to give up my cigarettes and alcohol." 3. "I won't be able to run in marathons anymore." 4. "My father had hypertension, did nothing, and lived to be 90 years old." 3. The nurse determines that a client receiving nefedipine for hypertension needs additional education when the client selects which menu for breakfast? 1. Eggs and sausage, a biscuit with margarine, coffee with cream, and cranberry juice 2. Whole-wheat pancakes with syrup, and bacon, oatmeal, and orange juice 3. Egg and cheese omelet, tea with sugar and lemon, hash brown potatoes, and prune juice 4. Eggs, whole-wheat toast with butter, Lucky Charms cereal, milk, and grapefruit juice 4. The home care nurse is seeing an elderly client whose blood pressure is 150/100 mmHg. When reviewing medications, the client reports taking the blood pressure medication only when feeling tense. The nurse should instruct the patient to: 1. Take the blood pressure medication twice the prescribed dosage for 1 day then resume the daily schedule. 2. Take the blood pressure medication as prescribed regardless of feeling tense. 3. Continue to take medication when feeling tense. 4. Contact the physician for an increase in blood pressure medication.

5. A client prescribed dioxazosin for HTN asks the nurse how the medication works. Which of the following should the nurse respond to the client? 1. "It works by making the heart work more efficiently." 2. "It works by decreasing the release of stress hormones." 3. "It works by causing the kidneys to excrete more urine." 4. "It works by making the blood vessels expand." 6. A client has a nighttime cough related to taking enalapril. What is the best nursing intervention to promote rest in this client? 1. Have the client sleep on 2 or 3 pillows at night
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2. 3. 4.

Have the client sit up at an 80 angle in a comfortable chair at night Contact the physician for an order for a cough-suppressant medication Contact the physician for an order for a sedative-hypnotic medication

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