G.P. is a 60-year-old retired businessman who is married and has 3 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 3-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 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 and 50% stenosis of the left anterior descending coronary artery. He tells you that both his mother and his father had coronary artery disease (CAD). He is currently taking amlodipine (Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day. He is retired and says that he spends his days watching television, with some occasional yard work. He has gained 25 lb (11.3 kg) since retiring and admits that he is overweight.
- What other information are you going to obtain about his episodes of chest pain?
- What are common sites for radiation of ischemic cardiac pain?
- There are several risk factors for coronary artery disease. For each risk factor listed, mark whether it is “M” modifiable or “N” nonmodifiable.
___ Age ___ Stress ___ Gender ___ Obesity ___ Smoking ___ Hypertension
___ Hyperlipidemia ___ Diabetes mellitus ___ Physical inactivity ___ Ethnic background
___ Excessive alcohol use ___ Family history of CAD
- Based on the history you have so far, which are the modifiable and nonmodifiable risk factors that apply to G.P.
- 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.
- Call 911 immediately.
- Stop the activity and lie or sit down.
- Chew the tablet slowly then swallow.
- Place the NTG tablet under the tongue.
- Call 911 if the pain is not relieved after taking 1 SL tablet.
- Call 911 if the pain is not relieved after taking 3 SL tablets, 5 minutes apart
- You review the use and storage of SL NTG with G.P. Which statement by G.P. indicates a need for further education? Explain your answer.
- “I carry the tablets with me at all times.”
- “I will keep the pills in their original brown bottle.”
- “I will not store other pills in the nitroglycerin bottle.”
- “I will discard any open bottle of nitroglycerin after a year.”
CASE STUDY PROGRESS
When you first admit G.P., you place him on telemetry and observe his cardiac rhythm.
- Identify the rhythm:
- Explain the primary complication that could occur if this heart rhythm were not treated.
- Review G.P.’s history. What conditions may have contributed to the development of this dysrhythmia?
- You review G.P.’s lab test results and note that all of them are within normal range, including troponin and creatinine phosphokinase levels. His potassium level is 4.7 mEq/L (4.7 mmol/L). Given this and his current dysrhythmia, what is the likely cause of the symptoms he has been experiencing this past week?
CASE STUDY PROGRESS
Within the hour, G.P. converts with intravenous diltiazem (Cardizem) to sick sinus syndrome with long sinus pauses that cause lightheadedness and hypotension.
- What risks does the new rhythm pose for G.P.? Explain the reasons for your answers.
CASE STUDY PROGRESS
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.
- What does the code DDDR mean?
- What is the purpose of DDDR pacing?
- The pacemaker insertion surgery places G.P. at risk for several serious complications. List three potential problems you would monitor for as you care for him.
The pacemaker insertion surgery places G.P. at risk for several serious complications. List three potential problems you would monitor for as you care for him.
- G.P. will need some education regarding his new pacemaker. What information will you give him before he leaves the hospital?
- G.P. and his wife tell you they have heard that people with pacemakers can have their hearts stop because of microwave ovens and cell phones. Where can you help them find more information?
CASE STUDY PROGRESS
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 results of the exercise test.
- What information will be obtained from a graded exercise (stress) test?
- What is included in an exercise prescription?
CASE STUDY OUTCOME
G.P. returns in 1 month for a pacemaker check. He reports that he and his wife go for a walk at least 3 times a week at the mall, and he is hoping to start volunteering soon. He has lost 8 pounds (3.6 kg).
