text:
Test Bank & Instr. Manual: Winningham's Critical Thinking Cases in Nursing 5th Harding 978-0323083256
Chapter 1
1 Medical-Surgical Cases
Cardiovascular Disorders
? Scenario
M.G., a "frequent flier," is admitted to the emergency department (ED) with a diagnosis of heart failure
(HF). She was discharged from the hospital 10 days ago and comes in today stating, "I just had to come
to the hospital today because I can't catch my breath and my legs are as big as tree trunks." After further
questioning, you learn she is strictly following the fluid and salt restriction ordered during her last
hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.
1. What error in teaching most likely occurred when M.G. was discharged 10 days ago?
A breakdown of successful communication occurred regarding when to call with early weight
gain. It is imperative that patients understand when to call their provider after being discharged
from the hospital for exacerbated HF. Comprehensive patient education starting at admission is
considered a standard of care and is mandated by The Joint Commission when providing care to
hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient selfmanagement,
minimize symptoms, and prevent readmission.
During the admission interview, the nurse makes a list of the medications M.G. took at home.
■ Chart View
2. Which of these medications may have contributed to M.G.'s heart failure? Explain.
Thiazolidinediones, such as pioglitazone, may increase the risk of heart failure and should not be
used in patients with symptoms of heart failure. They commonly cause peripheral edema and weight
gain (which are the result of both water retention and increased deposit of adipose tissue).
Nursing Assessment: Medications Taken at Home
Enalapril (Vasotec) 5 mg PO bid
Pioglitazone (Actos) 45 mg PO every morning
Furosemide (Lasix) 40 mg/day PO
Potassium chloride 20 mEq/day PO
Difficulty: Beginning
Setting: Emergency department, hospital
Index Words: heart failure (HF), cardiomyopathy, volume overload, quality of life
Case Study 1 Heart Failure
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3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work
to reduce heart failure? (Select all that apply.) ACE inhibitors:
a. prevent the conversion of angiotensin I to angiotensin II.
b. cause systemic vasodilation.
c. promote the excretion of sodium and water in the renal tubules.
d. reduce preload and afterload.
e. increase cardiac contractility.
f. block sympathetic nervous system stimulation to the heart.
Answers: A, B, D
ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent
vasoconstrictor. This results in systemic vasodilation, thereby reducing preload (reducing the
volume of blood entering the left ventricle) and afterload (reducing the resistance to the left
ventricular contraction) in patients with HF. ACE inhibitors do not promote the excretion of sodium
and water, and they do not cause increased cardiac contractility or block the sympathetic nervous
system to the heart.
After reviewing M.G.'s medications, the physician writes these medication orders:
■ Chart View
4. What is the rationale for changing the route of the furosemide (Lasix)?
M.G. is fluid overloaded and needs to decrease fluid volume in a short period. IV administration is
delivered directly into the vascular system, where it can start to work immediately. In HF, blood flow
to the entire gastrointestinal (GI) system is compromised; therefore, the absorption of orally ingested
medications may be variable and take longer to work.
5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to
monitor the effectiveness of this medication.
• Increased urine output
• Daily weight, looking for weight loss
• Intake and output (I&O)
• Decreased dependent edema
• Decreased shortness of breath, diminished crackles in the bases of the lungs, decreased work of
breathing, and decreased O 2 demands
• Decreased jugular venous distention (JVD)
6. What laboratory tests should be ordered for M.G. related to the order for furosemide
(Lasix)? (Select all that apply.)
a. Magnesium level
b. Sodium level
Medication Orders
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 100 mg PO every morning
Glipizide (Glucotrol) 10 mg PO every morning
Furosemide (Lasix) 80 mg IV push (IVP) now, then 40 mg/day IVP
Potassium chloride (K-Dur) 20 mEq/day PO
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c. Complete blood count (CBC)
d. Serum glucose levels
e. Potassium level
f. Coagulation studies
Answers: A, B, D, E
Furosemide is a potent diuretic, especially when given IVP, and may cause the loss of
electrolytes such as magnesium, sodium, and potassium. These electrolytes will need to be
supplemented if the levels are low. In addition, furosemide may increase serum glucose levels,
which is an issue, considering that M.G. has diabetes. It is not necessary to monitor CBC or
coagulation studies while on furosemide.
7. What is the purpose of the beta blocker carvedilol? It is given to:
a. increase the contractility of the heart
b. cause peripheral vasodilation
c. increase urine output
d. reduce cardiac stimulation by catecholamines
Answer: D
Beta blockers reduce or prevent stimulation of the heart by circulating catecholamines.
The next day, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added
to her orders.
8. What is the action of the digoxin? Digoxin:
a. causes systemic vasodilation.
b. promotes the excretion of sodium and water in the renal tubules.
c. increases cardiac contractility and cardiac output.
d. blocks sympathetic nervous system stimulation to the heart.
Answer: C
Digoxin works by increasing cardiac contractility, and thus increasing cardiac output.
9. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin
toxicity? Explain your answer.
a. Serum potassium level of 2.2 mEq/L
b. Serum sodium level of 139 mEq/L
c. Apical heart rate of 64 beats/minute
d. Digoxin level 1.6 ng/mL
Answer: A
Low potassium levels can increase the potential for digoxin toxicity. M.G. is taking
furosemide, a loop diuretic that excretes potassium as well as sodium and water. Potassium
levels should be monitored carefully during digoxin therapy. The other findings are within
normal limits.
10. When you go to give the digoxin, you notice that it is available in milligrams (mg) not
micrograms (mcg). Convert 125 mcg to mg.
If the student answers ".125 mg" the answer should be incorrect because, per The Joint Commission
"Do Not Use" list, the leading zero should not be omitted.
125mcg = 0.125mg
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11. M.G.'s symptoms improve with IV diuretics and the digoxin. She is placed back on oral
furosemide (Lasix) once her weight loss is deemed adequate to achieve a euvolemic
state. What will determine whether the oral dose will be adequate to consider her for
It is critical to provide the primary care provider with accurate, timely assessment data after the
change from IV to oral diuretic therapy. One of the fluid management goals for patients with HF is to
maintain a target weight. This is done by monitoring daily morning weight, keeping an accurate I&O,
and recording subjective symptoms.
12. M.G. is ready for discharge. Using the mnemonic MAWDS, what key management concepts
should be taught to prevent relapse and another admission?
The most essential aspect of teaching hospitalized patients is to focus on realistic key points.
Teaching should be aimed at successful communication of data to improve symptoms and prevent
readmission, without overwhelming the learner. The five most essential concepts for patients with
HF are included in MAWDS instructions.
Medications: Take as directed, do not skip a dose, and do not run out of medications.
Activity: Stay as active as you can while limiting your symptoms.
Weight: Weigh every morning. Call if you gain or lose 2 pounds overnight or 5 pounds from your
target weight.
Diet: Follow a low-salt diet, and limit fluids to less than 2 quarts or liters per day.
Symptoms: Know what symptoms to report to your provider; report early to prevent
1 Cardiovascular
? Scenario
M.P. is a 65-year-old African-American woman who comes to your clinic for a follow-up visit. She was
diagnosed with hypertension (HTN) 2 months ago and was given a prescription for a thiazide diuretic
but stopped taking it 2 weeks ago because "it made me dizzy and I kept getting up during the night to
empty my bladder." During today's clinic visit, she expresses fear because her mother died of a cerebrovascular
accident (CVA, stroke) at her age, and M.P. is afraid she will suffer the same fate. She states, "I've
never smoked and I don't drink, but I am so afraid of this high blood pressure." You review the data on her
past clinic visits.
■ Chart View
1. According to the most recent Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure, M.P.'s blood pressure falls under which
Stage 1 hypertension (defined as systolic BP from 140-159 mm Hg or diastolic BP from 90-99 mm Hg)
on each of two or more office visits. Instructors may refer to http://www.nhlbi.nih.gov/guidelines/
hypertension/express.pdf for the most recent guidelines from the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
2. What could M.P. be doing that is causing her nocturia?
She could be taking the HCTZ in the late afternoon or evening, instead of in the morning. Diuretics,
such as HCTZ, should be taken in the morning so that the diuretic effects do not disturb sleep.
Family History
Mother, died at age 65 years of CVA
Father, died at age 67 years of myocardial infarction (MI)
Sister, alive and well, age 62 years
Brother, alive, age 70 years, has coronary artery disease, HTN, type II diabetes mellitus (DM)
Patient Past History
Married for 45 years, two children, alive and well, six grandchildren
Cholecystectomy, age 42 years
Hysterectomy, age 48 years
Blood Pressure Assessments
January 2: 150/92
January 31: 156/94 (Given prescription for hydrochlorothiazide [HCTZ] 25 mg PO every morning)
February 28: 140/90
Difficulty: Beginning
Setting: Outpatient clinic
Index Words: coronary artery disease (CAD), hypertension (HTN), medications, patient education, laboratory
values, lifestyle modification, risk factors, Internet resources
Case Study 2 Managing Hypertension
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During today's visit, M.P.'s vital signs were BP: 162/102, P: 78, R: 16, T: 98.2 ° F (36.8 ° C). Her most recent
basic metabolic panel (BMP) and fasting lipids were within normal limits. Her height is 5 ft, 4 in., and she
weighs 110 lb. She tells you that she tries to go on walks but does not like to walk alone so has done so
only occasionally.
3. What risk factors does M.P. have that increase her risk for cardiovascular disease?
Hypertension, physical inactivity, age over 65 years, postmenopausal, family history of premature
cardiovascular disease (mother died at age 60 years of CVA)
Because M.P.'s BP continues to be high, the internist decides to put her on another drug and recommends
that she try again with the HCTZ.
4. According to national guidelines, what drug category or categories are recommended for
M.P. at this time?
Thiazide-type diuretics are considered first-line therapy in the treatment of HTN in patients
without other compelling indications, such as heart failure, history of MI, diabetes, and other
conditions. Other classes can be added if the thiazide-type diuretics are not effective alone.
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta
blockers, and calcium channel blockers are other drugs that are recommended as second-line
5. M.P. goes on to ask whether there is anything else she should do to help with her HTN. She
asks, "Do I need to lose weight?" Look up her height and weight for her age on a body mass
index chart. Is she considered overweight?
Depending on which BMI chart is used, M.P. would be considered either at optimal weight or even
slightly underweight. She does not need to lose weight.
6. What nonpharmacologic lifestyle alteration measures might help someone like M.P. control
her BP? (List two examples and explain.)
• Limiting the salt in a diet if one is salt sensitive. A good way to identify salt-sensitive people is
to monitor BP on and off salt; if the BP decreases when salt is withheld, then the person is saltsensitive,
and limiting salt might bring about a modest decline in BP. In people who are saltsensitive,
the most effective technique has been the "no salt shaker" approach (i.e., don't add salt
to food when cooking, and don't have a salt shaker on the table). Ultra–low-salt diets are generally
ineffective and might even lead to an iodine deficiency.
• The DASH diet has been shown to be effective in lowering BP, usually within 14 days. The DASH
diet is rich in fruits, vegetables, and low-fat dairy and is low in saturated fats. It is also higher
than normal in potassium; magnesium; calcium; and vitamins D, E, and C. Dietary changes might
have powerful cultural implications. Referral to a registered dietitian (RD) for meal planning and
nutrition instruction can be beneficial.
• Reduced caffeine and alcohol intake can lower BP (note that M.P. does not drink alcohol).
• Routine aerobic exercise, like walking, is also encouraged. Patients at risk for CAD should begin
an exercise program under supervision and with the approval of their physician. It is important to
start slowly and build up gradually. It is now recognized that any moderate activity is better than
none. Studies have shown that long-term exercise compliance is better in individuals engaging
in lower to moderate-intensity exercise rather than higher intensity exercise. Although some
patients may need to start walking as little as 3 to 5 minutes daily and increase by 1 to 2 minutes
1 Cardiovascular
per week, the eventual goal is to walk briskly, without discomfort or shortness of breath, for 30
minutes five or six times per week. Patients taking beta blockers cannot use normal exercise heart
rate recommendations and require special guidelines. Here are some rules of thumb for exercise:
(1) If you are stiff, sore, or exhausted as a result of the exercise, you have done something wrong or
have done too much; and (2) if you are out of breath during exercise, you are doing too much. Slow
down, enjoy, and live!
• Interventions, like stress management, might work with some individuals, but studies on the
efficacy of these interventions are less convincing.
The internist decreases M.P.'s HCTZ dosage to 12.5 mg PO daily and adds a prescription for benazepril
(Lotensin) 5 mg daily. M.P. is instructed to return to the clinic in 1 week to have her blood work checked.
She is also instructed to monitor her BP at least twice a week and return for a medication management
appointment in 1 month with her list of BP readings.
7. Why did the internist decrease the dose of the HCTZ?
M.P. had been complaining of dizziness, which may be caused by orthostatic hypotension. The elderly
might be more sensitive to hypotensive effects, and dosage adjustments can help reduce this problem.
8. You provide M.P. with education about the common side effects of benazepril, which can
include which conditions? (Select all that apply.)
a. Headache
b. Cough
c. Shortness of breath
d. Constipation
e. Dizziness
Answers: A, B, E
Headache, cough, and dizziness are common side effects of benazepril, as well as postural
hypotension with position changes. The other responses are not correct.
9. It is sometimes difficult to remember whether you've taken your medication. What
techniques might you teach M.P. to help her remember to take her medication each day?
(Name at least two.)
• Use a day-of-the-week medication holder so she can see whether she has taken her medication for
the day.
• Make a checkmark on her calendar each day when she takes her pills.
• Place her medication bottles in an area that is convenient for her so that she can see the
medications and take them.
10. After the teaching session, which statement by M.P. indicates a need for further
a. "I need to rise up slowly when I get out of bed or out of a chair before standing up."
b. "I will leave the salt shaker off the table and not salt my food when I cook."
c. "It's okay to skip a few doses if I am feeling bad as long as it's just for a few days."
d. "I will call if I feel very dizzy, weak, or short of breath while on this medicine."
Answer: C
Skipping doses is not recommended because it can result in severe rebound hypertension. If she
has questions about taking the drug or wants to stop taking it, she needs to contact her physician
1 Cardiovascular
M.P. returns in 1 month for her medication management appointment. She tells you she is feeling fine
and does not have any side effects from her new medication. Her BP, checked twice a week at the senior
center, ranges from 132 to 136/78 to 82 mm Hg.
11. When someone is taking HCTZ and an ACE inhibitor, such as benazepril, what laboratory
tests would you expect to be monitored?
It is especially important to monitor potassium levels; the HCTZ can cause decreased levels, but
ACE inhibitors, such as benazepril, can cause potassium levels to increase. Both drugs can cause
decreased sodium and creatinine levels. HCTZ can increase serum glucose levels and decrease serum
magnesium levels.
12. What lab results, if any, are of concern at this time?
Overall, the results are within normal limits. The serum glucose is slightly elevated over 110 mEq/L,
but note that the elderly can have an increase in the normal range of glucose levels after age 50. In
addition, remember that the HCTZ can cause an increase in glucose levels.
13. You take M.P.'s BP and get 134/82 mm Hg. She asks whether these BP readings are okay. On
what do you base your response?
Compare these readings with the national standards and the goal you both agreed on.
14. List at least three important ways you might help her maintain her success.
• Remind her of the therapeutic goal you worked on with her.
• Tell her you're proud of her! Therapeutic goals are individualized; however, these BP readings are
improved and at the "prehypertensive" levels, according to the national guidelines. Tell M.P. that
these readings are improving and that you'll pass them on to the physician.
• Review her progress over the past months with her. This is an excellent way to reinforce adherence.
• Remind her of the necessity of adhering to her treatment plan (because she is doing so well) and to
keep checking her BP and taking her medications as directed.
M.P. comes in for a routine follow-up visit 3 months later. She continues to do well on her daily BP drug
regimen, with average BP readings of 130/78 mm Hg. She participates in a senior citizens group-walking
program at the local mall. She admits she has not done as well with decreasing her salt intake but that she
is trying. She tells you she was recently at a luncheon with her garden club and that most of those women
take different BP pills than she does. She asks why their pills are different shapes and colors.
■ Chart View
Laboratory Test Results (Fasting)
Potassium 3.6 mEq/L
Sodium 138 mEq/L
Chloride 100 mEq/L
CO 2 28 mEq/L
Glucose 112 mEq/L
Creatinine 0.7 mg/dL
BUN 18 mg/dL
Magnesium 1.9 mEq/L
1 Cardiovascular
15. How can you explain the difference to M.P.?
• Start by explaining that many different drugs are used to treat HTN. The goal of her therapy is
to find a medication that adequately controls her BP with few or no side effects. Each patient is
individual in his or her medical history and tolerance for specific medications, so M.P. may find that
her friends are on different medications.
• Many drugs have generic versions, with different doses and formulations for each. All of these will
have different shapes and colors, so the same drug may have several different appearances. This
can be confusing, so patients should always double check with their pharmacist to ensure there
has been no mistake if their medication looks different.
1 Cardiovascular
? Scenario
You are a nurse at a freestanding cardiac prevention and rehabilitation center. Your new patient in
risk-factor modification is B.T., a 41-year-old traveling salesman, who is married and has three children. He
tells you that his work does not let him slow down. During a recent evaluation for chest pain, he underwent
a cardiac catheterization procedure that showed moderate single-vessel disease with a 50% stenosis in
the mid right coronary artery (RCA). He was given a prescription for sublingual (SL) nitroglycerin (NTG),
told how to use it, and referred to your cardiac rehabilitation program for sessions of 3 days a week. B.T.'s
wife comes along to help him with healthy lifestyle changes. You take a nursing history, as indicated in
the following.
■ Chart View
Family History
Father died suddenly at age 42 of a myocardial infarction (MI)
Mother (still living) had a quadruple coronary artery bypass graft (CABG Å~ 4) at age 52
Past History and Current Medications
Metoprolol (Lopressor) 25 mg PO every 12 hours
Aspirin (ASA) 325 mg per day PO
Simvastatin (Zocor) 20 mg PO every evening
Lifestyle Habits
Smokes an average of 1ó packs of cigarettes per day (PPD) for the past 20 years
Drinks an "occasional" beer, and "a 6-pack every weekend when watching football"
Dietary history: High in fried and fast foods because of his traveling
Exercise: "I don't have time to take walks."
General Assessment
White Male
Weight 235 lb
Height 5 ft, 8 in.
Waist circumference 48 in.
Blood pressure 148/88 mm Hg
Pulse 82 beats/min
Respiratory rate 18 breaths/min
Temperature 98.4 ° F (36.9 ° C)
Difficulty: Beginning
Setting: Outpatient cardiac rehabilitation center
Index Words: coronary artery disease (CAD), hypertension (HTN), angina, substance abuse, risk factors, family
history, obesity assessment, family counseling, crisis management
Case Study 3 Coronary Artery Disease: Prevention and Rehabilitation
1 Cardiovascular
1. Calculate B.T.'s smoking history in terms of pack-years.
Pack-year is calculated by taking the average number of packs smoked per day times the number of
years smoked. In this example, it is 1.5 packs Å~ 20 years = 30 pack-years.
2. There are several risk factors for coronary artery disease (CAD). For each risk factor listed,
mark whether it is nonmodifiable or modifiable.
a. Age
b. Smoking
c. Family history of CAD
d. Obesity
e. Physical inactivity
f. Gender
g. Hypertension
h. Diabetes mellitus
i. Hyperlipidemia
j. Ethnic background
k. Stress
l. Excessive alcohol use
Nonmodifiable risk factors : A. Age; C. Family history of CAD; F. Gender; J. Ethnic background. These
are personal characteristics that cannot be altered or controlled.
Modifiable risk factors : B. Smoking; D. Obesity; E. Physical inactivity; G. Hypertension; H. Diabetes
mellitus; I. Hyperlipidemia; K. Stress; L. Excessive alcohol use. These are lifestyle choices that can be
controlled or altered by the patient.
3. Circle the nonmodifiable and modifiable risk factors that apply to B.T.
You should have noted: B. Smoking; C. Family history of CAD; D. Obesity—fat distribution pattern;
E. Physical inactivity; F. Gender (male); G. Hypertension; I. Hyperlipidemia; K. Stress.
You review B.T.'s most recent lab results.
■ Chart View
4. Which lab values are of concern at this time? Explain your answers.
All of them. For those at risk for CAD, the fasting total cholesterol should be below 200 mg/dL, the
HDL should be above 40 mg/dL, the LDL should be less than 100 mg/dL, and the triglycerides should
be less than 150 mg/dL for men.
Laboratory Testing (Fasting)
Total cholesterol 240 mg/dL
HDL 35 mg/dL
LDL 112 mg/dL
Triglycerides 178 mg/dL
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5. B.T. asks you, "So, how is my 'good cholesterol' doing today?" Which is considered the "good
cholesterol," and why? What do his HDL and LDL levels indicate to you?
The HDL (high density lipoprotein) cholesterol is considered the "good" cholesterol because it
has protective properties. It functions to remove the cholesterol from the peripheral tissues and
transport them to the liver for excretion. B.T. has elevated LDL along with low levels of HDL. This
combination makes him more at risk for an MI.
B.T. laughingly tells you he believes in the five all-American food groups: salt, sugar, fat, chocolate,
and caffeine.
6. Identify health-related problems in this case description; the problem that is potentially life
threatening should be listed first.
High risk for sudden cardiac death (multiple risk factors such as family history, male); smoking;
inactivity (sedentary lifestyle); obesity; stressful lifestyle; HTN; hyperlipidemia; and a high-fat, lowfiber
7. Of all of his behaviors, which one is the most significant in promoting cardiac disease?
Without question, his smoking is the riskiest. According to the American Heart Association, a
smoker's risk of developing CAD is two to four times higher than that of nonsmokers. Those who
smoke a pack of cigarettes per day have more than twice the risk of MI than nonsmokers.
8. What is the highest priority problem that you need to address with B.T.? How will you
determine this? Identify the teaching strategy you would use with him.
• The most important problem is the one B.T. and his wife are willing to work on, the one they
identify as most important. This helps cement their commitment to behavioral change. For
example, they decide he needs to exercise. Inform him that cardiac rehabilitation will help him
become more active and do it safely—he might even enjoy it! You may help him change his
outlook because this is something he thinks is important.
• Praise his wife for being supportive in helping both of them live a healthier lifestyle.
• Try your best powers of persuasion to get B.T. to work on smoking cessation. This is probably
the biggest risk factor and affects not only him but also his wife and children's health (children
exposed to cigarette smoke are more likely to have asthma and other diseases).
• The American Heart Association, the American Lung Association, and the American Cancer Society
all have excellent literature and programs on smoking cessation.
9. What is the second problem you would work with B.T. to change? Identify an appropriate
strategy to resolve the problem.
Patient preference: Once again, find out from B.T. and his wife what they would like to work on.
• Smoking: Give B.T. and his wife a list of smoking cessation classes, and explain how stopping
smoking will reduce his risk for heart attack. Assure him that, although it will not be easy,
he can do it. He can consult his health care provider about pharmacologic aids for smoking
cessation, such as nicotine patches or gum, varenicline (Chantix), and bupropion (Zyban) that
might be helpful.
• Obesity: Do not assume that anyone is cooking these days—more and more people are eating
food from drive-through windows. If patients eat out a lot, refer them to a website, such as http://
www.calorieking.com for an education on restaurant food, portion sizes, and calories, or give
1 Cardiovascular
them a pamphlet on risk of obesity and cardiac disease from the American Heart Association and
then refer them to medical nutrition therapy (MNT). Inform them that eating low-fat meals does
not mean that they have to give up tasty foods. If the wife does the cooking, give her a few lowfat
recipes that taste good, and encourage her to swap recipes with other people in cardiac rehab.
Focus your teaching around a low-fat diet to decrease obesity and hyperlipidemia risks. There are
many excellent books and magazines available on tasty, low-fat healthy eating.
• Stress: Find out what helps B.T. relax. Help him analyze whether his current techniques are
healthy. For example, drinking a lot of beer is not a healthy technique. If necessary, teach positive
relaxation techniques that he can use when he is on the road.
10. B.T.'s wife takes you aside and tells you, "I'm so worried for B. I grew up in a really
dysfunctional family where there was a lot of violence. B. has been so good to the kids and
me. I'm so worried I'll lose him that I have nightmares about his heart stopping. I find
myself suddenly awakening at night just to see if he's breathing." How are you going to
• Thank her for sharing with you. Acknowledge that heart disease in a loved one can be a very
frightening thing.
• Suggest that she practice stress-relaxation techniques with him.
• Ask whether she would like to talk to someone about her anxiety.
Six weeks after you start working with B.T., he admits that he has been under a lot of stress. He is walking
on the treadmill and rubs his chest and says, "It feels really heavy on my chest right now." You feel his pulse
and note that his skin is slightly diaphoretic and that he is agitated and appears to be anxious.
11. What is the first action you are going to do? What other information will you obtain?
Have B.T. stop any activity and sit or lie down because you want to decrease the workload on his
heart and decrease his body's need for oxygen. You will also check his vital signs and ask whether he
has any SL NTG tablets with him.
12. B.T. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL
NTG) tablets. You decide to give him one tablet. After 5 minutes, which is the appropriate
action to take?
a. If the chest discomfort is relieved, call 911.
b. If the chest discomfort is not relieved, give another SL NTG tablet, and wait 5 minutes
c. If the chest discomfort is not relieved, have someone else call 911, while you give B.T.
another SL NTG tablet.
d. If the chest discomfort is not relieved, do a 12-lead electrocardiogram (ECG) to look for
ischemic changes, and call 911.
Answer: C. According to current guidelines, if the chest pain or discomfort is not relieved in 5
minutes, after one dose of SL NTG, call 911 immediately. The patient can take one more tablet, while
awaiting emergency care, and a third tablet 5 minutes later, but no more than three tablets total.
These guidelines reflect the fact that angina pain that does not respond to NTG might indicate that
an MI is occurring.
13. What other actions will you take at this time?
Continue to monitor his vital signs, and consider checking a 12-lead ECG (if available) to look for
ischemic changes. Reassure him that you will stay with him.
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
14. Five minutes after the first NTG tablet, B.T. states that the discomfort is still there and only
slightly relieved. Explain what you can expect to be doing while waiting for emergency
medical system (EMS) to arrive.
• Have one nurse call 911 and request emergency transport to the nearest emergency department
(ED) while you stay with B.T.
• Have B.T. chew two low-dose (81 mg, or "baby") aspirins, if available.
• Following the department protocols, while you are waiting for the medics, start 2 to 4 L of O 2 /NC
and establish IV access, in case IV medications have to be administered.
• Run a 12-lead ECG or rhythm strip to look for dysrhythmias and ischemic changes. Run a long
rhythm strip. If he needs to be transported by the paramedics to the ED, it may be valuable to the
medical personnel at the hospital.
• Continue to observe B.T. carefully and monitor his vital signs, and reassure him, making him as
comfortable as possible.
• Notify B.T.'s attending physician and his wife.
B.T. is transported to the ED of a local hospital and undergoes another cardiac catheterization with
coronary stent placement.
1 Cardiovascular
? Scenario
S.P. is a 68-year-old retired painter who is experiencing right leg calf pain. The pain began approximately
2 years ago but has become significantly worse in the past 4 months. The pain is precipitated by exercise
and is relieved with rest. Two years ago, S.P. could walk two city blocks before having to stop because of
leg pain. Today, he can barely walk across the yard. S.P. has smoked two to three packs of cigarettes per
day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN),
peripheral vascular disease (PVD), and osteoarthritis. Surgical history includes quadruple coronary artery
bypass graft (CABG Å~ 4) 3 years ago. He has had no further symptoms of cardiopulmonary disease since
that time, even though he has not been compliant with the exercise regimen his cardiologist prescribed,
he continues to eat anything he wants, and continues to smoke two to three PPD. Other surgical history
includes open reduction internal fixation of the right femoral fracture 20 years ago.
S.P. is in the clinic today for a routine semiannual follow-up appointment with his primary care
provider. As you take his vital signs, he tells you that, besides the calf pain, he is experiencing right hip
pain that gets worse with exercise, the pain doesn't go away promptly with rest, some days are worse
than others, and his condition is not affected by a resting position.
■ Chart View
General Assessment
Weight 261 lb
Height 5 ft, 10 in.
Blood pressure 163/91 mm Hg
Pulse 82 beats/min
Respiratory rate 16 breaths/min
Temperature 98.4° F (36.9° C)
Laboratory Testing (Fasting)
Cholesterol 239 mg/dL
Triglycerides 150 mg/dL
HDL 28 mg/dL
LDL 181 mg/dL
Current Medications
Lisinopril (Zestril) 20 mg/day
Metoprolol (Lopressor) 25 mg twice a day
Aspirin 325 mg/day
Simvastatin (Zocor) 20 mg/day
Difficulty: Beginning
Setting: Private clinic
Index Words: claudication, ankle-brachial index (ABI), risk factor modification, patient teaching
Case Study 4 Peripheral Vascular Disease
1 Cardiovascular
1. What are the likely sources of his calf pain and his hip pain?
• Given S.P.'s history, his calf pain is caused by intermittent claudication—this is a reproducible severe
pain in the calf muscle that occurs during exercise and is relieved during rest. It should be noted that
patients with advanced or severe arterial occlusive disease would experience pain even at rest.
• The history of his hip pain is consistent with osteoarthritis—the pain does not disappear promptly
after exercise, may be associated with changes in the weather, and can vary in intensity.
• Another possible source of hip pain could be pseudoclaudication—this pain is due to neurospinal
canal compression. The pain is related to posture and is not made worse with exertion or relieved
with rest. Pseudoclaudication causes pain when the body is in an erect position or leaning forward
(leaning over a shopping cart); lying or sitting can relieve the pain.
2. S.P. has several risk factors for claudication. From his history, list two risk factors, and explain
the reason they are risk factors.
Tobacco use: Smoking is associated with increased serum concentrations of cholesterol. It is also
associated with decreased serum HDLs. The changes put the individual at increased risk for
atherosclerosis and heart disease. In addition, cigarette smoking can cause transient arterial
Hypertension: HTN weakens blood vessel walls and increases the risk of intimal thickening. Intimal
thickening is associated with atherosclerotic disease.
Hyperlipidemia: Elevated lipids are associated with atherosclerosis and therefore increased risk of
coronary and cerebrovascular events. Controlling lipid levels reduces disease progression and
helps alleviate symptoms.
3. You decide to look at S.P.'s lower extremities. What signs do you expect to find with
intermittent claudication? (Select all that apply.)
a. Cool or cold extremity
b. Thin, dry, and scaly skin
c. Brown discoloration of the skin
d. Decreased or absent pedal pulses
e. Ankle edema
f. Thick, brittle nails
Answers: A, B, D, F
Assessment findings for intermittent claudication (peripheral artery disease) include diminished
or absent pulses below the level of stenosis; cool or cold extremity; shiny, thin, fragile skin that can
be dry and scaly; diminished or loss of hair in a stocking pattern; loss of subcutaneous tissue; nail
changes—thick, brittle, slow growing. Brown discoloration of the skin and ankle edema are changes
found with venous disease.
4. Where would you expect S.P. to complain of pain if he had superficial femoral artery
stenosis? Popliteal stenosis?
• Femoral artery stenosis would cause cramping pain in the upper two thirds of his calf.
• Popliteal disease would cause cramping pain in the lower third of his calf.
5. What is the purpose of the daily aspirin listed in his current medication?
Aspirin acts as a platelet aggregation inhibitor and is used to prevent thromboembolism. In S.P.'s
case, his history of CABG and CAD make him a higher risk for other cardiovascular events such as
myocardial infarction (MI), cerebrovascular accident (CVA), and pulmonary embolism.
1 Cardiovascular
S.P.'s primary care provider has seen him and wants you to schedule the patient for an ankle-brachial
index (ABI) test to determine the presence of arterial blood flow obstruction. You confirm the time and
date of the procedure and then call S.P. at home.
6. What will you tell S.P. to do to prepare for the tests?
Instruct him not to smoke for at least 30 minutes before the test because nicotine creates
constriction of the peripheral arteries and alters the test results. In addition, instruct him to wear
clothes that are easy to remove or pull up or down because blood pressure (BP) cuffs will be placed
on both arms and legs. He will need to lie still during the test. Inform him that the test is painless,
takes about 30 minutes, and that he can eat before the test.
S.P.'s ABI results showed 0.43 right (R) leg and 0.59 left (L) leg. His primary care provider discusses these
results with him and decides to wait 2 months to see whether his symptoms improve with medication
changes and risk factor modification before deciding about surgical intervention. S.P. receives a prescription
for clopidogrel (Plavix) 75 mg daily and is told to discontinue the daily aspirin. In addition, S.P.
received a consult for physical therapy.
7. What do these ABI results indicate?
The ABI is a ratio that is derived by dividing the ankle BP by the brachial BP. An ABI of less than 0.9 in
either leg is diagnostic of PAD. S.P.'s right leg shows a lower ABI, which means the disease is worse in
his right leg. His results indicate moderate to severe PAD.
8. You counsel S.P. on risk factor modification. What would you address, and why?
Quit smoking: Smoking cessation reduces the progression of the disease. Among other things,
smoking can cause repetitive endothelial damage that leads to increased risk of atherosclerosis
and related damage.
Exercise: Exercise decreases vascular resistance and enhances blood flow to the exercised extremity.
It is important to encourage the patient to walk through some of the pain before resting; this
stimulates the growth of new blood vessels to supply the oxygen- and nutrient-deprived muscles.
Claudication symptoms will decrease as collateral circulation is formed.
Control BP: Patients who have PVD almost certainly have concomitant cardiovascular and
cerebrovascular disease. Reducing BP helps reduce the risk of morbidity from all vascular
Comply with medication regimen: Patients need to be educated about the importance of taking
their medication as prescribed. It might be helpful to explain how each medication will help with
the treatment of PVD. For example, lipid-lowering agents, antihypertensives, and antiplatelet
agents, such as clopidogrel (and the aspirin), all help decrease the patient's risk for cardiovascular
and cerebrovascular disease.
9. How will the physical therapy help?
Exercise may improve collateral circulation to the limb. Exercise will be started slowly and gradually
increased. S.P. will be instructed to walk to the point of claudication, stop, rest, then resume to walk
a little farther. As collateral circulation improves, the distances walked will improve. It will take
persistence on S.P.'s part to continue this exercise.
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10. In addition to risk factor modification, what other measures to improve tissue perfusion or
to prevent skin damage should you recommend to S.P.?
• Ensure adequate hydration to prevent increased blood viscosity.
• Avoid exposing the right leg to temperatures less than 70Åã F (21.1Åã C) to prevent vasoconstriction
and subsequent reduction of arterial blood flow.
• Do not use heating pads and hot water bottles—the skin has poor circulation and is subject to
• Avoid crossing the legs, especially at the knee; it will further impair circulation.
• Take steps to prevent trauma to tissue; for example, wear socks or protective footwear at all times
(don't go barefoot).
• Use minimal pressure when applying lotions or creams because excessive pressure can damage
the skin. Tissue oxygenation is already compromised because of impaired arterial circulation. Any
damage to this tissue can result in ulceration.
11. S.P. tells you his neighbor told him to keep his legs elevated higher than his heart and ask for
compression stockings to keep swelling down in his legs. How should you respond?
• Elevating the legs and using compression stockings are common treatments for venous problems
in the lower extremities. S.P. does not have that problem; he has arterial problems, and wearing
compression stockings or socks with tight banding could further impair his circulation.
• His legs should be kept in a slightly dependent position to allow gravity to help with
12. S.P. has been on aspirin therapy and now will be taking clopidogrel. What is the most
important aspect of patient teaching that you will emphasize with this drug?
The risk for bleeding! He should be taught to report any unusual bleeding from anywhere in the
body, such as nosebleeds and dark, tarry stools. If bleeding occurs from a cut, he will need to apply
direct pressure to the site for 3 to 5 minutes or longer. He should wear a medical alert bracelet or
necklace, or carry an identification card that specifies that he is on this medication. He needs to
notify his dentist or other health care providers that he is on this medication before a procedure is
S.P. asks for nicotine patches to assist with smoking cessation and makes an appointment for a physical
therapy evaluation and a nutritional assessment. He assures you he doesn't want to lose his leg and will
be more careful in the future.
1 Cardiovascular
? Scenario
You are the nurse working in an anticoagulation clinic. One of your patients is K.N., who has a long-standing
history of an irregularly irregular heartbeat (atrial fibrillation, or A-fib) for which he takes the oral anticoagulant
warfarin (Coumadin). Recently, K.N. had his mitral heart valve replaced with a mechanical valve.
1. How does atrial fibrillation differ from a normal heart rhythm?
When the heart is beating with a normal rhythm, the atria contract together, pumping blood into
the ventricles, then the ventricles contract, pumping blood into the pulmonary arteries and aorta.
With atrial fibrillation, the atria beat in a disorganized manner, with a rate of 350 to 600 times per
minute—as if they are "quivering." The result is no atrial contractions with an irregular ventricular
response; in fact, the ventricles often beat with a rapid rate in response to the increased number
of atrial impulses. The rapid yet irregular ventricular rate decreases ventricular filling and reduces
cardiac output.
2. What is the purpose of the warfarin (Coumadin) in K.N.'s case?
During atrial fibrillation, blood pooling in the quivering atria might lead to thrombus formation,
which might lead to embolic events, such as pulmonary embolus or cerebrovascular accident (CVA).
Warfarin is given to prevent thrombus formation.
K.N. calls your anticoagulation clinic to report a nosebleed that is hard to stop. You ask him to come into
the office to check his coagulation levels. The laboratory technician draws a PT/INR test.
3. What is a PT/INR test, and what are the expected levels for K.N.? What is the purpose of
the INR?
PT stands for "prothrombin time" and is used to monitor the adequacy of warfarin therapy. However,
PT results can vary from facility to facility because of different reagents or methods used. INR stands
for "international normalized ratio," a mathematical calculation. INR results are independent of the
reagents or methods used, thus providing more standard monitoring.
INR goals vary according to the indication. For deep-vein thrombosis prophylaxis, the preferred
INR levels would be 1.5 to 2.0. For atrial fibrillation, the preferred INR is 2.0 to 3.0. However, because
K.N. also has a mechanical valve, the preferred INR would be as high as 3.0 to 4.0.
4. When you get the results, his INR is critical at 7.2. What is the danger of this INR level?
This INR level exceeds the INR goals for K.N. At this high level, his blood's clotting ability is severely
impaired, and he is at an increased risk for bleeding. His health care provider will want to examine
him to determine whether he has other complications associated with excessive anticoagulation. In
lay terms, his blood is "too thin."
Difficulty: Beginning
Setting: Outpatient anticoagulation clinic
Index Words: atrial fibrillation, bleeding complications, warfarin, patient education, PT/INR monitoring, vitamin K,
enoxaparin, safety precautions
Case Study 5 Atrial Fibrillation and Oral Anticoagulation
1 Cardiovascular
The health care provider does a brief focused history and physical examination, orders additional lab
tests, and determines that there are no signs of bleeding other than the nosebleed, which has stopped.
The provider discovers that K.N. recently went to the local urgent care center for a sinus infection and had
received a prescription for the antibiotic co-trimoxazole (sulfamethoxazole-trimethoprim) (Septra).
5. What happened when K.N. began taking the antibiotic?
A drug interaction occurred. The antibiotic prolonged the effects of the warfarin. As a result, K.N. had
an increased risk of bleeding.
6. What should K.N. have done to prevent this problem?
• He should have alerted the staff at the urgent care center that he was taking warfarin.
• He should have called the anticoagulation clinic as soon as possible after the urgent care center
visit and alerted his provider of the antibiotic.
7. The provider gives K.N. a low dose of vitamin K orally, asks him to hold his warfarin dose
that evening, and asks him to come back tomorrow for another PT/INR blood draw. Why do
you tell K.N. to take the vitamin K?
The goal of vitamin K therapy is to reverse the excessive anticoagulation of his blood in order to
bring his INR down to the goal levels.
8. You want to make certain K.N. knows what "hold the next dose" means. What should you
tell him?
"Hold the next dose" means he should skip, or not take, warfarin that evening.
9. K.N. asks you why his PT/INR has to be checked so soon. How will you respond?
"We need to be certain that the vitamin K has been effective in lowering your PT/INR to a safe range.
Also, we need to ensure you do not have any complications from the high INR."
K.N.'s INR the next day is 3.7, and the health care provider made no further medication changes. K.N. is
instructed to finish the remaining 2 days of antibiotics and return again in 7 days to have another PT/INR
10. Why should the INR be checked again so soon instead of the usual monthly follow-up?
• To be certain his INR level has stabilized (within the desired range) and to monitor for any
• The coagulation effect of vitamin K lasts for 1 week; the patient will not respond normally to
warfarin for approximately 1 week after taking vitamin K. Also, it is important to make sure that the
INR is not too low.
11. K.N. grumbles about all of the lab tests but agrees to follow through. You provide patient
education to K.N. and start with reviewing the signs and symptoms (S/S) of bleeding. What
are potential S/S of bleeding that should be taught to K.N.? (Select all that apply.)
a. Black, tarry stool
b. Stool that is pale in color
c. New onset of dizziness
d. Insomnia
1 Cardiovascular
e. New joint pain or swelling
f. Unexplained abdominal pain
Answers: A, C, E, F
S/S of bleeding include:
• Pink, brown, or red-tinged urine
• Blood in the stool; black, tarry stool; blood in the toilet water
• Coughing or spitting blood
• Nosebleeds or unexplained bleeding of any kind
• New dizziness, lightheadedness, unexplained abdominal pain
• New joint pain or swelling
• Cuts that won't stop bleeding
• Unexplained bruising and excessive bruising
• Prolonged menstrual bleeding for premenopausal women
12. What other patient education needs to be stressed at this time? (Identify two.)
• Remind him that many things interact with warfarin, and he needs to keep his provider informed
of any new medications. Patients are usually given a handout listing the major things that affect
INR. Ask whether he needs another copy of the warfarin education packet that he was given when
warfarin therapy was started.
• Remind him that not all providers know what interacts with warfarin. He needs to inquire about
warfarin interaction whenever any changes are being made.
• He needs to consider wearing a medical alert necklace or bracelet that would let others know that
he is on anticoagulant therapy with warfarin.
13. Four months later, K.N. informs you that he is going to have a knee replacement next month.
What will you do with this information?
Alert his health care provider about the pending surgery.
You know that sometimes the only needed action is to stop the warfarin (Coumadin) several days before
the surgery. Other times, the provider initiates "bridging therapy," or stops the warfarin and provides anticoagulation
protection by initiating low-molecular-weight heparin. After reviewing all of his anticoagulation
information, the provider decides that K.N. will need to stop the warfarin (Coumadin) 1 week before
the surgery and, in its place, be started on enoxaparin (Lovenox) therapy.
14. Compare the duration of action of warfarin (Coumadin) and enoxaparin (Lovenox), and
explain the reason the provider switched to enoxaparin at this time.
Warfarin has a duration of 2 to 5 days; enoxaparin has a duration of 12 hours. K.N. is still at risk for
thrombus formation because of the atrial fibrillation. Yet he needs to have the knee surgery, and it
would be risky to perform the knee surgery while anticoagulated with warfarin—there would be
a risk of excessive bleeding during and after the surgery. Therefore, the warfarin is discontinued
in advance of the surgery because it will take several days for the anticoagulation effects to
wear off. However, the enoxaparin can still be given at this time to provide needed levels of
anticoagulation. It will be stopped just before the surgery because of its shorter duration. The goal
is to have him off oral anticoagulation for a minimum amount of time to prevent the possible risk
of a clot formation and potential stroke. His provider will monitor him closely before and after
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
K.N. is in the office and ready for his first enoxaparin (Lovenox) injection.
15. Which nursing interventions are appropriate when administering enoxaparin? (Select all that
a. Monitor activated partial thromboplastin (aPTT) levels.
b. Administer via intramuscular (IM) injection into the deltoid muscle.
c. The preferred site of injection is the lateral abdominal fatty tissue.
d. Massage the area after the injection is given.
e. Hold extra pressure over the site after the injection.
Answers: C, E
It is not necessary to monitor aPTT levels for enoxaparin therapy. This drug is given by deep
subcutaneous injection into the fatty tissue between the left and right anterolateral and left and
right posterolateral abdominal wall. The area should not be massaged after the injection because
excessive bruising might occur. Holding extra pressure over the injection site might be needed to
prevent excessive bleeding; K.N. has been on an anticoagulant up to this time.
K.N. undergoes knee surgery without complications and does not experience any thrombotic events or
bleeding episodes during his recovery.
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
? Scenario
You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is
70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary
artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50%
stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and
orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months.
On his last clinic visit 3 weeks ago, a chest x-ray (CXR) showed cardiomegaly, and a 12-lead electrocardiogram
(ECG) showed sinus tachycardia with left bundle branch block (LBBB). You review his morning blood
work and initial assessment.
■ Chart View
1. As you review these results, which ones are of possible concern, and why?
The blood pressure and pulse are slightly elevated, with several possibilities, including worsening
of his CAD, HTN, or possibly heart failure (HF). More testing is needed to verify. His Hgb and Hct are
slightly decreased, and further testing is needed to determine whether an iron deficiency or vitamin
B 12 deficiency exists.
Laboratory Testing
Sodium 142 mEq/L
Chloride 95 mEq/L
Potassium 3.9 mEq/L
Creatinine 0.8 mg/dL
Glucose 82 mg/dL
BUN 19 mg/dL
WBC 5400/mm 3
Hgb 13 g/dL
Hct 41%
Platelets 229,000/mm 3
Initial Assessment
Complains of increased fatigue and shortness of breath, especially with activity, and "waking up
gasping for breath" at night, for the past 2 days.
Vital Signs
Temperature 97.9° F (36.6° C)
Blood pressure 142/83 mm Hg
Heart rate 105 beats/min
Respiratory rate 18 breaths/min
Difficulty: Intermediate
Setting: Outpatient clinic
Index Words: coronary artery disease (CAD), heart failure (HF), laboratory values, medications, therapeutic nutrition
Case Study 6 Coronary Artery Disease and Heart Failure
1 Cardiovascular
2. Knowing his history and seeing his condition this morning, what further questions are you
going to ask J.M. and his daughter?
Activity: What makes you tired? Do you sometimes feel like you can't get your breath (shortness of
Diet: What are your favorite foods? What did you eat within the past 48 hours? The biggest problem
usually is not added table salt. Many foods like chips, peanuts, pizza, pickles, canned soups,
turkey dressing, and ham (fill in local or ethnic salt-rich favorites) contain salt. Have you recently
eaten any of these? Try to relate salt intake to symptoms that started 2 days ago. Also ask about
microwave meals, lunch meats, canned foods, fast foods or restaurant foods, and entr.es.
Sleep: How many pillows do you sleep on? Do you wake up during the night with shortness of
Fluid retention: Have you gained weight, or has your urinary output decreased over the past few
days? Have you had trouble getting your shoes on? Do you weigh yourself daily?
Lungs: Do you have a cough? Do you cough anything up (is it productive)? (If so, have him describe
the sputum.) What happens when you wake up at night, "gasping" for breath? How often does this
happen? How many pillows do you use at night when sleeping?
Cardiac rhythm: Are you having any strange feelings in your chest (palpitations)? Does your heart
race at times or flutter, skip beats, pause, or thump? (Palpitations vary widely, as do individual
descriptions.) Have you experienced dizziness, lightheadedness, or passing out?
Chest pain: Are you having any discomfort or numbness in your chest, back, shoulders, arms, hands,
or neck and jaws? (If so, have him describe the sensations.)
Smoking history: Have you ever smoked? Do you smoke now? If so, how many packs a day do you
smoke? (J.M. stopped smoking 10 years ago.)
Occupational history: This question is critical with respect to smoking history. Watch for occupational
(or wartime) experience in mining, shipyard work, toxin exposure, or pulmonary irritant exposure
(e.g., asbestos, Agent Orange). Combined with smoking, these make a lethal combination for the
heart as well as lungs.
J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and
has to lie down and rest ("put my feet up") at least an hour twice a day. He has been sleeping on two
pillows for the past 2 weeks. He has not salted his food since the physician told him not to because of his
high blood pressure, but he admits having had ham and a whole bag of salted peanuts 3 days ago. He
denies having palpitations but has had a constant, irritating, nonproductive cough lately.
3. You think it's likely that J.M. has heart failure (HF). From his history, what do you identify as
probable causes for his HF?
HTN: Chronic HTN can require the heart to pump hard against the resistance of the vessels. This
results in cardiac muscle hypertrophy (the cardiomegaly seen on his CXR).
CAD: Ischemic myocardium is not able to produce adequate stroke volumes.
Anemia: Anemia decreases the availability of oxygen to all tissues of the body, and the heart
responds by increasing blood flow (stroke volume and/or heart rate), thereby increasing the
oxygen demands of the heart and contributing to myocardial ischemia. However, keep in mind
that hemodilution (from fluid volume excess) might cause his Hct to appear low.
4. You are now ready to do your physical assessment. For each potential assessment finding for
HF, indicate whether the finding indicates left-sided heart failure (L) or right-sided heart
failure (R).
1. Fatigue, weakness, especially with activity
2. Jugular (neck) vein distention
3. Dependent edema (legs and sacrum)
1 Cardiovascular
4. Hacking cough, worse at night
5. Enlarged liver and spleen
6. Exertional dyspnea
7. Distended abdomen
8. Weight gain
9. S3/S4 gallop
10. Crackles/wheezes in lungs
Assessment findings for left-sided heart failure:
1. Fatigue, weakness, especially with activity
4. Hacking cough, worse at night
6. Exertional dyspnea
9. S3/S4 gallop
10. Crackles/wheezes in lungs
Assessment findings for right-sided heart failure:
2. Jugular (neck) vein distention
3. Dependent edema (legs and sacrum)
5. Enlarged liver and spleen
7. Distended abdomen
8. Weight gain
■ Chart View
The physician confirms your suspicions and indicates that J.M. is experiencing symptoms of early
left-sided heart failure. Medication orders are written.
5. For each medication listed, identify its class, and describe its purpose for the treatment of HF.
Enalapril (Vasotec): Angiotensin-converting enzyme (ACE) inhibitor.
ACE inhibitors prevent sodium and water resorption by inhibiting aldosterone secretion, resulting in
diuresis, which decreases blood volume and blood return to the heart. As a result, the workload of
the heart is decreased.
Furosemide (Lasix): Loop diuretic.
Loop diuretics are given to decrease fluid volume (preload).
Carvedilol (Coreg): Nonspecific beta blocker.
Beta blockers work to reduce or to block sympathetic nervous system stimulation to the heart and to
the heart's conduction system (cardioprotective action). As a result, the heart rate is reduced.
Digoxin (Lanoxin): Cardiac glycoside/inotropic drug.
This drug increases myocardial contractility (positive inotropic effect), resulting in enhanced cardiac
efficiency and output.
Potassium chloride (K-Dur): Electrolyte supplement.
This supplement is given to replace potassium that might be lost with diuretic therapy.
Medication Orders
Enalapril (Vasotec) 10 mg PO twice a day
Furosemide (Lasix) 20 mg PO every morning
Carvedilol (Coreg) 6.25 mg PO twice a day
Digoxin (Lanoxin) 0.5 mg PO now, then 0.125 mg PO daily
Potassium chloride 10 mEq tablet PO once a day
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6. When you go to remove the medications from the automated dispensing machine, you see
that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain.
No! Coreg CR is a controlled-release formulation, which is released slowly, and the dosages are
different. The "plain" Coreg is an immediate-release formulation. The two are not interchangeable.
7. As you remove the digoxin tablet from the automated medication dispensing machine, you
note that the dosage on the tablet label is 250 mcg. How many tablets would you give?
250 mcg = 0.25 mg
Be sure students do not omit the leading zero before the decimal point (.25 mg) and they do not
add a trailing zero after the "5" (0.250 mg).
You would give two tablets:
0.25 mg/1 tablet = 0.5 mg/ x
0.25 x = 0.5; x = 2 tablets
8. Based on the new medication orders, which blood test or tests should be monitored
carefully? Explain your answer.
Potassium levels need to be monitored, for several reasons. The diuretic causes potassium to be
excreted along with sodium and water, thus the potassium supplement is ordered. However, the ACE
inhibitor retains potassium and can lead to hyperkalemia. Last, patients who are taking digoxin need
to have potassium levels monitored as well as periodic digoxin levels. If potassium levels get low,
the hypokalemia can make the patient more susceptible to digoxin toxicity. Digoxin levels must be
monitored carefully because digoxin toxicity can lead to serious complications.
9. When you give J.M. his medications, he looks at the potassium tablet, wrinkles his nose, and
tells you he "hates those horse pills." He tells you a friend of his said he could eat bananas
instead. He says he would rather eat a banana every day than take one of those pills. How will
you respond?
• Use empathy and humor. Tell him that sounds good, but to get as much potassium from a banana
as he would from the potassium tablet, he would have to eat a 4 foot long bananas every day!
• Tell him there are other ways the physician can order the potassium, such as in a liquid form or
a powder form that is dissolved in liquid. If J.M. would prefer, ask the physician for an order of a
different formulation.
This is J.M.'s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle
modifications he can make and monitoring techniques he can use to prevent or minimize future
10. List five suggestions you might make and the rationale for each.
• Gradually increase and pace your activities to decrease the work requirements and oxygen
demand of the heart.
• Minimize stress to reduce sympathetic nervous system response to increased workload of the
• Avoid hot or cold environments; both increase cardiac demand.
• Learn to take your pulse, and call your physician if your pulse is less than 50 beats/min, greater
than 100 beats/min, or very irregular. Very slow, very rapid, or irregular heart rates can
exacerbate HF.
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
• Weigh yourself daily to monitor for fluid retention. Report a 2- to 5-lb weight gain over 1 to 4 days
to your physician. Sudden weight gain indicates fluid retention.
• Carefully follow your salt-restricted diet to minimize fluid retention. Limit oral fluid intake to 2 L
• Take your medications faithfully, and call your health care provider immediately before stopping
your medication.
• If any new or worsening symptoms occur, notify your health care provider immediately.
11. You tell J.M. the combination of high-sodium foods he had during the past several days
might have contributed to his present episode of HF. He looks surprised. J.M. says, "But I
didn't add any salt to them!" To what health care professional could J.M. be referred to help
him understand how to prevent future crises? State your rationale.
He obviously does not understand that many foods contain high amounts of sodium. Some patients
might associate sodium with added salt only. J.M. needs help in understanding what foods are
"safe." A registered dietitian could provide medical nutrition therapy (MNT) and assist in low-sodium
modifications, how to read food labels, and how to use spices to make tasty meals. He needs to limit
daily sodium intake to 2 to 3 g, and limit daily fluid intake to 2 L.
12. You also include teaching about digoxin toxicity. When teaching J.M. about the signs and
symptoms of digoxin toxicity, which should be included? (Select all that apply.)
a. Dizziness when standing up
b. Visual changes
c. Loss of appetite or nausea
d. Increased urine output
e. Diarrhea
Answers: B, C, E
Signs and symptoms of digoxin toxicity include anorexia, nausea, vomiting, diarrhea, and visual
disturbances, such as flickering lights, blurred vision, or the perception of green or yellow halos
around lights.
J.M.'s condition improves after 5 days of treatment, and he is discharged to home. He has a follow-up
appointment with a cardiologist in 2 weeks.
1 Cardiovascular
? Scenario
It is midmorning on the cardiac unit where you work, and you are getting a new patient. G.P. is a 60-yearold
retired businessman, who is married and has three grown children. As you take his health history, he
tells you that he began feeling changes in his chest about 10 days ago. He has hypertension (HTN) and a
5-year history of angina pectoris. During the past week, he has had frequent episodes of mid-chest discomfort.
The chest pain responds to nitroglycerin (NTG), which he has taken sublingually (SL) about 8 to
10 times over the past week. During the week, he has also experienced increased fatigue. He states, "I just
feel crappy all the time." A cardiac catheterization done several years ago revealed 50% stenosis of the
right coronary artery (RCA) and 50% stenosis of the left anterior descending (LAD) coronary artery. He
tells you that both his mother and father had coronary artery disease (CAD). He is currently taking amlodipine
(Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day.
1. What other information are you going to ask about his episodes of chest pain?
• Are they accompanied by other signs and symptoms (S/S), such as nausea/vomiting (N/V),
diaphoresis, shortness of breath, dizziness, weakness, palpitations, or anxiety?
• Do they occur during exercise, after eating a large meal, in cold weather, or during periods of
stress? Or do the episodes of chest pain occur during rest?
• What is the quality of the pain? Ask him to describe the sensation in his own words. Ask him to rate
the chest pain on a scale of 1 to 10.
• How long do the episodes last?
• Does the pain radiate to other areas of the body?
• How many NTG tablets does he take before the chest pain is relieved?
2. What are common sites for radiation of ischemic cardiac pain?
Epigastric area, arms and hands (especially left), back (intrascapular area), shoulders, neck, and jaw
3. You know that G.P. has atherosclerosis of the coronary arteries. You need to know his risk
factors for CAD in order to plan teaching for lifestyle modifications. What will you ask him
Family history: Does he have a family history of CAD? If so, ask for specifics regarding which relatives
and what disease.
Weight: Obesity is a serious risk factor; calculate his body mass index (BMI) and waist-hip ratio.
Smoking history
Blood pressure (BP): The goal is SBP less than 120 mm Hg, DBP less than 80 mm Hg.
Diet: Ask about his favorite foods. For example, ask, "What did you eat for breakfast, lunch, and
dinner yesterday and today?"
Stress: Find out what stressors he has in his life and what he does when he is feeling stressed.
Exercise: Does he exercise? If so, what kind of exercises does he do? Does he have angina or become
short of breath when he exercises or does yard work?
Drug use: Has he taken any street drugs or abused prescription medication in the past? If yes, take a
complete drug history: type, quantity, frequency, route.
Difficulty: Intermediate
Setting: Hospital, outpatient cardiac rehabilitation
Index Words: coronary artery disease (CAD), hypertension (HTN), angina, lifestyle modification, medications,
laboratory values, assessment, risk factors, pacemaker, ECG strip, graded exercise (stress) test
Case Study 7 Coronary Artery Disease and Pacemakers
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
4. Although he has been taking sublingual nitroglycerin (SL NTG) for a long time, you want to
be certain he is using it correctly. Which actions are correct when taking SL NTG for chest
pain? (Select all that apply.)
a. Stop the activity and lie or sit down.
b. Call 911 immediately.
c. Call 911 if the pain is not relieved after taking one SL tablet.
d. Call 911 if the pain is not relieved after taking three SL tablets, 5 minutes apart.
e. Chew the tablet slowly then swallow.
f. Place the NTG tablet under the tongue.
Answers: A, C, F
SL NTG should be placed under the tongue and allowed to dissolve naturally and not swallowed
until the drug is entirely dissolved.
He should sit or lie down on first indication of anginal pain and place the tablet under his tongue.
Lying down will reduce hypotensive effects.
According to the latest American Heart Association guidelines, 911 (EMS) should be called if the
pain is not relieved after one SL tablet. Pain that is not relieved by one tablet may be indicative of
acute myocardial infarction (MI) or severe coronary insufficiency.
5. What other information would you need to make certain he understands the side effects and
storage of SL NTG?
• Tablets should be kept tightly sealed in their original brown bottle to protect them from heat,
moisture, and light. An open bottle of tablets should not be kept longer than 6 months; an
unopened bottle should be stored at room temperature until the expiration date, then discarded.
No other pills should be placed in this bottle.
• He should carry the tablets with him at all times for emergency use.
• The antihypertensive medications he is taking might compound the hypotensive effects of NTG.
When you first admitted G.P., you placed him on telemetry and observed his cardiac rhythm.
6. Identify the rhythm:
Answer: Atrial fibrillation
As you check his chart, you note that his vital signs (VS) and all of his lab tests were within normal range,
including troponin and creatinine phosphokinase (CPK) levels; potassium (K) was 4.7 mEq/L. Within the
hour, he spontaneously converted with medication (diltiazem [Cardizem]) to sick sinus syndrome with
long sinus pauses that caused lightheadedness and hypotension.
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
7. What risks does the new rhythm pose for G.P.?
• Syncope and falls because of the hypotension and lightheadedness
• Increased anginal episodes and more serious dysrhythmias because of decreased perfusion to the
• Confusion, altered level of consciousness (LOC) because of decreased perfusion to the brain
• Heart failure (HF) because of inadequate heart rate during bradycardia and inadequate ventricular
filling during tachycardia
Because G.P.'s dysrhythmia is causing unacceptable symptoms, he is taken to surgery and a permanent
DDDR pacemaker is placed and set at a rate of 70 beats/min.
8. What does the code DDDR mean?
DDDR pacing is used for patients with a symptomatic bradycardia in which the atrium can be
stimulated by a pacemaker, but atrioventricular conduction is, or possibly might become, unreliable.
• The first D indicates the heart chamber paced, meaning dual pacing, because both the atrium and
ventricle are paced.
• The second D indicates the chamber sensed, meaning dual sensing, because both the atrium and
ventricle are sensed.
• The third D indicates how the pacemaker will respond to the patient's own activity; D indicates
"dual" response to sensing, either triggered or inhibited.
• The R indicates rate-responsive pacing.
9. The pacemaker insertion surgery places G.P. at risk for several serious complications. List
three potential problems that you will monitor for as you care for him.
Infection: To prevent infection or irritation of the pacemaker site, use sterile technique with dressing
Pacemaker dysfunction: The pacemaker can fail to pace (initiate an electrical impulse), fail to sense
(be responsive to the patient's own cardiac activity), or fail to capture (stimulate a ventricular
contraction). All of these problems can result in dysrhythmias, ineffective cardiac function, and
symptoms for the patient.
Perforation of the endocardium: The result could be cardiac tamponade. The patient might
experience sharp chest pain on inspiration and excessive hiccups, increased heart rate, decreased
BP, and shortness of breath.
Hematoma at the incision site: You would see evidence of increased ecchymosis, swelling, and
tenderness at the incision site.
Pneumothorax: The patient would experience sudden, sharp chest pain and shortness of breath.
10. G.P. will need some education regarding his new pacemaker. What information will you give
him before he leaves the hospital?
• Call the physician if you have S/S of infection, such as fever or excessive redness, swelling, unusual
pain, or drainage at the incision site.
• Restrict arm lifting movements or exercises for 2 to 3 weeks after surgery. This applies only to the
arm on the same side of the body as the surgical site. Frequently, patients are asked to wear a sling
and swath to prevent arm movement.
• Call the physician if you have any of the following S/S of pacemaker malfunction: dizziness, passing
out, palpitations, chest pain, unusual weight gain.
• Observe safety precautions by avoiding contact sports, avoiding pressure on the incision, wearing
a medical alert bracelet/necklace, carrying a pacemaker ID card, and avoiding high-voltage
electrical and magnetic equipment.
1 Cardiovascular
11. G.P.'s wife approaches you and anxiously inquires, "My neighbor saw this science fiction
movie about this guy who got a pacemaker and then he couldn't die. Is that for real?" How
are you going to respond to her?
• Do not laugh! Patients and their families sometimes hear bizarre stories about "high-tech" health
care issues. It is fortunate she felt she could ask you this question. Keep in mind that if she asked
you about it, she probably worried about it a great deal.
• Reassure her that it might have made a great plot for a movie, but it's not a "real" situation.
• Explain to her the pacemaker gives off only "mini-electrical signals" to make the heart beat
• This might be a good time to ask whether she and G.P. have discussed and done anything about
health care power of attorney and advance directives for each other.
12. G.P. and his wife tell you they have heard that people with pacemakers can have their hearts
stop because of theft and security sensors in stores and airports. Where can you help them
find more information?
• The manufacturer of the pacemaker should also provide information on the vulnerability of its
product. Information might vary with the different devices.
• The American Heart Association is a good source of information and literature with the most recent
warnings and standards.
After discharge, G.P. is referred to a cardiac rehabilitation center to start an exercise program. He will
be exercise tested, and an individualized exercise prescription will be developed for him, based on the
exercise test.
13. What information will be obtained from the graded exercise (stress) test (GXT), and what is
included in an exercise prescription?
• G.P.'s cardiorespiratory responses (pulse, BP, respiratory gases [oxygen and carbon dioxide], and
perceived exertion) to specific workloads will be evaluated to ensure that he can safely exercise in
the intensity range prescribed for him.
• His resting (lowest) and peak (highest) exertional heart rates will be incorporated into the exercise
• The exercise prescription will start him at a workload that is not dangerous or emotionally
threatening to him (e.g., slow and easy).
• Just as medications are prescribed (type, dose, time, route), exercise for cardiac patients should be
prescribed in these terms:
• Type of exercise (what kind)
• Intensity of exercise (how hard)—usually as pulse or perceived exertion
• Frequency of exercise (how often)—usually beginning 3 days per week
• Duration of exercise (how long)—usually measured in minutes or distance
• What is the safest level of activity for G.P., and what problems could develop at what intensity?
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
? Scenario
You are assigned to care for L.J., a 70-year-old retired bus driver who has just been admitted to your
medical floor with right leg deep vein thrombosis (DVT). L.J. has a 48-pack-year smoking history, although
he states he quit 2 years ago. He has had pneumonia several times and frequent episodes of atrial flutter/
fibrillation. He has had two previous episodes of DVT and was diagnosed with rheumatoid arthritis
3 years ago. Two months ago he began experiencing shortness of breath on exertion and noticed swelling
of his right lower leg that became progressively worse until it extended up to his groin. His wife brought
him to the hospital when he complained of increasingly severe pain in his leg. When a Doppler study indicated
a probable thrombus of the external iliac vein extending distally to the lower leg, he was admitted
for bed rest and to initiate heparin therapy. His basic metabolic panel was normal; other laboratory results
are listed as follows:
■ Chart View
1. List six risk factors for DVT.
Most risk factors fall within the three categories of Virchow's triad:
Venous stasis: lengthy surgery, immobility, older than age 40, pregnancy, atrial fibrillation, heart
failure, obesity, stroke, denervated limb, hip or knee replacement
Venous endothelial injury: previous DVT, IV catheter, fractures, chemical injury (e.g., cigarette or
tobacco products, elevated glucose), trauma, varicose veins, hypertension
Hypercoagulability: malignant neoplasms, dehydration, oral contraceptives, estrogen therapy, sepsis,
blood dyscrasias, burns, genetic predisposition (i.e., antiphospholipid syndrome, activated protein C
resistance, protein C deficiency, protein S deficiency, antithrombin III deficiency, and factor V Leiden)
2. Identify at least five problems from L.J.'s history that represent his personal risk factors.
• Smoking history
• Decrease in mobility related to shortness of breath and rheumatoid arthritis
• History of atrial flutter/fibrillation
• Previous DVT
• 70 years of age
• Lifetime history of sedentary jobs
Laboratory Testing
PT 12.4 sec
aPTT 25 sec
Hgb 13.3 g/dL
Hct 38.9%
Cholesterol 206 mg/dL
Difficulty: Intermediate
Setting: Hospital
Index Words: deep vein thrombosis (DVT), atrial fibrillation, atrial flutter, laboratory values, medications,
assessment, diagnostic tests, patient education, electrocardiogram (ECG) strip
Case Study 8 Deep Vein Thrombosis
1 Cardiovascular
3. Something is missing from the scenario. Based on his history, L.J. should have been taking an
important medication. What is it, and why should he be taking it?
Warfarin (Coumadin), an oral anticoagulant, would be given because of his history of multiple DVT
and atrial flutter/fibrillation.
4. Keeping in mind L.J.'s health history and admitting diagnosis, what are the most important
assessments you will make during your physical examination and assessment?
Cardiovascular: Obtain baseline vital signs (VS); assess heart sounds; compare perfusion of the
Venous compromise of affected leg: Assess warmth, redness, pain, edema, Homans' sign, distal
pulses, capillary refill, and baseline calf and thigh girth. Don't forget to compare both legs.
Lungs: Assess breath sounds; assess for dyspnea and chest pain.
Mental status: Assess for confusion, restlessness, and lethargy.
5. What is the most serious complication of DVT?
Pulmonary embolism
Your assessment of L.J. reveals bibasilar crackles with moist cough; normal heart sounds; blood pressure
(BP) 138/88 mm Hg; pulse 104 beats/min; 3+ pitting edema of right lower extremity; mild erythema of
right foot and calf; and severe right calf pain. He is awake, alert, and oriented but a little restless. His Sa O 2
is 92% on room air. He denies chest pain but does have shortness of breath with exertion.
6. List at least eight assessment findings you should monitor closely for in the development of
the complication identified in Question 5.
• Crackles
• Cough
• Tachycardia
• Restlessness
• Dyspnea and tachypnea (occur in 85% of cases)
• Sudden pleuritic chest pain (occurs in 74% of cases)
• Apprehension
• Hemoptysis
• Fever
• Nausea and vomiting
• Cyanosis
L.J. is placed on 72-hour bed rest with bathroom privileges and given acetaminophen (Tylenol) for pain.
The physician also writes orders for enoxaparin (Lovenox) injections.
7. L.J. asks, "Why do I have to get these shots? Why can't I just get a Coumadin pill to thin my
blood?" What would be your response?
a. "Good idea! I will call to ask the physician to switch medications."
b. "It would take the Coumadin pills several days to be effective."
c. "Your physician prefers the injections over the pills."
d. "The enoxaparin will work to dissolve the blood clot in your leg."
Answer: B
Enoxaparin takes 3 to 5 hours to reach maximum antithrombotic activity; warfarin (Coumadin)
takes 12 to 24 hours for onset and peaks in 1. to 4 days. It takes several days for warfarin to reach an
effective anticoagulation level.
1 Cardiovascular
8. The order for the enoxaparin reads: Enoxaparin 70 mg every 12 hours subcut . L.J. is 5 ft, 6 in.
and weighs 156 lb. Is this dose appropriate?
The appropriate dose for enoxaparin is 1 mg/kg. 154 lb = 70 kg.
1 mg/kg Å~ 70 kg = 70 mg; therefore, the ordered dose of 70 mg is appropriate for L.J.
9. What special techniques do you use when giving the subcutaneous injection of enoxaparin?
(Select all that apply.)
a. Rotate injection sites.
b. Give the injection near the umbilicus.
c. Expel the bubble from the prefilled syringe before giving the injection.
d. After inserting the needle, do not aspirate before giving the injection.
e. Massage the injection site gently after the injection is given.
Answers: A, D
The injection sites are the left/right anterolateral, or left/right posterolateral abdominal wall; the
injection should be at least 2 in. away from the umbilicus because of the vascular structure near
the umbilicus. Injection sites need to be rotated to reduce bruising. Do not expel the bubble from
the prefilled syringes. Do not aspirate before giving the injection; this might cause more trauma to the
injection site and increase bruising. You might need to hold gentle pressure on the injection site to
reduce bleeding, but do not massage the site because this will also increase bruising.
10. True or False: Enoxaparin dosage is directed by monitoring activated partial thromboplastin
time (aPTT) levels. Explain your answer.
False. Low molecular weight heparins, such as enoxaparin, do not require any laboratory monitoring
because of their greater affinity for factor Xa (compared to heparin, which is monitored by aPTT
levels when given intravenously).
11. What instructions will you give L.J. about his activity?
• Maintain bed rest to prevent dislodgment of an embolus from the DVT. Ask him to immediately
report to you any signs and symptoms of pulmonary embolism.
• Frequently change positions in bed; this helps prevent problems of immobility.
• Perform frequent gentle dorsiflexion and plantar flexion of the feet, and perform ankle circles to
promote circulation and to facilitate venous return.
• Do not cross legs; crossing legs can decrease circulation.
• Do not massage right leg; massage could dislodge a thrombus.
• Keep right leg elevated without pressure under the knee to promote circulation.
• Avoid sudden muscle movement of affected limb, which could dislodge a thrombus.
12. What pertinent laboratory values or test results would you expect the physician to order and
you to monitor? Explain the reason for each test.
• Platelet count: Enoxaparin might decrease the platelet count.
• CBC: Used to monitor for blood loss from bleeding that might or might not be evident while L.J. is
on anticoagulant therapy.
• CXR: For evaluation of pulmonary and cardiac systems.
• D-dimer assay: High levels are associated with thrombotic problems, such as DVT.
• V/Q scan (ventilation/perfusion lung scan): Used to test for the presence of pulmonary
• ABGs: Used to monitor respiratory status/oxygenation.
• Test for occult blood in stool (Guaiac) and/or emesis: To monitor for occult gastrointestinal
1 Cardiovascular
13. You identify pain as a key issue in the care of L.J. List four interventions you will choose for
L.J. to address his pain.
• Get specific information on the symptoms; verify with the patient the location, quality, intensity,
onset, duration, and expression of pain.
• Assess and monitor those factors that increase or decrease pain.
• Assess and monitor emotional responses and coping mechanisms to pain.
• Eliminate or modify those stimuli that increase pain.
• Evaluate the effectiveness of his pain medication.
• Teach him techniques he can use to modify his own pain (e.g., relaxation, imagery, distraction).
14. You evaluate L.J.'s ECG strip. Name this rhythm, and explain what consequences it could
have for L.J.
The rhythm is atrial flutter. You can see flutter waves, with varying numbers between the QRS
intervals. The problem with atrial flutter is that the atria are "quivering," or not contracting correctly.
Blood can pool inside the atria, and clot formation might occur.
A week has passed. L.J. responded to heparin therapy, was started on warfarin therapy, and is being
discharged to home with home care follow-up. "Good," he says, "just in time to fly out West for my
grandson's wedding." His wife, who has come to pick him up, rolls her eyes and looks at the ceiling. You
almost drop the discharge papers in disbelief. (You thought you had done such a good job of discharge
15. What are you going to tell him?
You observe that L.J. doesn't seem to have realistic expectations associated with his recovery, so you
explain the following:
• He is going to require daily follow-up visits to monitor his status.
• Sitting on a plane for several hours, along with the vigorous activity required to make plane
changes, is not safe for him at this time. He is likely to have another DVT develop from sitting on
the plane (not to mention sitting at the wedding and reception). He is going to continue to receive
warfarin for life and will be at risk for bleeding and bruising; in addition, after his hospitalization
and bed rest, it will take him weeks or even months to adapt to the rigors of everyday life.
• Explore with him the possibility of sending an audiotaped or videotaped message from him to the
newlyweds. Ask whether anyone can video-record the ceremony and parts of the reception for him
to view at home so that he won't feel so isolated.
L.J. listens to you, and Mrs. J. is quite relieved. L.J.'s son arranges to record the wedding ceremony, and
guests at the reception record special greetings for him. It's been 2 weeks, and he seems quite pleased.
He watches the recording daily and points out his favorite parts to the home care nurse every time she
1 Cardiovascular
? Scenario
A.H. is a 70-year-old retired construction worker who has experienced lumbosacral pain, nausea, and
upset stomach for the past 6 months. He has a history of heart failure, high cholesterol, hypertension
(HTN), sleep apnea, and depression. His chronic medical problems have been managed over the years
with oral medications: benazepril (Lotensin) 5 mg/day, fluoxetine (Prozac) 40 mg/day, furosemide (Lasix)
20 mg/day, KCl 20 mEq bid, and lovastatin (Mevacor) 40 mg with the evening meal.
A.H. has just been admitted to the hospital for surgical repair of a 6.2-cm abdominal aortic aneurysm
(AAA) that is now causing him constant pain. On arrival on your floor, his vital signs are 109/81, 61, 16,
and 98.3° F (36.8° C). When you perform your assessment, you find that his apical heart rhythm is regular
and his peripheral pulses are strong. His lungs are clear, and he is awake, alert, and oriented. There
are no abnormal physical findings; however, he hasn't had a bowel movement for 3 days. His electrolytes,
blood chemistries, and clotting studies are within normal range, except his hematocrit is 30.1%, and
hemoglobin is 9 g/dL.
1. A.H. has several common risk factors for AAA, which are evident from his health history.
Identify and explain three factors.
Hyperlipidemia, leading to atherosclerosis: This is inferred because he is taking lovastatin, a drug
used to reduce serum lipid levels. Atherosclerosis injures vessel walls, causing weakness.
HTN: The elevated blood pressure (BP) puts a continuous strain on weakened arterial walls.
Advanced age: HTN and atherosclerosis are more common in the elderly.
Male gender: For unknown reasons, the incidence of AAA is higher in men than in women.
While A.H. awaits his surgery, it is important that you monitor him carefully for decreased tissue
2. Identify five things you would assess for, and state your rationale for each.
Urinary output: A decrease in kidney perfusion will result in decreased urine production.
Abdominal or lumbosacral pain: An increase in pain can mean enlargement of the aneurysm or
possible leakage.
Bowel sounds: Decreased or absent bowel sounds can indicate decreased perfusion to the
gastrointestinal (GI) tract.
Peripheral circulation: Decrease in pedal pulses, coolness, cyanosis, or mottling of the skin of the
feet, or increase in capillary refill time, indicates impaired peripheral circulation.
Chest pain: If perfusion to the myocardium is decreased, the heart can become ischemic.
VS: Hypotension, tachycardia, and tachypnea are signs of hypovolemia or hemorrhagic shock.
Level of consciousness (LOC): If cerebral perfusion is diminished, the patient might become confused
and anxious.
Difficulty: Intermediate
Setting: Hospital, home care
Index Words: abdominal aortic aneurysm (AAA), hypertension (HTN), patient education, surgery, assessment
Case Study 9 Abdominal Aortic Aneurysm
1 Cardiovascular
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
3. What is the most serious, life-threatening complication of AAA, and why?
Rupture of the aneurysm: A ruptured aneurysm (as opposed to one with a slow leak) is usually
rapidly fatal.
4. What single problem mentioned in the first paragraph of this case study presents a risk for
AAA rupture? Why?
• Risk for AAA rupture is evident in the statement, "He hasn't had a bowel movement for 3 days."
• Straining to have a bowel movement (Valsalva's maneuver) can cause a profound increase in
intra-abdominal pressure that could result in rupture.
5. During your assessment, you notice a pulsation in A.H.'s upper abdomen, slightly left of
the midline, between the umbilicus and the xiphoid process. True or False: You will need to
palpate this mass as part of your physical assessment. Explain your answer.
False. If a pulsating abdominal mass is noted, you might gently auscultate it for a bruit, but do
not palpate the mass! It might be tender, but, more importantly, there is a risk of rupture of the
aneurysm with palpation.
The resection of A.H.'s aneurysm was successful, but, for the first 3 postoperative days, he was delirious
and required one-to-one nursing care before he became coherent and oriented again. He was still
somewhat confused when he was transferred back to your floor.
6. What assessments should be made specific to his postoperative care?
• Check pulses distal to the aneurysm to make certain the graft has not clotted off. In addition, check
the temperature of the extremities below the graft.
• Maintain his BP within the range specified by the surgeon to (1) allow the clot to form on the inside
of the graft and to (2) ensure that the graft doesn't come apart as a result of high BP.
• Continuous cardiac monitoring will be done to watch for any dysrhythmias.
• Monitor urinary output every hour for the first 8 hours and then check every 4 hours for the next
16 hours. After the first 8 hours, this is a matter of judgment, so recommendations might vary.
• Monitor for other signs of graft occlusion, such as severe pain, abdominal distention, and white or
blue extremities or flank.
7. List five problems that are high priorities in A.H.'s postoperative care.
• Pain from his surgery
• Confusion or disorientation related to the surgical intervention
• Risk for infection as a result of the surgery
• Possible altered systemic tissue perfusion as the result of a leak, rupture, or occlusion of the aortic graft
• Possible hypoventilation (breathing too shallow) because of pain and history of sleep apnea and
abdominal surgery
• Possible constipation because of his history of constipation, pain medication, and the abdominal
surgery (inability to bear down effectively to create sufficient intra-abdominal pressure)
• Reduced physical mobility as a result of his surgery
8. During the postoperative period after an aneurysmectomy, the nurse will implement which
actions? (Select all that apply.)
a. Keep the head of bed (HOB) elevated at 60 degrees.
b. Keep firm pressure on the abdominal incision during coughing exercises.
c. Change dressings as ordered with aseptic technique.
d. Monitor peripheral pulses on both lower extremities.
e. Use the bed's knee gatch to allow for knee flexion during bed rest.
1 Cardiovascular
Answers: B, C, D
Elevation of HOB should not exceed 30 to 40 degrees because sharp hip flexion could cause
the graft to kink. Knees should not be gatched because knee flexion compresses popliteal vessels,
restricting venous return. Dressing changes should be done with careful aseptic technique. Careful
and regular assessment for decreased tissue perfusion (see previous text) should be done to detect
leak, rupture, or occlusion of the graft.
When A.H. is being prepared for discharge, you talk to him about health promotion and lifestyle change
issues that are pertinent to his health problems.
9. Identify four health-related issues you might appropriately address with him and what you
would teach in each area.
HTN: Importance of low-sodium diet, proper use of antihypertensive medications, and exercise. With
his history of AAA, he will need to keep his BP under control.
Exercise: Rationale and methods. Exercise is valuable in the treatment of atherosclerosis and
depression, but it is essential that A.H. receive prescriptive exercise guidelines. Exercise carries
great benefit, but it also carries great risk if it is done inappropriately.
Diet: Importance of low-sodium, low-cholesterol, high-fiber diet. Obtain a referral to a registered
dietitian (RD).
Nutritional status: Does he have adequate nutritional intake to promote healing? Get a referral to an
RD. He might also benefit from an at-home meal service, such as Meals-on-Wheels, not only for
the improved nutrition, but also for the social stimulation.
Constipation: Importance of high-fluid, high-fiber intake and exercise.
Psychosocial support needs: Discuss resources available in A.H.'s community for meeting
psychosocial support needs.
10. A.H. will be receiving follow-up visits from the home health care nurse to change his
dressing and evaluate his incision. What can you discuss with A.H. before discharge that will
help him understand what the nurse will be doing?
• Explain to A.H. that he will be having a home health care nurse visit him after he goes home. The
nurse will take care of his wound and dressing.
• Ask him whether he would like to look at his incision. This will give you an opportunity to teach
him about signs and symptoms of infection or dehiscence. Get a mirror so that he can get a good
look while you point out (with a sterile, gloved hand) the incision line and the "normal" healing
tissue color. Tell A.H. to keep an eye on the wound to make sure it is not puffy and that there is
nothing oozing from the incision. Let him know that he needs to notify his physician immediately
if he notices any sudden drainage, elevated temperature, or sudden severe abdominal pain.
1 Cardiovascular
? 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). Labs were
drawn in the emergency department. She was started on oxygen ( O 2 ) at 2 L via nasal cannula and given
nonenteric-coated aspirin 325 mg to be chewed and swallowed. An IV was started.
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 132/84, 88, 18,
and 99° F (37.2° C). Her weight is 114 lb and height is 5 ft, 4 in. Moderate edema of both ankles is present,
but capillary refill is brisk, and peripheral pulses are 1+. You hear a soft systolic murmur. You place her on
telemetry, which shows the rhythm in the figure, as follows. She denies any discomfort at present.
1. Identify her cardiac rhythm.
Sinus rhythm, with premature atrial contractions (PACs). No ventricular ectopy.
2. Give at least two reasons an IV would be inserted.
To have IV access in case of cardiac arrest, for bolus fluid administration, and for administration of
nitroglycerin (NTG) or other medications
3. Explain the purpose of the aspirin tablet. Why is "nonenteric-coated" aspirin specified? What
would be a contraindication to administering aspirin?
• Enteric coating slows down the availability of the aspirin, and, in this case, you want the
medication to be rapidly absorbed for rapid availability in the bloodstream. Chewing the tablet
also enhances the absorption.
• Contraindications would include allergy to aspirin, active major bleeding or major bleeding within
the past 2 weeks, hemorrhagic stroke, active or recent gastric bleeding, ulcer disease, and acute
bronchospasm. Aspirin is effective in reducing mortality in MI.
Difficulty: Intermediate
Setting: Hospital, intensive care unit
Index Words: angina, rule out myocardial infarction (R/O MI), assessment, differential diagnosis, diagnostic tests,
symptom assessment, laboratory values, geriatric, ECG strip, aspirin therapy
Case Study 10 Angina
1 Cardiovascular
4. What additional history and physical information should you obtain related to her admitting
• Medication allergies.
• Herbal products: Try to identify exactly what herbs she takes, the implications for interaction with
her current medications, and her complaints.
• General activity level: Especially focus on changes in housework or increased fatigue or symptoms
during housework in women.
• Sleep patterns.
• General perceived stress level and coping mechanisms.
• Accustomed diet.
• Help that she and her husband need at home to stay independent.
• Pain, fatigue, or dyspnea (if present) and whether there are recent changes in any of them: Assess
intensity, characteristics, onset, location, duration, what makes it better or worse, associated
symptoms, and possible radiation of pain.
• Cardiac sounds: Listen for S1 and S2 and for additional sounds such as S3, S4, valvular click, or rub.
Listen to the heart murmur, and identify quality and intensity and whether the extra sound occurs
during systole or diastole.
• Jugular venous distention (JVD): This is an indication of elevated right atrial pressure, which can be
elevated in severe heart failure (HF) and fluid overload.
• Lungs: Assess for signs and symptoms of HF. Early-stage HF cough is a persistent, dry hack; endstage
HF features crackles, dyspnea, and cough productive of frothy sputum.
• Mental status: Assess for orientation, alertness, anxiety, confusion, and restlessness.
5. List seven laboratory or diagnostic tests you would expect to be performed; suggest what
each might contribute.
Twelve-lead ECG: To determine whether R.K. has had a prior MI, whether she is showing ischemic
changes, in what part of her heart, and whether she is having irregular rhythms. (ECG is not an
exclusive test for MI.)
Chest x-ray (CXR): To see whether the heart (cardiac silhouette) is enlarged or whether there might
be any visible structural problems or defects that are contributing to her symptoms. Check for
pulmonary edema.
Oxygen saturation: To determine whether her symptoms might be related to a respiratory disorder
or whether her heart is able to adequately pump blood through her lungs.
Cardiac enzymes: Creatine phosphokinase with isoenzymes if elevated and troponin T or I to
determine whether she has had an MI.
Complete blood count (CBC) with differential: To check for anemia or infection.
D-dimer test to rule out pulmonary embolus.
Metabolic/chemistry panel, or acute care panel, including serum lipid panel
urinalysis (UA).
Prothrombin time/International normalized ratio (PT/INR) and partial thromboplastin time (PTT):
To examine for basic coagulation disorders.
6. What other source, besides cardiac ischemia, might be responsible for her chest and
abdominal discomfort? (Specify.)
Gastrointestinal: indigestion, gastritis, hiatal hernia, reflux esophagitis, gastroesophageal reflux
disease (GERD), gallbladder disease, esophageal spasm, peptic ulcer disease (PUD)
Respiratory: pleurisy, pulmonary embolism, pneumonia, pneumothorax
Cardiac: vasospastic angina, mitral valve prolapse (MVP), severe aortic stenosis, cardiac dysrhythmia,
1 Cardiovascular
Musculoskeletal: rib fracture, costochondritis, respiratory muscle strain, vertebral fractures or
compression resulting in nerve impingement
Metabolic: anemia, carbon monoxide toxicity
Psychosocial: anxiety or stress, panic attack
7. Define the concept of differential diagnosis, and explain how the concept applies to R.K.'s
Differential diagnosis is the medical process of discovering which of a number of possible diseases
or conditions is responsible for the symptoms the patient has. The clinical process of making a
differential diagnosis involves a systematic comparison and contrast of clinical findings. Tests
are done to differentiate and eliminate (as in a process of elimination). In this case, it means to
distinguish R.K.'s symptoms as cardiac versus noncardiac.
R.K.'s symptoms could come from several sources, some serious and life threatening, some less
significant. By performing a careful assessment and a series of diagnostic tests, the physician can
rule out what the diagnosis is not by a process of elimination. After the physician narrows the
possibilities, the diagnosis usually is whatever is left.
After some rest, R.K.'s chest pain has subsided, and she tells you that she feels much better now. You
review her laboratory results.
■ Chart View
8. On the basis of the information presented so far, do you believe she had an MI? What is your
No. Her cardiac symptoms are probably due to angina secondary to CAD rather than an MI, based on
the following:
• Cardiac enzymes are within the normal range (for a female, 30-235 units/L). In the presence of
myocardial damage, CK-MB levels would rise 3 to 6 hours after infarction occurs, and peak at 12
to 24 hours (if no further infarction occurs), then return to normal 12 to 48 hours after infarction.
CK-MB levels are not usually elevated with angina. Cardiac troponins typically become elevated
within 2 to 3 hours after an MI.
• The D-dimer test results rule out the occurrence of a pulmonary embolus.
• ECG did not show ST, T wave, or Q wave changes.
• Decreased activity and change of position somewhat relieved pain.
9. While you care for R.K., you carefully observe her. Identify two possible complications of
coronary artery disease (CAD) and the signs and symptoms associated with each.
• Cardiac ischemia
• Cardiac dysrhythmias, particularly premature ventricular contractions: dysrhythmias seen on
telemetry, syncope, lightheadedness, shortness, palpitations felt by patient
• HF: crackles; dyspnea; confusion; dry, hacking, nonproductive cough; peripheral edema; JVD
Laboratory Results
12-lead ECG: Light left-axis deviation, normal sinus rhythm with no ventricular ectopy
Serial CPK tests are 30 units/L (admission), 32 units/L (4 hours after admission)
Cardiac troponin T is less than 0.01 ng/mL (admission) and same result 4 hours after admission
Cardiac troponin T is less than 0.03 ng/mL (admission) and same result 4 hours after admission
D-dimer test less than 250 ng/mL
1 Cardiovascular
10. 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. What else do you assess, and what can you do to make her more
• Assess her vital signs, including pulse oximetry, and cardiac rhythm on telemetry.
• Order a STAT ECG.
• Give her supplemental oxygen as ordered (2 to 4 L/NC) if she is not wearing it.
• Give her nitroglycerin (NTG) 0.4 mg sublingual (SL) as ordered (1 q 5 min prn chest pain Å~ 3 doses)
to decrease the venous return to the heart and dilate the coronary arteries to increase the O 2
supply to the heart.
• Obtain an order for 30 mL aluminum hydroxide/magnesium hydroxide (such as Maalox) to rule out
• Have her rest quietly in bed to decrease O 2 demand.
• Elevate the head of the bed to facilitate respiratory expansion.
• Encourage verbalization of concerns to decrease anxiety and O 2 demand.
R.K.'s husband is upset. He tells you they have been married for 62 years and he doesn't know what he
would do without his wife. One way to help people deal with their anxieties is to help them focus on concrete
11. What information would be useful to get from him? What other health care professional
might be able to help with some of these issues?
• Support systems: Do they have any relatives or resources, like a church, that can help them with
things like meals, shopping, and housekeeping?
• What is their economic status? Can they afford any long-term help or medications she might need?
• A social worker might be able to help them access community resources and make appropriate
• Spiritual support: Do they have a minister to call, or would he like to have the hospital chaplain
visit him?
R.K. has no further episodes of chest pain, and she is discharged to home the next day. As you present the
discharge instructions, you review the proper technique for taking sublingual nitroglycerin for chest pain.
12. Which statement by R.K. indicates that further teaching is needed?
a. "At the first sign of chest discomfort, I will stop what I'm doing and sit down."
b. "I will place one nitroglycerin tablet under my tongue."
c. "If the chest pain does not stop, 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."
Answer: D
Current guidelines state that if chest discomfort/pain is unimproved or worsening 5 minutes
after one nitroglycerin dose has been taken, then the patient or family member needs to access EMS
1 Cardiovascular
? Scenario
The time is 1900. You are working in a small, rural hospital. It has been snowing heavily all day, and the
medical helicopters at the large regional medical center, 4 hours away by car (in good weather), have
been grounded by the weather until morning. The roads are barely passable. W.R., a 48-year-old plumber
with a 36-pack-year smoking history, is admitted to your floor with a diagnosis of rule out myocardial
infarction (R/O MI). He has significant male-pattern obesity ("beer belly," large waist circumference) and
a barrel chest, and he reports a dietary history of high-fat food. His wife brought him to the emergency
department after he complained of unrelieved "indigestion." His admission vital signs (VS) were 202/124,
106, 18, and 98.2° F (36.8° C). W.R. was put on oxygen ( O 2 ) by nasal cannula (NC) titrated to maintain Sa O 2
(arterial oxygen saturation) over 90% and started on an IV of nitroglycerin (NTG). He was given aspirin
325 mg to chew and swallow and was admitted to Dr. A.'s service. There are plans to transfer him by helicopter
to the regional medical center for a cardiac catheterization in the morning when the weather
clears. Meanwhile, you have to deal with limited laboratory and pharmacy resources. The minute W.R.
comes through the door of your unit, he announces he's just fine in a loud and angry voice and demands
a cigarette. He also says he has no time to fool around with hospitals.
1. From the perspective of basic human needs, what is the first priority in his care?
The first priority is his safety. That means, in the event he has had an MI, keeping him alive and
limiting cardiac damage.
2. Are these VS reasonable for a man of his age? If not, which one(s) concern(s) you? Explain
why or why not.
His blood pressure (BP) is dangerously high, and his pulse (P) is rapid for a 48-year-old man who is at
rest. Both of these can contribute to myocardial ischemia.
3. Identify five priority problems associated with the care of a patient like W.R.
BP control : Monitor for efficacy of medication and side effects.
Myocardial ischemia : This results from (1) increased oxygen demand because of increased CO (high BP
and P); (2) probable decreased oxygen availability related to coronary artery disease (CAD) and/or
chronic obstructive pulmonary disease (COPD); and (3) possible decreased diffusion of gases across
the alveolar-capillary membrane. The latter two issues are directly related to his smoking history.
Cigarette smoking : He is going to want to smoke. Smoking negatively affects the heart because of
the increased stress on the lungs and the vasoconstriction that restricts oxygenation. You need
to caution him about not smoking during his stay in the hospital, and ask his wife to take his
cigarettes and lighter or matches home with her.
Teaching needs : Teach him to report any chest pain or discomfort or difficult breathing.
Pain Control : Pain will increase his anxiety and the heart rate, which increases the workload of the heart.
Cardiac dysrhythmias secondary to MI : These increase the possibility of sudden death.
Constipation : His high-fat, low-fiber dietary preferences and decreased activity during
hospitalization increase his risk for constipation; the pattern of breath-holding during a bowel
movement is termed Valsalva's maneuver. In cardiac patients who are constipated, it can lead to
an MI or sudden death.
Difficulty: Intermediate
Setting: Hospital emergency department
Index Words: rule out myocardial infarction (R/O MI), substance abuse, coronary artery disease (CAD),
hypertension (HTN), angina, crisis management, risk factors, laboratory values, medications
Case Study 11 Rule Out Myocardial Infarction
1 Cardiovascular
Hostility : His anger is probably masking fear of death and fear of loss of control, which can
contribute to more stress on his heart and would be dangerous at this time.
Denial : His denial is a coping mechanism related to his fear. Although denial sometimes serves a positive
purpose, in this situation, it is contributing to behaviors that increase his risk for cardiac damage.
4. Which laboratory tests might be ordered to investigate W.R.'s condition? If the order is
appropriate, place an "A" in the space provided. If inappropriate, mark with an "I," and
provide rationales for your decisions.
2. EEG in the morning
3. Chem 7 (electrolytes)
5. Bilirubin
6. Urinalysis (UA)
7. STAT 12-lead ECG
8. Type and crossmatch for 2 units of packed RBCs (PRBCs)
Answers: 1. A; 2. I; 3. A; 4. A; 5. I; 6. A; 7. A; 8. I
The CBC, chem 7, PT/PTT, and UA are appropriate admitting lab tests for all patients with BP
disorders. The STAT 12-lead ECG is appropriate for this patient because his heart is involved. The EEG,
bilirubin, and type and crossmatch are not appropriate for this patient.
5. What significant lab tests are missing from the previous list?
Serial cardiac enzymes; the order should read CK, troponin T and I q8h. In addition, a D-dimer test
should be ordered.
6. How are you going to respond to W.R.'s angry demands for a cigarette? He also demands
something for his "heartburn." How will you respond?
• Address his feelings of loss of control by acknowledging his legitimate issues of craving (cigarettes)
and pain or discomfort. Assure him you will call the physician and get something to help him feel
more comfortable.
• Explain that smoking could cut off oxygen to his heart and increase his pain, burning, or
discomfort (use his choice of words).
• Reassure him that you will be available if he needs help.
• Offer him a choice by asking him whether he would like an antacid (such as Maalox or Mylanta,
which are combination products that contain aluminum and magnesium) per your unit protocol
for his heartburn while you contact the physician. Ask whether there is anything else you can do to
make him more comfortable. (No, he still can't smoke.)
• Remind him that lit cigarettes are not safe when oxygen is being delivered by NC.
• Professional confidence and competence communicate themselves to people experiencing fear
and help meet their needs for security.
You phone Dr. A.'s partner, who is on call. She prescribes morphine sulfate 4 to 10 mg IV push (IVP) q1h prn
for pain (burning, pressure, angina).
7. Explain two reasons for this order.
• Morphine sulfate, an opioid analgesic, will make him more comfortable and help reduce his stress.
(With opioids, be sure to institute a bowel care program to prevent constipation.)
• Morphine sulfate also functions to dilate pulmonary vessels and decrease preload on the heart.
• Morphine sulfate also dilates the coronary arteries to increase blood flow and oxygen delivery.
• Relieving pain will help decrease myocardial oxygen demand.
1 Cardiovascular
8. What special precautions should you follow when administering morphine sulfate IVP?
• Ask about prior allergy, hypersensitivity reaction to morphine sulfate, or impaired liver
• Assess VS, especially respirations (do not give if respirations are less than 12 per minute); level of
consciousness with opioid use; and location and intensity of pain before and 30 to 60 minutes after
• After diluting with 5 mL or more sterile normal saline, administer IVP over 4 to 5 minutes (for 15 mg
or less).
• Start with smallest dose ordered and titrate to eliminate pain.
9. The pharmacy supplies morphine for injection in vials of 5 mg/mL only. For the first dose,
you will be giving 4 mg of morphine. How many milliliters will you give for this dose? Mark
the syringe with your answer.
10. What will you do with the rest of the morphine in the vial?
a. Discard it.
b. Save it for the next dose.
c. Return it to the pharmacy.
d. Discard it with a second witness.
Answer: D
Morphine is a Schedule II drug, and any drug that is not used needs to be "wasted" with a second
witness documenting that the drug was discarded.
11. Angina is not always experienced as "pain" as many people understand pain. How would you
describe symptoms you want him to warn you about? Why is this important?
• Tell him you want him to notify you of any unusual or uncomfortable feelings that develop.
• It is possible that he could develop an MI even if he has not already had one.
• He could also develop lethal dysrhythmias or cardiac arrest.
12. What safety measures or instructions would you give W.R. before you leave his room?
• He should press the nurses' call light as soon as he starts to experience any uncomfortable
feelings (the word pain might be misunderstood), becomes nauseated, or experiences more
• Inform him of his activity status, for example, "The doctor has placed you on bed rest with
bathroom privileges. That means if you need to use the bathroom, you need to turn on your call
light and someone will assist you. Do not try to get up by yourself."
• It is against the hospital policy for him to smoke in the hospital. Have his wife take his cigarettes
and lighter or matches home.
• It's very important that he let you know whether he has to have a bowel movement because,
during a bowel movement, Valsalva's maneuver (you might have to explain this) can contribute to
sudden death.
0.8 mL
1 Cardiovascular
13. Mrs. R. asks you, "If he can't smoke, why can't you give him one of those nicotine patches?"
How will you respond?
Explain that use of the nicotine patch should be avoided in patients with severe angina or
uncontrolled HTN and for 8 weeks following an MI. Nicotine in the patch will constrict his coronary
arteries and might decrease blood flow and oxygen to his heart.
14. Are there any alternatives to help him with his nicotine cravings? Would they be
helpful now?
Bupropion (Zyban) is an antidepressant that is used for smoking cessation. Varenicline (Chantix) is
another drug that can be used for smoking cessation. However, these drugs take several weeks to
have any effect on nicotine cravings.
15. Before leaving for the night, Mrs. R. approaches you and asks, "Did my husband have a
heart attack? I'm really scared. His father died of one when he was 51." How are you going to
respond to her question?
• It is important to recognize and address Mrs. R.'s anxiety. Reassure her that he is getting excellent
care and he will be closely monitored.
• Explain that no one can tell whether he's had a heart attack until the test results come back.
• Thank her for the additional information, and tell her you will pass it along to the physician. Tell
her that he is going to need her help when he goes home so that he can begin to live a healthier
16. When you come into W.R.'s room at 2200 hours to answer his call light, you see he is holding
his left arm and complaining about aching in his left shoulder and arm. What information
will you gather? What questions will you ask him?
• Take his VS. Obtain a STAT ECG.
• Evaluate his level of anxiety.
• Perform a focused assessment: Observe his color; feel for diaphoresis.
• Ask about the presence of pain and symptoms: quality; intensity (have W.R. rate his pain on a scale
of 1 to 10, with 1 being no pain and 10 being the worst possible pain); location (where did it start,
and has it traveled anywhere?); and duration.
• Ask about nausea.
17. You give him one sublingual NTG tablet, per protocol, but his pain is not relieved. Based
on your assessment findings, you decide to call the physician. Using SBAR ( S ituation,
B ackground, A ssessment, R ecommendation), what information would you provide to the
physician when you call?
Following SBAR, you would first identify yourself, then explain that W.R. is complaining about aching
in his left shoulder and arm that has been unrelieved by one NTG tablet. For background, state
that W.R. was admitted at 1900 for unrelieved "indigestion." He cannot be transported to the larger
medical center until the morning because of the weather conditions. Give current VS and pertinent
details of his physical exam, including ECG and lab results, and any other assessment items that have
changed. The assessment of the situation is that W.R. is experiencing angina and possibly an MI. You
would anticipate diagnostic testing, medication with intravenous morphine and nitrates, and close
monitoring until he is able to be transported to the medical center.
In the morning, W.R. is transferred by helicopter to the medical center, and a cardiac catheterization is performed.
It is determined that W.R. has coronary artery disease (CAD). The cardiologist suggests it would
be best to treat him medically for now, with follow-up counseling on risk factor modification, especially
smoking cessation. He is discharged with a referral for a follow-up visit to his local internist in 1 week.
1 Cardiovascular
18. What does it mean to treat him "medically" (conservatively)? What other approaches might
be used to treat CAD?
Medical management involves several components. Adjustment or addition of pharmacologic
treatment for coronary risk factors (e.g., hyperlipidemia, HTN) with medications has been shown
to reduce mortality and future coronary events: nitrates, beta-adrenergic blockers, aspirin therapy,
and "statins" (lipid-lowering agents). Advice about lifestyle modification might be needed (weight
loss, smoking cessation, exercise, dietary modifications, alcohol moderation). Other approaches
involve some kind of surgical procedures: coronary artery bypass graft (CABG), stent placement,
percutaneous transluminal coronary angioplasty (PTCA), or balloon angioplasty with stent
placement. 1
? Scenario
You are working at the local cardiac rehabilitation center, and R.M. is walking around the track. He summons
you and asks if you could help him understand his recent lab report. He admits to being confused by the
overwhelming data on the test and doesn't understand how the results relate to his recent heart attack and
need for a stent. You take a moment to locate his lab reports and review his history. The findings are as follows:
R.M. is an active 61-year-old man who works full time for the postal service. He walks 3 miles every
other day and admits he doesn't eat a "perfect diet." He enjoys two or three beers every night, uses stick
margarine, eats red meat two or three times per week, and is a self-professed "sweet eater." He has tried
to quit smoking and is down to one pack per day. His cardiac history includes a recent inferior myocardial
infarction (MI) and a heart catheterization revealing three-vessel disease: in the left anterior descending
(LAD) coronary artery, a proximal 60% lesion; in the right coronary artery (RCA), proximal 100% occlusion
with thrombus; and a circumflex with 40% to 60% diffuse ecstatic (dilated) lesions. A stent was
deployed to the RCA and reduced the lesion to 0% residual stenosis. He has had no need for sublingual
nitroglycerin (NTG). He was discharged on enteric-coated aspirin 325 mg daily, clopidogrel (Plavix) 75 mg
daily, atorvastatin (Lipitor) 10 mg at bedtime, and ramipril (Altace) 10 mg/day. Six weeks after his MI and
stent placement, he had a fasting advanced lipid profile with other blood work.
■ Chart View
1. Given the previous information, what assessment questions are important to ask R.M.?
• Is he or anyone in his family diagnosed with diabetes mellitus (DM)?
• How long does it take for him to walk 3 miles at home?
• What are his height and weight? (to calculate body mass index [BMI])
• Does he eat white food (white rice, white potatoes); white flour products (white bread, pasta, junk
food); and sweets, juices, or sodas?
The patient's blood glucose is normal, so although knowing a family history for DM would be
helpful, it is not crucial to initiate treatment. Exercise is important, but it doesn't have a significant
bearing on the laboratory results. Height, weight, and BMI are always important; however, they
don't have a significant impact on treatment options, at this point. Refined carbohydrates, such as
products made with white flour, are important because they will cause an increase in triglycerides.
Six-Week Post Procedure Laboratory Work (Fasting)
Total cholesterol 188 mg/dL
High density lipoprotein (HDL) 34 mg/dL
Low density lipoprotein (LDL) 98 mg/dL
Triglycerides 176 mg/dL
Homocysteine 18 mmol/dL
Highly-sensitive C-reactive protein (hsCRP) 12 mg/dL
Fasting blood glucose (FBG) 99 mg/dL
Thyroid-stimulating hormone (TSH) 1.04 mU/L
Difficulty: Advanced
Setting: Outpatient office, cardiac rehabilitation, or lipid clinic
Index Words: lifestyle modification, high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides,
cholesterol, medications, advanced lipid profiles
Case Study 12 Hyperlipidemia
1 Cardiovascular
2. When you start to discuss R.M.'s laboratory values with him, he is pleased about his results.
"My cholesterol level is below 200!—and my 'bad cholesterol' is good! That's good news,
right?" What would you say to him?
He needs further information! When reviewing his HDL and triglyceride levels, there is still more
work to be done. You might explain:
"LDL particles are small, dense particles that accelerate atherogenesis by burrowing into the
endothelium to form a lipid core. LDL levels, when elevated, are positively correlated to coronary
artery disease. That is why LDL is often called the 'bad cholesterol.'
HDL, however, has a protective action, when levels are sufficient. Your HDL is too low (should be
above 45 mg/dL), which decreases your protection from plaque formation. In addition, your triglyceride
level should be below 160 mg/dL. When triglycerides are elevated, then triglycerides are deposited into
the fatty tissues. You need to work on reducing your triglyceride level and increasing your HDL levels."
3. R.M.'s physician adds niacin, a vitamin preparation (folic acid, vitamin B 6 , and vitamin B 12
[Foltyx]) daily with food, and omega-3 fatty acids to his list of medications. How do
these medications affect lipids? R.M. states, "But I already take Lipitor. What do all these
medications do?" How do you answer him?
• Atorvastatin (Lipitor) is a "statin," also known as an HMG-CoA reductase inhibitor, and works to
reduce cholesterol synthesis. It is used to reduce elevated cholesterol and triglyceride levels, and
thus aids in the prevention of cardiovascular disease.
• Folic acid, B 6 , and B 12 are B vitamins that will help stabilize arteries and prevent restenosis of
lesions that have been angioplastied or stented. In addition, they might help reduce the elevated
homocysteine level.
• Niacin will increase HDL particles and provide more protection to the arteries and also works to
reduce cholesterol, LDL, and triglyceride levels.
• Omega-3 fatty acids will help increase HDL and decrease triglycerides. They are also helpful in
preventing sudden cardiac death.
4. Discuss the significance of R.M.'s highly sensitive C-reactive protein (hsCRP) level.
The hsCRP can be an indicator of any type of inflammatory response in the body. Values should be
between 1.0 and 3.0 mg/dL. Values above 3.0 mg/dL place the patient at high risk for heart disease;
elevated levels are seen in patients with low HDL and high triglyceride levels, such as in R.M.'s lab results.
5. Discuss the significance of the homocysteine test and R.M.'s results.
Homocysteine is an amino acid that formed during the metabolism of methionine. There is
increasing evidence that seems to indicate that elevated levels of homocysteine are associated
with the progression of atherosclerosis, thus increasing the risk of heart disease.
Normal levels are between 4 and 14 mmol/L; R.M.'s result indicates an elevation.
6. What else in R.M.'s history might be contributing to his elevated homocysteine levels?
Smoking is associated with increased levels. Also, patients with a low intake of B vitamins might have
higher levels of homocysteine.
7. You are teaching R.M. about the side effects of niacin. Which effects will you include in your
teaching? (Select all that apply.)
a. Flushed skin
b. Headache
c. Gastrointestinal (GI) distress
d. Pruritus
e. Dizziness
1 Cardiovascular
Answers: A, C, D.
Niacin might cause flushing of the skin, pruritus, and GI distress.
8. You have reviewed his other medications, including atorvastatin (Lipitor). Which statement
by R.M. indicates a need for further teaching?
a. "I will take this medication at night."
b. "I will try to exercise more each week."
c. "I like to take my medicines with grapefruit juice."
d. "I will call the doctor right away if I experience muscle pain."
Answer: C
HMC-CoA reductase inhibitors, or statins, should not be taken with grapefruit juice. Taking this
medication with grapefruit juice might lead to toxic levels of the medication.
You enter R.M.'s room and hear the physician say, "There are many options for changing your LDL and
triglyceride levels. You need to continue modifying your diet and exercise to enhance your medication
regimen." The physician asks R.M. whether he has any questions, and the patient responds, "No."
9. After the physician leaves the room, R.M. tells you he really didn't understand what the
physician said. Explain the necessary lifestyle changes to R.M.
"The medications and vitamins will help change the lethal type of fat to one that is not as bad,
but you have to eat a low-fat diet and exercise to lower your risk factors. If you don't change your
lifestyle, you run the risk of your stent blocking off again, and you could have a heart attack. In
addition, you should try to stop smoking all together, and there are several options available to help
with this."
1 Cardiovascular
? Scenario
Your patient, 58-year-old K.Z., has a significant cardiac history. He has long-standing coronary artery
disease (CAD) with occasional episodes of heart failure (HF). One year ago, he had an anterior wall
myocardial infarction (MI). In addition, he has chronic anemia, hypertension, chronic renal insufficiency,
and a recently diagnosed 4-cm suprarenal abdominal aortic aneurysm. Because of his severe CAD, he had
to retire from his job as a railroad engineer about 6 months ago. This morning, he is being admitted to
your telemetry unit for a same-day cardiac catheterization. As you take his health history, you note that
his wife died a year ago (about the same time that he had his MI) and that he does not have any children.
He is a current cigarette smoker with a 50-pack-year smoking history. His vital signs (VS) are 158/94, 88,
20, and 97.2° F (36.2° C). As you talk with him, you realize that he has only minimal understanding of the
catheterization procedure.
1. Before he leaves for the catheterization laboratory, you briefly teach him the important things
he needs to know before having the procedure. List five priority topics you will address.
• The purpose of the procedure
• How he will be prepared for the procedure
• What to expect during the catheterization itself (what the cath lab will look like; sensations he may
feel during the procedure, such as a feeling of heat or a hot flash, or palpitations; that someone will
be applying pressure to the groin to prevent bleeding after the procedure)
• What routine monitoring to expect after the procedure, and that he will have to stay in bed for 4 to
6 hours after the procedure, with the procedure leg flat and possible pressure with a sandbag over
the insertion site
• What staff members will be present to support him
• Possible complications, and how they will be prevented or managed
2. Look at his past history. What other factors are present that could contribute to his risk for
cardiac ischemia?
Factors that may contribute to a higher risk for cardiac ischemia are K.Z.'s chronic anemia and his
smoking, which causes vasoconstriction and maintains a higher level of circulating carbon monoxide
in his red blood cells (RBCs).
Several hours later, K.Z. returns from his catheterization. The catheterization report shows 90% occlusion
of the proximal left anterior descending (LAD) coronary artery, 90% occlusion of the distal LAD, 70% to
80% occlusion of the distal right coronary artery (RCA), an old apical infarct, and an ejection fraction (EF)
of 37%. About an hour after the procedure was finished, you perform a brief physical assessment and
note a grade III/VI systolic ejection murmur at the cardiac apex, crackles bilaterally in the lung bases,
and trace pitting edema of his feet and ankles. Except for the soft systolic murmur, these findings were
not present before the catheterization.
Difficulty: Advanced
Setting: Hospital
Index Words: coronary artery disease (CAD), heart failure (HF), coronary artery bypass graft (CABG), cardiac
catheterization, hemodynamic monitoring, laboratory values, medications, assessment
Case Study 13 Coronary Artery Disease and Coronary Artery
Bypass Surgery
1 Cardiovascular
3. Using the following diagram, identify the superior vena cava, the aorta, and the left and right
ventricles. Identify the main coronary arteries, and circle the areas of the LAD and RCA that
have significant occlusion, as identified in the previous report. Lightly shade the area of the
heart where K.Z. had the earlier infarct.
4. What is your evaluation of the catheterization results?
He has severe occlusion of two major coronary arteries (RCA, LAD), meaning that much of
his ventricular muscle is without adequate blood supply. The old apical infarct is now tough,
noncontractile scar tissue. The coronary occlusions and scar tissue contribute to the low EF. Normally
about 55% to 70% of the blood present in the left ventricle at the end of diastole (preload) is ejected
with each cardiac contraction. An EF of 37% indicates that his left ventricle has lost almost half of its
ability to pump blood.
5. Explain the significance of having an ejection fraction of 37%.
• The ejection fraction is the percentage of blood that is ejected from the heart during systole. EF in
a normal heart is 50% to 70%. When it drops to below 40%, it indicates left ventricular heart failure
and a serious drop in cardiac output.
• It is important that students recognize that the left ventricle has lost much of its pumping ability.
This is especially important because this is the "working ventricle" that pumps blood throughout
the body. It is important to recognize and explain the signs and symptoms (S/S) of HF. Also, it is
important for K.Z. to understand that he will not have as much energy for daily activities because
his heart can't pump oxygen as efficiently.
Distal right
coronary artery
Proximal left anterior
descending coronary artery
Distal left anterior
descending coronary artery
Apical area (site of old infarct)
vena cava
1 Cardiovascular
6. What problem do the changes in assessment findings suggest to you? What led you to your
K.Z. is developing HF with valve involvement. He has crackles in bilateral bases, pitting edema in his
lower extremities, and a systolic ejection murmur (indicating valve involvement).
7. List five actions you should take as a result of your evaluation of the assessment, and state
your rationales.
• Take K.Z.'s VS and continue taking them every 15 minutes. K.Z. is experiencing some sudden
changes in his cardiovascular status that require close monitoring.
• Ask him about symptoms relevant to HF such as shortness of breath and anxiety. Subjective
reports of how the patient feels (symptoms) supplement the objective data (signs) obtained by
your assessment.
• Note K.Z.'s mental status. Is he restless, confused, or lethargic? Mental status is a good indicator of
cerebral perfusion and hypoxemia. Watch carefully for changes.
• Determine his need for supplemental oxygen. Initiate oxygen therapy if needed. The crackles
indicate the development of pulmonary edema and potential need for oxygen.
• Call the physician immediately, and report the previous findings.
After assessing K.Z., the physician admits him (with a diagnosis of CAD and HF) for CABG surgery.
Significant laboratory results drawn at this time are Hct 25.3%, Hgb 8.8 g/dL, BUN 33 mg/dL, and creatinine
3.1 mg/dL. K.Z. is given furosemide (Lasix) and 2 units of packed RBCs (PRBCs).
8. Review K.Z.'s health history. Can you identify a probable explanation for his chronic renal
insufficiency and anemia?
If the perfusion to the kidneys is poor over a prolonged period, renal insufficiency develops.
One major cause of chronic, poor perfusion to his kidneys may be renal artery vascular disease
promoted by his long-term smoking habit. In addition, poorly perfused kidneys are not able to
produce adequate amounts of erythropoietin, an important factor stimulating RBC production. This
contributes to a chronic anemic condition.
9. Why did he receive 2 units of PRBCs instead of whole blood? What was the purpose of the
K.Z. was anemic, and RBCs are necessary to carry oxygen and remove carbon dioxide. The packed
RBCs were given because the plasma has been removed from the units of blood. K.Z. is in HF and
does not need the extra fluid that would be in the units of whole blood. The furosemide is a diuretic
and is given to help K.Z. eliminate excess fluid.
Five days later, after his condition is stabilized, K.Z. is taken to surgery for a three-vessel coronary artery
bypass graft (CABG Å~ 3 V). When he arrives in the surgical intensive care unit (SICU), he has a Swan-Ganz
catheter in place for hemodynamic monitoring and is intubated. He is put on a ventilator at Fi O 2 0.70
and positive end-expiratory pressure (PEEP) at 5 cm H 2 O . His latest hemoglobin (Hgb) is 10.3 mg/dL. You
review his first hemodynamic readings and arterial blood gases.
1 Cardiovascular
10. Why are arterial blood gases necessary in the case of K.Z.? Explain why it would be
inappropriate to use pulse oximetry to assess his O2 saturation status.
Remember that K.Z. suffers from anemia, which invalidates the use of oximetry to evaluate adequate
oxygenation. Sa O2 indicates only the percentage of existing RBCs that is saturated with oxygen. It
says nothing about whether the patient has enough Hgb to meet existing demands for oxygen.
11. What is your interpretation of his arterial blood gases on 70% oxygen?
His acid-base balance is normal, but he is not oxygenating adequately. His Pa O2 and Sa O2 are both
below normal and should be much higher on 70% oxygen and PEEP. Keep in mind, too, that the
oxygen-carrying capacity of his blood is low, as evidenced by the low Hgb level.
12. What is your evaluation of K.Z.'s hemodynamic status, based on the results displayed?
• PAP is slightly high (normal 15 to 28 mm Hg PA systolic/5 to 16 mm Hg diastolic).
• CVP is slightly elevated (normal 2 to 14 mm Hg).
• PCWP is slightly high (normal 6 to 15 mm Hg).
• CI is low (normal 2.8 to 4.2 L/min/mm 2 ).
Clinically, these values show that the pressures within his heart and lungs are a little high and that
his cardiac output is a little low. Both of these findings indicate that his heart is still having difficulty
pumping out all of the blood that is returned to it and/or that he is a little fluid overloaded. His
condition will require careful monitoring.
13. K.Z. is receiving continuous IV infusions of nitroprusside (Nitropress) and dobutamine. Do
you think the hemodynamic values reported previously reflect poor left ventricular function
or fluid overload, and why?
Poor left ventricular function. If K.Z. were fluid overloaded and had adequate ventricular function,
all of the numbers would be elevated. A decrease in cardiac index and an elevation of the rest of the
values indicate poor left ventricular function.
14. Why is K.Z. receiving the nitroprusside and dobutamine?
To increase cardiac output (CO). Nitroprusside produces peripheral vasodilation. Because
more blood remains in the peripheral cardiovascular system, cardiac preload and afterload are
decreased. Dobutamine stimulates myocardial adrenergic receptors, thereby increasing CO without
significantly increasing heart rate. Dobutamine, when used with nitroprusside, has a synergistic
effect to increase CO.
■ Chart View
Hemodynamic Readings
Pulmonary artery pressure (PAP) 38/23 mm Hg
Central venous pressure (CVP) 16 mm Hg
Pulmonary capillary wedge pressure (PCWP) 18 mm Hg
Cardiac index (CI) 1.88 L/min/mm 2
Arterial Blood Gases
pH 7.37
Pa CO 2 46 mm Hg
Pa O 2 61 mm Hg
Sa O 2 85%
1 Cardiovascular
15. What is your responsibility when administering nitroprusside and dobutamine to your
• Monitor the efficacy and side effects of both drugs. The major side effects of nitroprusside are
hypotension, headache, dizziness, nausea, and abdominal pain. Also, because nitroprusside is rapidly
metabolized to cyanide and thiocyanate, patients receiving prolonged infusions of greater than
3 mcg/kg/min should be monitored for thiocyanate toxicity. Levels should not exceed 1 mmol/L.
• The desired effects of dobutamine are increased cardiac output and stroke volume and
decreased PCWP and systemic vascular resistance (SVR). The major side effects of dobutamine are
hypertension and hypotension, palpitations, dysrhythmias (particularly tachycardia and premature
ventricular contractions), nausea and vomiting, and dyspnea.
After 3 days in the SICU, K.Z.'s condition is stable, and he is returned to your telemetry floor. Now, 5 days
later, he is ready to go home, and you are preparing him for discharge.
16. List at least four general areas related to his CABG surgery in which he should receive
instruction before he goes home.
S/S of problems: What to watch for, what to do if he has them, and when to call the physician.
Medications: How to use them, why he needs them, and what possible side effects to be aware of.
Diet: Guidelines for lifestyle changes. In specific patient populations, this is considered a specialized
activity. Obtain a consult for medical nutrition therapy by a registered dietitian.
Activity: Guidelines for lifestyle changes.
Mental status: What to expect in mood swings and changes in short-term memory.
Resources: The availability in his community, particularly cardiac rehabilitation centers and smoking
cessation programs. It is critical that this man quit smoking!
Community resources: These will be particularly important for K.Z. because he is without a wife and
children for support.
1 Cardiovascular
? Scenario
The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 4:30 this morning. She
told the ED triage nurse that he had had dysentery for the past 3 days, and, last night, he had a lot of "dark red"
diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the
hospital. C.W.'s vital signs (VS) were 70/- (systolic blood pressure [BP] 70 mm Hg, diastolic BP inaudible), 110,
20, 99.1° F (37.3° C). A 16-gauge IV catheter was inserted, and a lactated Ringer's (LR) infusion was started. The
triage nurse obtained the following history from the patient and his wife. C.W. has had idiopathic dilated cardiomyopathy
for several years. The onset was insidious, but the cardiomyopathy is now severe, as evidenced
by an ejection fraction (EF) of 13% found during a recent cardiac catheterization. He experiences frequent
problems with heart failure (HF) because of the cardiomyopathy. Two years ago, he had a cardiac arrest that
was attributed to hypokalemia. He also has a long history of hypertension (HTN) and arthritis. He has also had
atrial fibrillation in the past but it has been under control recently. Fifteen years ago he had a peptic ulcer.
An endoscopy showed a 25 Å~ 15 mm duodenal ulcer with adherent clot. The ulcer was cauterized, and
C.W. was admitted to the medical intensive care unit (MICU) for treatment of his volume deficit. You are his
admitting nurse. As you are making him comfortable, Mrs. W. gives you a paper sack filled with the bottles of
medications he has been taking: enalapril (Vasotec) 5 mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin
(Lanoxin) 0.125 mg/day, PO, potassium chloride 20 mEq PO bid, and diclofenac sodium (Voltaren) 50 mg PO
tid. As you connect him to the cardiac monitor, you note that he is in sinus tachycardia. Doing a quick assessment,
you find a pale man who is sleepy but arousable and oriented. He is still dizzy, hypotensive, and tachycardic.
You hear S3 and S4 heart sounds and a grade II/VI systolic murmur. Peripheral pulses are all 2+, and trace
pedal edema is present. Lungs are clear. Bowel sounds are present, midepigastric tenderness is noted, and the
liver margin is 4 cm below the costal margin. A Swan-Ganz catheter and an arterial line are inserted.
1. What may have precipitated C.W.'s gastrointestinal (GI) bleeding?
Diclofenac: C.W. has been taking diclofenac for his arthritis. Overwhelming evidence has linked
NSAIDs to gastroduodenal ulcers and bleeding. NSAIDs irritate the gastric mucosa and decrease
the mucosa's ability to protect the stomach lining from hydrochloric acid. Elderly patients have a
higher risk for serious GI events related to NSAID therapy.
Warfarin: Warfarin inhibits the extrinsic pathway of the coagulation cascade. Although warfarin
didn't cause the bleeding, it allowed him to bleed in connection with the NSAID use.
2. From his history and assessment, identify five signs and symptoms (S/S) of GI bleeding and
loss of blood volume.
• Three-day history of diarrhea
• Dark red blood visible in the stool
• Dizziness and disorientation because of inadequate perfusion of the cerebral cortex
• Weakness because of inadequate O 2 delivery to the tissues
• Very low BP, a direct result of volume loss
• Tachycardia, in compensation for low BP
• Increased respiratory rate, in compensation for inadequate O 2 delivery to the tissues
3. What is the most serious potential complication of C.W.'s bleeding?
Hypovolemic shock that could lead to renal failure or even death
Difficulty: Advanced
Setting: Hospital emergency department, medical intensive care unit
Index Words: hypovolemia, hypertension (HTN), idiopathic dilated cardiomyopathy, peptic ulcer disease,
assessment, laboratory values, fluid balance, hyperkalemia, ECG strip
Case Study 14 Hypovolemia
1 Cardiovascular
4. What is the effect of C.W.'s blood pressure on his kidneys?
When systolic BP drops to below 70 mm Hg, glomerular filtration stops and the kidneys are not perfused.
C.W. receives a total of 4 units of packed red blood cells (PRBCs), 5 units of fresh frozen plasma (FFP), and
several liters of crystalloids to keep his mean BP above 60 mm Hg. On the second day in the MICU, his
total fluid intake is 8.498 L and output is 3.66 L for a positive fluid balance of 4.838 L. His hemodynamic
parameters after fluid resuscitation are pulmonary capillary wedge pressure (PCWP) 30 mm Hg and
cardiac output (CO) 4.5 L/min.
5. Why will you want to monitor his fluid status very carefully?
C.W. needs fluids and blood products to replace the lost blood volume, but, because of his history of
HF, it would be easy to overload him with fluids and push him into pulmonary edema.
6. List at least six things you will monitor to assess C.W.'s fluid balance.
Urinary output: With inadequate volume to perfuse the kidneys, the urinary output will drop below
30 mL/hr.
Fluid intake: Compare output and intake. Many people don't understand what qualifies as a fluid.
Fluid intake includes anything that is liquid at room temperature.
Daily weight: Fluid weight is lost or gained rapidly and is an excellent indicator of changes in fluid volume.
VS: As the intravascular volume rises in response to IV fluids, the BP can be expected to increase and
the heart rate decrease.
CO and PCWP: Both are good measures of left ventricular function and preload. The PCWP is already
high; an increase could be a first indication of fluid overload.
Mental status: This is a good indication of cerebral perfusion and Sa O 2 .
Lungs: Crackles and dyspnea are indicators of pulmonary edema.
Heart sounds: An increase in the baseline murmur and gallops could indicate fluid overload.
7. Explain the purpose of the FFP for C.W.
The purpose is replacement of intravascular fluid and reversal of the effects of warfarin to prevent
further bleeding. FFP also contains plasma proteins and clotting factors. The albumin will pull
interstitial fluid into the intravascular compartment. The clotting factors will help the bleeding.
As soon as you get a chance, you review C.W.'s admission laboratory results. These were drawn before he
received the PRBCs.
■ Chart View
Lab Work
Sodium 138 mEq/L
Potassium 6.9 mEq/L
BUN 90 mg/dL
Creatinine 2.1 mg/dL
WBC 16,000/mm 3
Hgb 8.4 g/dL
Hct 25%
PT 23.4 seconds
1 Cardiovascular
8. After examining the lab results, are there any concerns with C.W.'s electrolyte levels? Explain
your answer.
C.W.'s potassium level reflects hyperkalemia (above 5 mEq/L), which, in the presence of digoxin, may
lead to serious ventricular dysrhythmias. Keep in mind that hyperkalemia may be present in later
stages of hypovolemia, and that the fluid resuscitation will dilute the potassium.
9. In view of the previous lab results, what diagnostic test will be performed and why?
An electrocardiogram (ECG) should be performed because the patient is on digoxin and has elevated
10. Evaluate this ECG strip, and note the effect of any electrolyte imbalances.
The P waves begin to flatten and become wider as serum potassium increases; the PR interval
may be prolonged. The QRS complex begins to widen with potassium levels of 6.0 to 6.5 mEq/L.
Also, ST segments disappear. The T waves become narrow, tall, and peaked, sometimes
described as "tentlike." These T waves reach a height that is about 50% of the height of the QRS
11. Why do you think BUN and creatinine are elevated?
Inadequate renal perfusion as a result of hypovolemia. An elevated BUN may also be secondary to
hemolysis related to digestion of blood in the GI tract.
12. What do the low hemoglobin (Hgb) and hematocrit (Hct) levels indicate about the rapidity
of C.W.'s blood loss?
Because the Hgb and Hct are low, the bleeding has probably taken place over several days.
Interstitial fluid has had time to move into the vascular compartment, diluting the RBCs. In an acute
bleed, the Hgb and Hct would be normal (undiluted).
13. What is the explanation for the prolonged prothrombin time/international normalized ratio
It is caused by warfarin therapy.
14. What will be your response to the prolonged PT/INR? (Select all that apply.)
a. Prepare to administer a STAT dose of protamine sulfate.
b. Hold the warfarin.
c. Monitor C.W. for signs and symptoms of bleeding.
d. Obtain an order for aspirin if needed for pain.
e. Avoid injections as much as possible.
Answers: B, C, E
The warfarin should be held, and you should monitor for S/S of bleeding. Injections need to be avoided
as much as possible to reduce bleeding. Vitamin K, not protamine sulfate, is the antidote for management
of warfarin toxicity. Aspirin would be contraindicated for C.W. because of its antiplatelet action.
1 Cardiovascular
15. What safety precautions should be considered in light of his prolonged PT/INR?
While in the MICU, he should be protected from anything that might cause bruising or bleeding, such
as excessive venipuncture and injections. He should use a soft-bristled toothbrush and an electric
shaver, not a razor, to avoid the potential for cuts. He should ask for assistance with ambulation, in
case he is light-headed during activity, and fall prevention precautions should be initiated.
16. How do you account for the elevated white blood cell count?
Physical stress and inflammation caused by the severe bleeding and tissue hypoxia can increase the
neutrophil count.
Mrs. W. has been with her husband since he arrived at the emergency department and is worried about
his condition and his care.
17. List four things you might do to make her more comfortable while her husband is in the MICU.
• Tell her that a nurse is watching her husband closely and that his heart rhythm is being monitored
at all times.
• Explain the equipment (monitoring devices, tubes, wires, alarms) used for his care. Familiarity with
them might make them seem less intimidating.
• Explain all procedures and treatments before they are performed.
• Report her husband's condition to her regularly. This demonstrates caring if the report is unsolicited.
It also engenders trust.
• Encourage her to take care of herself while her husband is in the hospital by eating well and
getting enough rest.
• Let her know that if she goes home for brief periods, she can call the MICU at any time to inquire
about her husband.
• Encourage her to seek support from friends, family, or clergy.
• Let her know it is OK to ask questions.
1 Cardiovascular
C i ht b M b ffili t f El i I
Admission Orders
STAT blood cultures (aerobic and anaerobic) Å~ 2
STAT electrolytes & CBC
Begin parenteral nutrition (PN) at 85 mL/hr
Penicillin 2 million units IV piggyback q4h
Furosemide (Lasix) 80 mg/day PO
Amlodipine (Norvasc) 5 mg/day PO
Potassium chloride (K-Dur) 40 mEq/day PO
Metoprolol (Lopressor) 25 mg PO bid
Prochlorperazine (Compazine) 5 mg IV push prn for N/V
Transesophageal echocardiogram ASAP
Admission Assessment
Blood pressure 152/48 (supine) and 100/40 (sitting)
Pulse rate 116 beats/min
Respiratory rate 22 breaths/min
Temperature 100.2° F (37.9° C)
Oriented Å~ 3 but drowsy
Grade II/VI holosystolic murmur and a grade III/VI diastolic murmur noted on auscultation
Lungs clear bilaterally
Abdomen soft with slight left upper quadrant (LUQ) tenderness
Multiple petechiae on skin of arms, legs, and chest; and splinter hemorrhages under the fi ngernails
Hematuria noted in voided urine
? Scenario
J.F. is a 50-year-old married homemaker with a genetic autoimmune deficiency; she has suffered from
recurrent infective endocarditis. The most recent episodes were a Staphylococcus aureus infection of the
mitral valve 16 months ago and a Streptococcus viridans infection of the aortic valve 1 month ago. During this
latter hospitalization, an echocardiogram showed moderate aortic stenosis, moderate aortic insufficiency,
chronic valvular vegetations, and moderate left atrial enlargement. Two years ago, J.F. received an 18-month
course of parenteral nutrition for malnutrition caused by idiopathic, relentless nausea and vomiting (N/V).
She has also had coronary artery disease for several years and, 2 years ago, suffered an acute anterior wall
myocardial infarction (MI). In addition, she has a history of chronic joint pain.
Now, after being home for only a week, J.F. has been readmitted to your floor with endocarditis, N/V,
and renal failure. Since yesterday, she has been vomiting and retching constantly; she also has had chills,
fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that
she wears glasses and has a dental bridge. Intravenous access is obtained with a double lumen peripherally
inserted central catheter (PICC) line, and other orders are written below. Your assessment is also documented.
■ Chart View
Difficulty: Advanced
Setting: Hospital, home care
Index Words: endocarditis, coronary artery disease (CAD), home care, medications, assessment, laboratory values
Case Study 15 Endocarditis
1 Cardiovascular
1. What is the significance of the orthostatic hypotension and the tachycardia?
These phenomena might indicate hypovolemia secondary to the intractable N/V and furosemide.
2. What is the significance of the abdominal tenderness, hematuria, joint pain, and petechiae?
Embolization of vegetations from damaged heart valves, with resulting infarction of various organs,
is a common complication of endocarditis. Infarction of the spleen can manifest as abdominal
tenderness. Infarction of the kidneys causes hematuria and reduced urinary output. Petechiae result
from microembolization to small skin vessels, and arthritis from embolization to joints.
3. What are splinter hemorrhages, and what is their significance?
Splinter hemorrhages are red-brown linear streaks located under the fingernails. They are embolic
lesions and often occur with infectious endocarditis, although they also appear with trauma to the nails.
4. As you monitor J.F. throughout the day, what other signs and symptoms (S/S) of
embolization will you watch for?
• Cerebral embolization manifested by changes in level of consciousness (LOC), visual changes,
headache, transient ischemic attacks (TIAs), and stroke
• Embolization to the extremities manifested by decreased or absent arterial pulses, cool fingers and
toes with delayed capillary refill, and cyanosis
• Coronary artery embolization manifested by signs of angina, MI, heart failure (HF), or cardiac
• Embolization to the bowel manifested by abdominal pain, cramping, and N/V
5. Explain the diagnostic criteria for infectious endocarditis.
Positive blood cultures: These are the prime diagnostic test, even though definitive results might
take a few weeks to obtain if the organisms are slow-growing.
Cardiac murmurs: Turbulent blood flow through the damaged valves produces murmurs. In J.F.'s case,
the holosystolic murmur is caused by blood being forced through the stenotic aortic valve during
systole, and the diastolic murmur by backflow of blood from the aorta into the left ventricle through
the incompetent aortic valve during diastole (aortic regurgitation). The best way to evaluate these
murmurs is through cardiac echocardiography—the transesophageal echocardiogram.
Fever: Inflammatory mediators, released in response to the infectious organisms, produce fever.
The next day, you review J.F.'s laboratory test results:
■ Chart View
Laboratory Test Results
Na 138 mEq/L
K 3.9 mEq/L
Cl 103 mEq/L
BUN 85 mg/dL
Creatinine 3.9 mg/dL
Glucose 165 mg/dL
WBC 6700/mm 3
Hct 27%
Hgb 9.0 g/dL
1 Cardiovascular
6. Identify the values that are not within normal ranges, and explain the reason for each
BUN and creatinine: Elevated because of the renal failure.
Glucose: Elevated in response to the release of stress hormones, particularly catecholamines.
Remember that these were drawn upon admission, before the PN was started.
Hct and Hgb: Decreased secondary to renal failure (see previous results) and bleeding into skin and
other organs. Low Hct/Hgb are also seen with infectious endocarditis.
7. You note that a new intern writes an order for "Fasting blood glucose levels daily." Is this
order appropriate for J.F.? Explain.
• Because PN is given intravenously and continuously, the pancreas is not stimulated to produce
insulin as it is with PO nutritional intake. Therefore, glucose has to be monitored to guide the
administration of supplemental insulin.
• With 24-hour PN, fasting blood glucose levels are not appropriate; usual practice is to check blood
glucose levels at the bedside on an every 6-hour schedule. Some facilities will calculate insulin to
be given on a sliding scale basis to cover elevated blood glucose levels; some facilities will begin
insulin drips based on the patient's glucose levels.
8. What is the greatest risk for J.F. during the process of rehydration, and what would you
monitor to detect its development?
Inability to oxygenate: Increased intravascular volume combined with aortic stenosis and
regurgitation can cause severe HF. Monitor for crackles, dyspnea, cough with frothy sputum,
increased pedal edema, jugular venous distention (JVD), confusion, anxiety, increased drowsiness
and lethargy, increased intensity of murmurs, and new S3/S4 heart sounds.
As you admitted J.F., you were aware that as soon as she became stable, she would be going home in a
few days on PN and IV antibiotics. The home care agency that will be supervising her care is contacted to
coordinate discharge preparations and teaching.
9. List five important questions in assessing her home health care needs.
• Is her husband able to help care for her physical needs? Is he home during the day, or does he
work? Is he comfortable with tasks such as PN administration, pain management, and activities of
daily living assistance?
• Is her husband a good source of emotional support for her?
• Does she have any other friends or relatives living nearby who would be available for help with
physical care or emotional support?
• What additional assistance will she need from a home health care agency? Regular visits from a
registered nurse (RN) for antibiotic and PN administration and IV maintenance, pain control? Home
health aide? Housekeeper? Occupational therapist or physical therapist?
• What is the physical setup of her home? Are there stairs she might be too weak to climb? Are there
any changes that would make things easier for her, such as converting a downstairs room into a
• What is the family's financial situation? Should a social worker be brought in for consultation?
• What are J.F.'s emotional and coping needs? Should you involve a psychotherapist in her care?
• Significant others need to be taught how to measure and administer PN before she leaves the
1 Cardiovascular
Fortunately, J.F. has a supportive husband and two daughters who live nearby who can function as caregivers
when J.F. is discharged. They, along with the patient, will need teaching about endocarditis. Although
J.F. has been ill for several years, you discover that she and her family have received little education
about the disease. You prepare a teaching plan for the family. The home care agency has a parenteralenteral
nutrition team to address her nutritional needs, which will also include vitamins, minerals, and lipids.
PN formulations require complex calculations. The parenteral-enteral nutrition team takes care of the
formulation of the PN through the pharmacy or dietary staff (depending on local arrangements).
10. List three things you will teach J.F. and her family.
• Explain the disease process and the purpose of treatment procedures. Include the anatomy and
physiology of the disease.
• Teach her to read a thermometer accurately and to consult a physician for a temperature greater
than 101Åã F (38.3Åã C).
• Teach the importance of informing dentists and other health care personnel about her history of
endocarditis before having any procedures performed and to notify her dentist at the first signs of
oral infection or gum disease.
• Instruct her to carry emergency identification at all times.
11. After teaching J.F. about oral hygiene, which statement by J.F. reflects a need for further
a. "I will remove my bridge after every meal and clean it thoroughly before replacing it."
b. "I will use a water irrigation device to clean my teeth and gums."
c. "I will use a soft toothbrush to brush my teeth."
d. "I will rinse my mouth thoroughly with water after brushing my teeth."
Answer: B
Patients with endocarditis should not use oral irrigation devices or floss their teeth because this
might result in bacteremia.
Your hospital discharge planner facilitates J.F.'s transition to home care.
12. During the initial home visit, the home health nurse evaluates J.F.'s IV site for implementation
of the IV therapy program. The nurse interviews the family members to determine their
willingness to be caregivers and their level of understanding and enlists the patient's and
family's assistance to identify 10 teaching goals. What topics would be included on this list?
• Teach J.F. and family proper handwashing technique.
• Teach about actions and side effects of medications.
• Teach S/S of infection at the IV site and infiltration of the IV.
• Teach S/S of impeded or rapid flow of medication solutions.
• Teach accurate calculation of milliliter per minute and regulation of IV drip rate.
• Teach care of IV lock for intermittent antibiotic medications.
• Teach flush of IV lock with normal saline (NS) solution to ensure patency.
• Teach family to document date and time of all infusions started and completed.
• Teach J.F. and family regarding positioning of site with IV.
• Teach J.F. and family S/S of infection and phlebitis.
• Teach J.F. and family when to contact an on-call RN and/or physician.
• J.F. is on PN with a PICC. The PN will be administered using an infusion pump; teach J.F. and her
family about PN and how to use the infusion pump.
1 Cardiovascular
13. The home health nurse also writes short- and long-term goals for J.F. and her family. Identify
two short-term and three long-term goals.
Short-term goals:
• J.F. receives ordered solution and medications without complications.
• J.F. has a patent IV.
• J.F.'s family is able to support her care at home.
Long-term goals:
• Vital signs are normal (afebrile).
• Infection is resolved.
• Adequate hydration is achieved.
• Fluid and electrolyte status is within normal limits for J.F.
Mr. F. and his two daughters learned to administer J.F.'s PN during the 8-month treatment. J.F.'s endocarditis
resolves with no worsening of her cardiac condition.
1 Cardiovascular
? Scenario
You are just getting caught up with your work when you receive the following phone call: "Hi, this is Deb
in the emergency department. We're sending you M.M., a 63-year-old Hispanic woman with a past medical
history of coronary artery disease (CAD). Her daughter reports that her mom has become increasingly
weak over the past couple of weeks and has been unable to do her housework. Apparently, she has had
complaints of swelling in her ankles and feet by late afternoon ("she can't wear her shoes") and has nocturnal
diuresis Å~ 4. Her daughter brought her in because she has had heaviness in her chest off and on
over the past few days but denies any discomfort at this time. The daughter took her to see her family physician,
who immediately sent her here. Vital signs are 146/92, 96, 24, 99° F (37.2° C). She has an IV of D 5 W
at 10 mL/hr in her right forearm. Her lab results are as follows: Na 134 mEq/L, K 3.5 mEq/L, Cl 103 mEq/L,
HCO 3 23 mEq/L, BUN 13 mg/dL, creatinine 1.3 mg/dL, glucose 153 mg/dL, WBC 8300/mm 3 , Hct 33.9%,
Hgb 11.7 g/dL, platelets 162,000/mm 3 . PT/INR, PTT, and urinalysis are pending. She has had her chest x-ray
and ECG, and her orders have been written."
1. What additional information do you need from the emergency department (ED) nurse?
• What is the patient's admitting diagnosis?
• Does she speak English? Some facilities state that family members can be used only if the patient
gives permission and only if it is documented that an interpreter was offered and refused.
• Have any cardiac enzymes been drawn?
• What did her CXR show? Any changes from the last time?
• What medications does she take? Any medication allergies? Was she given any medication in the ED?
• Does she have diabetes? Keep in mind that people with diabetes sometimes experience atypical
chest discomfort, such as heaviness in the chest, instead of the "classic" substernal chest pain.
• Does she have a history of anemia or any bleeding recently? Sa O 2 ?
• What are assessment findings? (Alert and oriented Å~ 3, voiding)
2. How are you going to prepare for this patient?
• If the patient doesn't speak English and the daughter isn't coming to the unit with her, find out
what the hospital's procedures are on finding an interpreter. Many facilities have an interpreter
service and/or a resource list of employees who speak Spanish.
• Turn the bed down and place an IV pole in her room. Obtain an infusion pump.
• Make certain there is a thermometer, blood pressure cuff, and admission pack in the room.
• Have a scale in the room to get a baseline weight.
• Make certain there is a "hat" in the toilet to measure urinary output.
3. M.M. arrives by wheelchair. As she transfers to the bed, what observations will you make? Why?
• Before she gets out of the wheelchair, ask her if she can stand to transfer to the bed, and observe
her ability to communicate, general skin color, respiratory rate and pattern, and balance and
coordination (safety issues for ambulation and self-care). In addition, you will be able to assess her
general hygiene status.
Difficulty: Advanced
Setting: Emergency department, hospital, home care
Index Words: heart failure (HF), coronary artery disease (CAD), arm fracture, communication deficit, cultural
diversity, geriatric, laboratory values, therapeutic nutrition, medications
Case Study 16 Acute Coronary Syndrome
1 Cardiovascular
• Place your hands on the patient's skin to note temperature, turgor, and moisture on the skin; this
can be done while obtaining initial VS.
• Observe the following as she moves from the wheelchair to the bed: gait, strength of arms and
legs, need for assistance, balance, coordination, effort, change in color, change in respiratory
pattern as she exerts herself.
4. Given the previous information, you can anticipate orders for this patient. Carefully review
each order to determine whether it is appropriate or inappropriate as written. If the order is
appropriate, mark it as "A"; if the order is inappropriate, mark it as "I" and change the order
to make it appropriate. Provide any other orders that might be appropriate for this patient.
1. Routine VS
2. Serum magnesium (Mg) STAT
3. Up ad lib
4. 10 g sodium (Na), low-fat diet
5. Change IV to normal saline (NS) at 100 mL/hr
6. Cardiac enzymes on admission and q8h Å~ 24 hr, then daily every morning
7. CBC, chem 7, and fasting lipid profile in morning
8. Schedule for abdominal CT scan for am
9. Heparin 10,000 units subcut q8h
10. Docusate sodium (Colace) 100 mg/day PO
11. Ampicillin 250 mg IV piggyback q6h
12. Furosemide (Lasix) 200 mg IV push STAT
13. Nitroglycerin (NTG) 0.4 mg 1 SL q4h prn for chest pain
14. Schedule echocardiogram
1. I; VS should be every 4 hours.
3. I; activity should be up in chair/ambulate with assistance.
4. I; diet should be 2 g sodium (low sodium).
5. I; IV fluid should be D 5 . NS at 10 mL/hr (to keep vein open). Her sodium level is just barely under
the normal range, and NS at 100 mL/hr might lead to fluid overload.
8. I; not necessary at this time.
9. I; dose should be 5000 units bid.
11. I; no current indication for antibiotic therapy.
12. I; 200 mg is too large of a dose; a dose of 20 to 40 mg might be more appropriate.
13. I; dosage for SL NTG if chest pain is present is 1 tablet SL every 5 minutes, repeat in 5 minutes Å~ 2
if chest pain is not relieved, up to 3 tablets total. Call the staff on-call physician if no relief after
the first tablet; every 4 hours is an incorrect interval.
Missing orders:
• Obtain ECG: To note any ischemic changes or rhythm problems.
• Potassium at 3.5 mEq/L; potassium level is borderline low; should consider adding potassium to
the continuous IV solution or give oral potassium supplementation.
• Also, based on serum magnesium results, magnesium supplementation might be required.
• Nonenteric aspirin 325 mg PO should be given.
• TSH: Subclinical hypothyroidism is now recognized as a risk factor for HF.
• BNP (brain natriuretic peptide) might be ordered to check for HF.
• Oxygen therapy: Check Sao 2 and administer oxygen as needed.
1 Cardiovascular
5. Which interventions are appropriate for administering subcutaneous heparin? (Select all
that apply.)
a. Rotate injection sites with each dose.
b. Monitor aPTT levels daily.
c. Massage the area after the injection.
d. Give the injection at least 2 inches away from the umbilicus.
e. Do not aspirate the syringe before injecting the heparin.
Answers: A, D, E
Subcutaneous heparin is considered "low-dose" heparin and is not monitored by aPTT levels.
The area should not be massaged after injection; this might lead to increased bruising.
6. When you respond to M.M.'s call light, you observe she is talking rapidly in Spanish and
pointing to the bathroom. Her speech pattern indicates she is short of breath; she is having
trouble completing a sentence without taking a labored breath. You assist her to use a bedpan
and note that her skin feels clammy. While sitting on the bedpan, she vomits. On a scale
of 0 to 10 (0 being no problem, 10 being a code-level emergency), how would you rate this
situation, and why?
8 or 9: The patient's skin is clammy and she has vomited; these are signs of cardiac ischemia and
indicate that the patient needs immediate medical attention.
7. Identify at least four actions you should take next, and state your rationale.
• Pull emergency light in the room and call for help. Stay with M.M. You want additional personnel,
in case the patient's condition continues to deteriorate. Have your unit's staff call for the Rapid
Response Team.
• Remove the bedpan, if possible, take her VS, and complete a brief assessment of the heart and
lungs. You want to determine whether the patient is having dysrhythmias or has abnormal lung
• Initiate oxygen (titrate to maintain Sa O 2 over 92%), oximeter monitoring, and cardiac monitoring (if
available). Call for a STAT ECG.
• Reassure M.M. as well as possible (tone of voice and touch communicate across language barriers)
that you'll stay with her and help her. If you don't speak Spanish, ask the unit clerk to STAT page
anyone who does.
• Have someone STAT page M.M.'s physician.
• As soon as possible, have someone bring an adult aspirin and give it to M.M. Instruct her to
chew it.
• Ask the patient about symptoms. Facilitate understanding with nonverbal signs. Gather as much
relevant data as possible to determine whether the patient is manifesting a myocardial infarction
(MI), pulmonary edema, pulmonary embolus, etc.
8. M.M.'s physician calls your unit to find out what is happening. Using SBAR, what
information would you need to convey at this time?
Following SBAR ( S ituation, B ackground, A ssessment, R ecommendation), you would first identify
yourself, the patient, and her admitting diagnosis. For background, you would tell the physician that
the patient speaks Spanish only, and that she was admitted because of heaviness in her chest off and
on over the past few days and with signs of HF. Describe how she vomited once she was assisted to
the commode and that her skin was clammy; report your assessment findings, VS, and what you have
done so far. The assessment of the situation is that M.M. might be experiencing an MI, and you would
anticipate a transfer to the coronary care unit and medications to maintain cardiac and respiratory
1 Cardiovascular
9. The hospital's staff physician is coming to the floor immediately to evaluate the patient. In
the meantime she orders furosemide (Lasix) 40 mg IV push STAT. You have only 20 mg in
stock. Should you give the 20 mg now, and then give the additional 20 mg when it comes up
from the pharmacy? Explain your answer.
• Give the 20 mg furosemide to start treatment. However, you should know that response to
furosemide is dose-related; 20 mg now plus 20 mg later does not equal the same response as 40 mg
given at one time. You need to make the physician aware that you gave only 20 mg and ask how
much more the physician wants to give when it becomes available. The physician might say, "Give
another 20 later" or "Give 40 later when it gets here."
• Call the pharmacy and have furosemide brought to the floor STAT or send someone to get it.
10. M.M. continues to experience vomiting and diaphoresis that are unrelieved by medication
and comfort measures. A STAT 12-lead ECG reveals ischemic changes. The patient is
transferred to the coronary care unit (CCU). As you give the report to the receiving
registered nurse, what laboratory value is the most important to report, and why?
Potassium: The potassium level was 3.5 mEq/L before any furosemide was given, and there is no
potassium in the IV fluid; the patient is going to need some potassium supplement. The order
might read "potassium chloride 40 mEq in 100 mL D5W to infuse over 4 hours." Also indicate serum
magnesium level if the report has come back.
11. While recovering in the CCU, M.M. tried to get up out of the bed, fell, and fractured her right
humerus. Because of the surgical risks involved, M.M. was treated conservatively and put in a
full arm cast. She is again transferred to your floor. A case manager has been asked to evaluate
M.M.'s home to see whether she can be discharged to her own home or will need to stay in a
long-term care facility. Identify at least eight things that the CM would assess.
• Is there telephone service?
• How many steps are in the home or apartment? Is her bedroom and a bathroom downstairs?
• Is there a danger of tripping on throw rugs, loose carpeting, etc.?
• Are there handrails in stairways?
• How wide are the doorways?
• Where are the bathrooms? Does she have to negotiate steps to get there?
• Can the toilet seat be raised and railings applied?
• Is the lighting adequate?
• What is she going to do for meals, grocery shopping, and laundry?
• Can she get to a refrigerator? Will she be able to heat her meals?
• Will someone check on her every day? Help her with medications?
• Does she have sufficient lower body strength to ambulate independently and safely?
• Are there Spanish-speaking health care workers available to work with M.M.?
12. M.M.'s nutritional intake over the past few weeks has been poor. She also has increased
nutritional needs because of her fractured arm. What are some of the nutritional needs that
should be met? What would you recommend to help her with this?
• It is important that M.M. gets a consult with a registered dietitian (RD) to assess her additional
nutritional needs. This should be completed as soon as possible and certainly before discharge.
• She is going to need help meeting her increased caloric, protein, calcium, vitamin, and mineral
needs to promote healing. The RD can assist with suggesting supplements that can help with
intake of these nutrients yet still avoid increasing her sodium and fat intake.
• Have the family bring food from home.
1 Cardiovascular
Because the case manager determined that M.M. lived in an apartment with poor access, M.M. elects to
stay with her daughter and five grandchildren in their small home. A home care nurse comes three times
a week to check on her. M.M. is easily fatigued, and the children are quite lively. School is out for the
13. Suggest some ways the daughter can ensure that her mother isn't overwhelmed and doesn't
become exhausted in this situation.
• Even if M.M. can't have her own room, arrange for her to have a quiet corner where she can
withdraw as needed.
• Establish a "nap time" every day when she will not be disturbed.
• Keep the children occupied with a video (or something they would enjoy) to keep them quiet for
specific times each day.
• Ask the children who are able to follow directions to take turns helping their grandmother during
certain times of the day.
• Ask whether there is a responsible friend or relative with a van or large vehicle who can take M.M.
for a brief daily drive or out for a refreshment to help her get out of the house on a regular basis.
This is best followed by a nap.
1 Cardiovascular
? Scenario
You are in the middle of your shift in the coronary care unit (CCU) of a large urban medical center. Your
new admission, C.B., a 47-year-old woman, was just flown to your institution from a small rural community
more than 100 miles away. She had an acute anterior wall myocardial infarction (MI) last evening. Her
current vital signs (VS) are 100/60, 86, 14. After you make C.B. comfortable, you receive this report from
the flight nurse: "C.B. is a full-time homemaker with four children. She has had episodes of 'chest tightness'
with exertion for the past year, but this is her first known MI. She has a history of hyperlipidemia and has
smoked one pack of cigarettes daily for more than 30 years. Surgical history consists of total abdominal
hysterectomy 10 years ago after the birth of her last child. She has no other known medical problems.
Yesterday at 8 PM , she began to have severe substernal chest pain that referred into her neck and down
both arms. She rated the pain as 9 or 10 on a 0-to-10 scale. She thought it was severe indigestion and
began taking Maalox with no relief. Her husband then took her to the local emergency department (ED),
where a 12-lead ECG showed hyperacute ST elevation in the inferior leads II, III, and aVF and V5 to V6.
Before tissue plasminogen activator (TPA) could be given, she went into ventricular fibrillation (V-fib)
and was successfully defibrillated after two shocks. She then was given TPA and started on nitroglycerin
(NTG), heparin, and lidocaine drips. She also was given IV metoprolol and aspirin 325 mg to chew and
swallow. This morning, her systolic pressure dropped into the 80s, and she was placed on a dopamine
drip and urgently flown to your institution for coronary angiography and possible percutaneous coronary
angioplasty (PTCA). Currently, she has lidocaine infusing at 2 mg/min, heparin at 1200 units/hr, and
dopamine at 5 mcg/kg/min. The NTG has been stopped because of low blood pressure. Lab work that was
done yesterday showed Na 145 mEq/L, K 3.6 mEq/L, HC O 3 19 mEq/L, BUN 9 mg/dL, creatinine 0.8 mg/dL,
WBC 14,500/mm 3 , Hct 44.3%, and Hgb 14.5 g/dL."
1. Because the 12-lead ECG can tell you the location of the infarction, evaluate the leads that
showed ST elevation. What areas of C.B.'s heart have been damaged?
Leads II, III, and aVF "look at" the heart from below. ST elevation in these leads indicates inferior
wall damage. Leads V5 and V6 view the heart from the left side. ST elevation in these leads indicates
lateral wall damage.
2. Given the diagnosis of acute MI, what other lab results are you going to look at?
• CK and its isoenzymes; troponins T and I
• Cholesterol and triglyceride levels: HDL, LDL, VLDL
• Arterial blood gases
• PT/INR and PTT
• Lidocaine level
• Mg
Difficulty: Advanced
Setting: Hospital coronary care unit
Index Words: Percutaneous coronary intervention, myocardial infarction (MI), dysfunctional family, domestic
violence, ECG, patient education, assessment, medications, laboratory values
Case Study 17 Percutaneous Coronary Intervention
1 Cardiovascular
3. You review the lab work on her chart. For each laboratory value listed previously, interpret
the result, and evaluate the meaning for C.B.
• Creatine phosphokinase (CK) levels drawn on admission to the ED and at 4-hour intervals were 95
units/L, 1931 units/L, and 4175 units/L. CK-MB isoenzymes were 5%, 79%, and 216%.
• The normal CK for a female should be 30 to 135 units/L; the CK-MB isoenzymes should be 0%. CK
is released from several tissues after damage. The MB isoenzyme is specific for damaged cardiac
muscle. Because the CK level is proportional to the amount of myocardial injury, CKs give a good
indication of the severity of the MI. C.B. has had a massive MI.
• LDL: 160 mg/dL with a known coronary disease, the latest National Cholesterol Education Program
guidelines recommend a level of LDL below 100 mg/dL. C.B.'s LDL level is elevated.
• The PT/INR and aPTT are within normal limits for someone who is not receiving anticoagulant therapy.
• Hypomagnesemia can cause cardiac dysrhythmias. The usual goal is to keep serum Mg at 2 mg/dL
or greater. C.B.'s Mg level is within normal limits.
• A common normal reference level for serum potassium is 3.5 to 5 mEq/L. Hypokalemia might lead
to increased electrical instability and ventricular dysrhythmias. In light of C.B.'s history of V-fib, it is
important to monitor her potassium level and supplement as needed.
4. You note that C.B.'s Sa o 2 on oxygen ( O 2 ) at 6 L/min by nasal cannula is 92%. How do you
interpret this result?
Ideal Sa O 2 values are 95% to 100% (depending on altitude). Her oxygen saturation on 6 L/min is not
5. You are working with a nursing student, who asks you about the tissue plasminogen activator
(TPA) therapy. Which of these statements about TPA is true? (Select all that apply.)
a. TPA is a thrombolytic agent used to dissolve the clot in the coronary artery.
b. Treatment with TPA must start within 4 hours after the onset of chest pain.
c. TPA, when given properly, is able to reverse cardiac tissue infarction.
d. The use of TPA might cause internal, intercranial, and superficial bleeding.
e. Monitor the patient closely for cardiac dysrhythmias and anaphylactoid reactions while
on TPA.
■ Chart View
Laboratory Test Results
Creatine Phosphokinase (CK) Levels
On ED admission 95 units/L
4 hours 1931 units/L
8 hours 4175 units/L
CK-MB Isoenzymes
On ED admission 5%
4 hours 79%
8 hours 216%
LDL 160 mg/dL
PT 11.9 sec
aPTT (before heparin) 26.9 sec.
Mg 2.2 mg/dL
K 3.3 mEq/L
1 Cardiovascular
Answers: A, B, D, E
TPA is a thrombolytic agent used to lyse the clot in the coronary artery that is causing occlusion
leading to infarction. Treatment must be started within the first 4 hours after onset of chest pain to
prevent cardiac tissue death. The earlier that flow is restored, the more likely myocardial damage will
be minimized and infarction might be prevented. TPA cannot reverse tissue infarction. Bleeding, as
well as cardiac dysrhythmias and possible anaphylactic reactions, might occur. When administering
TPA, be certain to follow institutional protocol.
6. You are working with a nursing student. The student asks you, "If C.B. has received TPA,
then why is she also receiving heparin at this time? Isn't she in danger of bleeding to death?"
How will you respond?
TPA has a very short half life, and therefore it can open the clogged artery rapidly but the action is
short-lived. The heparin is used with the TPA to prevent reocclusion of the affected blood vessel.
Heparin, which is given parenterally, is capable of reaching adequate levels of anticoagulation faster
than oral anticoagulants. However, she will need to be monitored closely for signs and symptoms of
7. An hour after her admission, you are preparing C.B. for her coronary intervention. Evaluate
her readiness for teaching and her learning needs. What would you tell her?
• Be brief in your explanation because she is still in some pain and in unstable condition. This is not
the time to go into lengthy anatomy and physiology discussions. Her biggest problem right now
probably is fear.
• Briefly explain that this is a common procedure, and the physicians do many of these every day.
Tell her that the purpose is to restore blood flow to her narrowed (stenosed) coronary artery
by inserting a stent. She will be taken to the cardiac catheterization laboratory where the stent
insertion will be performed while she is under local anesthesia.
• Tell C.B., "During the procedure, the physician will tell you what you will feel and when." This might
help her relax by knowing she will get a heads-up.
• Briefly explain what she might experience. Tell her she might feel a warm, flushed sensation; a sudden
burning feeling; or the need to urinate as the dye is injected. She will experience chest pain for a brief
time during the insertion of the stent into the vessel. During or after the procedure, she might feel
irregular heartbeats or temporary numbness and tingling of the extremity used for the procedure.
• Reassure her that physicians and/or nurses will be with her at all times to assist her with pain
control and give support and information as she requires it.
• If you feel comfortable doing so, explore whether she would like someone to pray with her. This
can be extremely powerful in relieving fear.
The following day, you care for C.B. again. She is still on the lidocaine and heparin drips. The dopamine has
been discontinued. VS are stable. Pulmonary capillary wedge pressure (PCWP) is 14 mm Hg, and cardiac
output (CO) is 6 L/min. You check her lab results for lidocaine and aPTT levels.
8. The lidocaine level is 2.5 mg/mL, and the aPTT is 40 seconds. Analyze the results, and state
any actions you would take.
• Therapeutic lidocaine levels are between 1.5 and 5 mcg/mL; her lidocaine level is therapeutic.
Continue to follow daily levels and watch for signs of neurotoxicity (drowsiness, dizziness,
confusion, seizures, and behavioral changes). Evaluate the antidysrhythmic effectiveness of
lidocaine; also evaluate C.B. for S/S of lidocaine toxicity.
• The aPTT is monitored to assess effectiveness of heparin in inhibiting the intrinsic clotting pathway
in the clotting cascade. An aPTT of 40 seconds is below therapeutic level. Follow your institution's
guidelines to adjust the heparin. Check follow-up lab results per institutional protocol.
1 Cardiovascular
As you work with C.B., you notice that she is extremely anxious. You had observed some anxiety yesterday,
which you had attributed to the strange CCU environment, pain, and anticipation of the stenting
procedure. You know that the stent was successful and that she is physically stable. You wonder what
is wrong. She tells you that her MI occurred right in the middle of a move with her family from her rural
community to an even smaller and unfamiliar town some 500 miles away in a neighboring state. She
is dreading the move. Her husband "becomes angry easily and starts lashing out" toward her and the
children. She is afraid to move to a community where she will have no friends and family to support her.
9. How can you help your patient? Evaluate the situation and describe possible interventions.
The reasons for C.B.'s anxiety are much more complicated than you had thought. You need to decide
whether you have the experience and background to help her or whether you should involve
another member of the interdisciplinary team. Possible actions:
• Support the patient with your presence and active listening. Assure her that she is doing well
• If spousal abuse is involved or suspected, a social worker or psychiatric nurse specialist who
specializes in abuse would be an important resource.
• If child abuse is involved, you have an absolute ethical and, in most states, legal obligation
to report the abuse to the authorities. C.B. should be given the number of a "safe house" or a
community resource.
• It may be wise to obtain a medical order for a consult about domestic violence.
• If her children are being abused, she should understand this might involve child protective
10. C.B.'s husband comes to visit. He is a handsome, well-dressed man who appears to be loving
and attentive toward C.B. He brought a bouquet of roses for her and a box of chocolates for
the nurses, "because I appreciate how good you girls have been to my wife." One of your
younger colleagues comments to you, "Why, what a nice guy! What is her problem? Every
woman would love to be married to a man like that!" How are you going to respond?
• "You have very little information on which to base your judgment."
• "She has expressed fear for herself and the children."
• "Abusive spouses are often very charming and personable outside the home. This often
contributes to the reluctance of abused wives and children to tell anyone because, 'No one
would ever believe me.'"
• "You should never allow your professional judgment to be clouded by gifts or impressive
1 Cardiovascular