HESI Case Study Coronary Artery Disease (CAD)

Therapeutic Communication: Noncompliance Kristin has numerous risk factors for CAD and she takes the clinic's online learning course on reducing the risk for heart disease. At the conclusion of the course, Kristin tells the nurse, "I don't need more of these classes because God will take care of my heart." 3. What is the best response by the nurse? "I believe that God helps those who help themselves." "You will have a heart attack if you don't change your lifestyle." "Do you feel that you do not need to be involved in your health care?" "You must accept that you have a responsibility to care for yourself."

"Do you feel that you do not need to be involved in your health care?" Clarification of the client's statement is a useful therapeutic technique that encourages further communication.

Clinical Manifestations The nurse assesses Kristin's symptoms during the MI. 16. Which question should the nurse include in the assessment of Kristin's chest pain? "Did you follow your diet and exercise plan?" "Why do you think the pain started?" "What other symptoms are you experiencing?" "Did you tell anyone about your pain?"

"What other symptoms are you experiencing?" The client should describe the onset, location, duration, and quality of the pain, as well as any pain radiation, such as to the arm, jaw, or back. Additional symptoms, such as dyspnea, palpitations, or diaphoresis should be noted, as well as any actions that were taken in an attempt to relieve the pain.

18. Which important interventions should the nurse implement for Kristin? Select all that apply A quiet environment. Relexation techniques. Initiate sodium replacement. Assess Kristin's level of knowledge and ability to learn.

-A quiet environment. A quiet environment decreases external stimuli that may aggravate anxiety, strain, and limit coping abilities. -Relexation techniques. Deep and slow breathing, visualization, and guided imagery are helpful tools that can be used to provide a sense of control over the situation, increasing positive attitude. -Assess Kristin's level of knowledge and ability to learn. This is a necessary step in developing an individualized plan of care.

1. Which information in Kristen's history indicates an increased risk for coronary artery disease (CAD)? Select all that apply Frequent episodes of hypoglycemia. Family history of hyperlipidemia. Frequent consumption of a high fat diet. Participation in a bowling league. Smoking two packs of cigarettes per day.

-Family history or hyperlipidemia Genetic predisposition is a significant factor in the development of CAD. -Frequent consumption of high fat diet Unhealthy habits, such as consuming fatty foods, are contributing risk factors to CAD. -smoking two packs of cigarettes per day Other risk factors identified by the nurse include obesity and reported job stress.

25. Which expected outcomes indicate that the nurse's discharge teaching was effective? Select all that apply Kristin chooses walking as her initial form of exercise. Kristin recognizes the need to avoid all aspirin products. Kristin talks with her husband about avoiding sexual intercourse for the next 6 months. Kristin states that she feels confident about driving herself home from the hospital. Kristin chooses a diet low in saturated fat and cholesterol.

-Kristen chooses walking as her initial form of exercise. Walking is the best initial activity/exercise for the post-MI client. Kristin should be instructed to establish a gradually progressive walking schedule and to assess pulse and tolerance when increasing activity. Activities such as heavy lifting that cause straining should be avoided for several weeks. -Kristin chooses a diet low in saturated fat and cholesterol. A diet low in saturated fat and cholesterol will reduce the risk for Kristin developing another MI.

20. The primary HCP prescribes a continuous IV infusion of amiodarone (Cordarone) 1 mg/min for Kristen. The available drug is amiodarone (Cordarone) 900 mg in 500 mL of D5W. The nurse should set the IV pump at how many mL/hr?

33 1mg/min =60mg/hr X 500ml/900mg = 30,000/900=33.33mL/hr.

19. Which intervention should the nurse initiate first? Place the crash cart in close proximity to the room. Administer amiodarone (Cordarone) IV. Hang an IV infusion of dopamine (Intropin). Charge the defibrillator to 200 joules.

Administer amiodarone (Cordarone) IV. The treatment of choice for frequent premature ventricular contractions (PVCs) and ventricular tachycardia is an immediate IV bolus of amiodarone.

17. Which nursing intervention should be included in the plan of care? Encourage Kristin to refrain from discussing fears for the first few days. Maintain client in shock position. Discuss cardiac rehabilitation exercise protocols. Administer morphine sulfate IV PRN for chest pain.

Administer morphine sulfate IV PRN for chest pain Following an HCP's prescription or agency protocol, the nurse should ensure that Kristin receives adequate analgesia. Morphine sulfate is frequently prescribed to relieve the pain of MI. It should be administered intravenously to provide the fastest relief and to avoid the muscle damage caused by IM injections. Other important interventions include maintaining oxygen per nasal cannula; ensuring a calm, quiet environment; providing adequate rest with limited stimuli; and gradually increasing activity.

4. How should the nurse explain the test results to Kristen? Serum cholesterol under 300 mg/dL is considered a healthy heart level. Serum cholesterol greater than 200 mg/dL requires medical intervention. As long as LDL is less than 200 mg/dL, it is within an acceptable range. An HDL of less than 50 mg/dL for women indicates increased risk.

An HDL of less than 50 mg/dL for women indicates increased risk. HDL is considered the "good" cholesterol, which reduces the risk of heart disease. Current guidelines state that an HDL of less than 50 mg/dL for women is too low to safeguard the arteries.

In addition to teaching Kristin about her antihyperlipidemic medication, the nurse provides information about a low-fat/low-cholesterol diet, an exercise regimen, a smoking cessation plan, and stress management skills. Kristin agrees to attend a series of "healthy heart" classes at the clinic.

Angina Several months later, Kristin visits the clinic for her routine lab work. After walking into the clinic on a very hot day, she reports to the nurse that she is experiencing chest pain. Following assessment and ECG evaluation, Kristin is diagnosed with stable angina and receives two prescriptions: Nitroglycerin 0.2 mg/hour transdermal patch. Apply every morning and remove at bedtime daily.Nitroglycerin 0.3 mg sublingual PRN for chest pain.

After further discussion, Kristin agrees to go to her scheduled lab appointment, and she considers making some modifications in her lifestyle.

Client Teaching: Hyperlipidemia Kristen's lab results include: Serum cholesterol of 280 mg/dL.Low-density lipoproteins (LDL) of 180 mg/dL.High-density lipoproteins (HDL) of 32 mg/dL. Kristin asks the nurse if these results are bad

15. Which cardiac isoenzyme is the most sensitive indicator for myocardial damage? Creatine kinase - Total (CK). Creatine kinase - MB fraction (CK-MB). Lactate dehydrogenase (LDH). Low-density lipoproteins (LDL).

Creatine kinase-MB fraction (CK-MB). This is the most sensitive isoenzyme for myocardial damage. Peak elevation occurs within 24 hours. In addition to cardiac isoenzymes, a serum troponin level may be obtained. Troponin is a marker of myocardial injury with a broad diagnostic time frame, especially useful when clients are seen several hours after the suspected infarction has occurred.

8. The nurse should prepare Kristen for which adverse effect that can occur when a daily dose of transdermal nitroglycerin in started? Green-yellow visual changes. Diarrhea. Dizziness. Tinnitus.

Dizziness. Nitroglycerin is a nitrate, causing systemic vasodilation. This often leads to hypotension, which can cause Kristin to feel dizzy. She should be instructed to change positions slowly and to avoid prolonged standing. In addition, Kristin may experience tachycardia and a headache.

When determining the highest priority need, the nurse should always intervene first for the client who is the most physiologically unstable, establishing priorities using the ABCs of emergency care: airway, breathing, and circulation.

Ethical-Legal Considerations: Client Rights While the nurse is assessing Kristin, a group of people dressed in street clothes and lab coats enters Kristin's room. They are carrying clipboards and pens, and they begin to ask Kristin questions related to her hospitalization. Kristin seems unsure how to respond.

10. Which nursing interventions should be implemented first? IV access and administer Morphine Sulfate prescribed by HPC. Administer oxygen 4 to 6 liters per nasal cannula. Obtain a 12 lead electrocardiogram (ECG). Assess the client's blood pressure.

IV access and administer Morphine Sulfate prescribed by HCP Acute Chest Pain related to myocardial infarction, ischemia, or reduced coronary artery blood flow is the most important nursing diagnosis for the client with Acute Coronary Syndrome. Treating pain is critical, as pain activates the sympathetic nervous system and aggravates diaphoresis, weakness, light-headedness, and palpitations which, in turn, increases cardiac work load.

2. Which intervention should the nurse consider when assisting Kristen in achieving her goal to quit smoking. Identify 4 feelings associated with smoking. Discuss smoking cessation before the end of the shift. Provide education concerning the health risks associated with long-term cigarette use. Insist that she give up cigarettes within 1 week.

Identify 4 feelings associated with smoking. Asking the client to identify her feelings associated with smoking is a step toward cognitive behavioral change, and it is a client-specific goal.

22. Which nursing intervention should be implemented first when Kristin returns to her room? Encourage intake of oral fluids. Immobilize the affected leg. Obtain apical pulse every 15 minutes. Limit visitors to one per hour.

Immobilize the affected leg The prevention of catheter dislodgement and of bleeding or oozing at the insertion site is a high priority in the immediate post-procedure period. The site should be immobilized and closely monitored for signs of hematoma formation (bleeding, inflammation, tenderness, or swelling). In addition, distal circulation should be monitored closely by assessment of pedal pulses, color, warmth, and capillary refill.

11. ECG finding indicate that Kristin has had a myocardial infarction (MI). Which intervention should then nurse implement first? Notify the gynecologist of Kristin's admission. Notify the hospital chaplain or Kristin's spiritual leader. Inform the ED physician of Kristin's recent surgery. Notify Kristin's husband of her condition.

Inform the ED physician of Kristen's recent surgery. Since Kristin has had recent surgery, she may not be a candidate for some post MI treatments, such as tPA. The emergency department physician should be notified immediately, so that further evaluation can be done. tPA is a thrombolytic agent, or coagulation modifier, that breaks down clots in the coronary arteries. If blood flow is established quickly, the heart muscle will not become ischemic or necrotic. To be most effective, tPA should be given within the first 4 hours following an MI.

9. Kristen is scheduled for a stress echocardiogram. Which instructions should the nurse provide to Kristen prior to the test? The dye that is injected may cause a flushing sensation. A mild sedative will be given during the test. It will be necessary to keep a diary of all activities while wearing the monitor. It is important to return to the exam table immediately after exercising.

It is important to return to the exam table immediately after exercising. This is important so the echocardiogram can be performed while the heart is still stressed from the exercise on the treadmill.

The prevention of catheter dislodgement and of bleeding or oozing at the insertion site is a high priority in the immediate post-procedure period. The site should be immobilized and closely monitored for signs of hematoma formation (bleeding, inflammation, tenderness, or swelling). In addition, distal circulation should be monitored closely by assessment of pedal pulses, color, warmth, and capillary refill. 23. Which client should the nurse assess first? Kristin, post-PTCA, whose pulse distal to the insertion site is +3, with capillary refill of 2 seconds. Jack, a client with unstable angina who is complaining of chest discomfort and who has been given one nitroglycerin tablet sublingually (SL). Kent, a client 5 days post-MI who is complaining that he is constipated and demands that his HCP be called. Carl, a client recently started on propranolol (Inderal) and aspirin for coronary artery disease.

Jack, a client with unstable angina who is complaining of chest discomfort and who has been given one nitroglycerin tablet sublingually (SL). Jack is the least stable of the four clients. The nurse needs to assess for the effectiveness of the nitroglycerin and for other symptoms that may indicate the onset of an MI.

6. Which ongoing lab test should Kristen anticipate during antihyperlipdemics therapy? T3, T4 and TSH. Liver enzymes. Serum amylase. Serum electrolytes.

Liver enzymes Because antihyperlipidemics can cause increased liver enzymes, these should be monitored periodically during treatment.

21. What steps should the nurse take to minimize the development of these adverse effects? Select all that apply Monitor serum lidocaine levels. Continue the infusion as prescribed. Monitor ECG, blood pressure, and respiratory status. Monitor Kristin's anxiety level.

Monitor serum lidocaine levels. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/mL. Monitor ECG, blood pressure, and respiratory status. Heart rhythm and VS, especially blood pressure and respirations must be monitored closely. Monitor Kristin's anxiety level. Nervousness and excitation are adverse effects of lidocaine and the nurse should monitor Kristin closely for these developments.

12. IV nitroglycerin (Tridil) is prescribed for Kristen. What is a primary goal of this medication? Increase the force and velocity of myocardial systolic contraction. Perfuse cardiac tissue by dilating coronary arteries. Provide relaxation to cardiac muscles. Dilate cerebral vessels to prevent hypoxia to the brain during MI.

Perfuse cardiac tissue by dilating coronary arteries. Nitrates cause the coronary blood vessels to dilate, allowing improved oxygen delivery to cardiac muscle. In addition, nitrates cause systemic vasodilation, reducing the workload on the heart, which in turn reduces the myocardium's need for oxygen.

Meet the Client: Kristin ElrodKristin Elrod, who is 58 years old and postmenopausal, is seen at the women's health clinic for a routine checkup. She reports to the clinic because she is experiencing fatigue, vaginal bleeding, and occasional heartburn.

Physical Assessment Ms. Elrod is alert and oriented x 3. Her complexion is pale and skin is warm to the touch. She describes her symptoms of vaginal bleeding as intermittent and moderate. Her heartburn occurs she says on a daily basis and coincides with eating acidic foods like tomatoes. Exercise such as walking is impossible for her because of the generalized weakness and fatigue she experiences on a daily basis. Her height is 5' 6". The client is obese and weighs 200 lbs. (90.72 kg) with a body mass index (BMI) of 30. Ms. Elrod was diagnosed with diabetes mellitus 2 years ago and takes oral antidiabetic medication. She says that her lower left leg feels sore and tender and the nurse notices a red rash with a swollen appearance on the anterior portion of the leg. Ms. Elrod states her pain level is more like discomfort, but rates it as 4 out of 10. The nurse's initial assessment identifies the client at high risk for coronary artery disease (CAD) and notifies the healthcare provider (HCP). A lab screening and diagnostic tests are prescribed by the HCP so the nurse schedules the client for a complete coronary artery disease screening.

7. Which instruction should the nurse include when teaching Kristen about the use of sublingual nitroglycerin?

Place a tablet under the tongue every 5 minutes until the pain is relieved, up to 3 tablets Nitroglycerin tablets should be placed under the tongue when chest pain occurs. They may be taken one tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets. If the pain is not relieved after three doses, the client should be instructed to go to the Emergency Department.

5. After discussing these test results with the HCP and the nurse, Kristen expresses interest in learning how to lower her cholesterol and lose weight. The HCP prescribes the antihyperlipidemic agent lovastatin (mevacor) 20 mg PO daily. Which instructions should the nurse include in Kristen's teaching plan realted to the used on an antihyperlipidemic?

Report any side effects. There are many side effects and possible drug reactions with statins. One example is rhabdomyolysis, especially when an antihyperlipidemic is taken with other drugs, such as erythromycin. Client education should include the side effects, such as an increase in liver enzymes, rhabdomyolysis and CNS effects.

13. In addition to Nitroglycerin, the HCP prescribes morphine sulfate 4mg IV for Kristin. Which reation requires immediate intervention by the nurse? Blood pressure 110/70 mmHg. Drowsiness. Pain not relieved in 15 minutes. Respiratory rate of 10 breaths/min.

Respiratory rate of 10 breaths/min. Profound respiratory depression may be caused by activation of mu and kappa receptors. Respiratory rate should remain about 12 breaths/min.

Diagnostic Tests Kristin's HCP orders serial cardiac enzymes. The diagnosis of myocardial infarction is confirmed by ECG changes and the elevation of cardiac enzymes and isoenzymes. 14. Which ECG change is indicative of myocardial injury? ST segment elevation. Peaked P waves. Inverted P wave. Prolonged PR interval.

ST segment elevation ST segment elevation is indicative of myocardial injury. ST segment depression and inverted T waves are indicative of ischemia, and the development of a pathological Q wave is indicative of myocardial necrosis.

24. The nurse should immediately intervene to prevent violation of which client right? The right to be free from assault and battery. The right to sufficient information to make an informed decision about treatment. The right to have information about the qualifications of caregivers. The right to healthcare without discrimination.

The right to have information about the qualifications of caregivers The individuals in the group should wear name tags that clearly identify their roles, they should introduce themselves, and they should explain to Kristin why they would like to ask her some questions. Clients have the right to privacy during examination and treatment, as well as the right to refuse observation by those not directly involved in their care.

Home Medications: Metformin 500 mg, po BID Lisinopril 20 mg, po BID Sudafed 12 hour relief 1 tab every morning

Vital Signs: Blood Pressure 175/85 mmHg Pulse 95 beats/min Temperature 99° F (37.2° C) Respirations 20 breaths/min O 2Sat 95% Pain level 4/10 Blood Glucose 246