angina - Nursing Case Study

Pathophysiology

• Primary mechanism: Reduced blood supply - Angina occurs when the heart muscles don't receive enough oxygen-rich blood. This is often due to narrowed or blocked coronary arteries (atherosclerosis), which restrict blood flow to the heart.

• Secondary mechanism: Increased demand - Physical exertion, emotional stress, or other conditions that increase the heart's demand for oxygen can trigger angina. The heart needs more oxygen than the compromised arteries can deliver, leading to chest pain or discomfort.

• Key complication: Heart attack - If the blood flow to a part of the heart is completely blocked, it can cause a heart attack. Angina symptoms that change suddenly or worsen may indicate a heart attack, requiring immediate medical attention.

Patient Profile

Demographics:

58 year old male, office worker

History:

• No significant past medical history

• No current medications

• No known allergies

Current Presentation:

• Chief complaint: Chest discomfort during physical exertion

• Key symptoms: Mild chest pain, shortness of breath with mild exertion, fatigue

• Vital signs: Blood pressure 120/80mmHg, Pulse 72 bpm, Respiratory rate 16 breaths per minute, Temperature 98.6 F, Oxygen saturation 98% on room air.

Section 1

Initial Assessment Findings:

Upon physical examination, the patient appeared well-groomed but slightly anxious. His skin was warm and dry, with no noticeable changes in color or texture. The cardiovascular examination revealed no irregular heart rhythms or murmurs. His jugular venous pressure was within normal limits. The respiratory exam was unremarkable with clear lung fields bilaterally. He denied any change in bowel or bladder habits. There was no peripheral edema noted in the extremities. The patient's body mass index was 28, indicating overweight status.

Routine blood tests were ordered including a complete blood count, metabolic panel, lipid profile, and troponin levels. An electrocardiogram (ECG) was also done which showed normal sinus rhythm with no signs of ischemia or infarction. Despite the normal findings, his symptoms of chest discomfort during exertion, mild chest pain, and shortness of breath were concerning for angina. The patient was advised to avoid strenuous activity and was scheduled for a stress test to further evaluate his symptoms.

This initial assessment finding indicates a need for ongoing monitoring and further diagnostic testing to rule out angina and potential future heart complications. The nurse would need to educate the patient on the importance of lifestyle modifications such as weight management, regular exercises, and dietary changes to control the potential risk of atherosclerosis. The patient's mild anxiety may also need to be addressed, possibly by providing reassurance and education about his condition.

Section 2

Response to Interventions:

The patient was seen again one week later for a follow-up appointment. He had taken the nurse's advice to heart and had made some lifestyle changes. He reported that he had been walking every day, had started a low-sodium diet, and had been trying to lose weight. His body mass index had dropped slightly to 27.5.

Despite these positive changes, he still reported experiencing mild chest pain and shortness of breath during exertion. His blood pressure was slightly elevated at 140/90 mmHg, up from 130/85 mmHg at the previous visit. This could be due to the patient's anxiety or an indication of the worsening of his condition. The nurse decided to continue with the planned stress test and encouraged the patient to continue his lifestyle changes. The nurse also discussed the possibility of starting medication to manage his symptoms and prevent potential complications. This provided an opportunity for the nurse to demonstrate clinical reasoning by linking the patient's symptoms, vital signs, and lifestyle changes to his potential diagnosis and treatment plan.

Section 3

New Diagnostic Results:

The nurse carried out the stress test, which involved the patient exercising on a treadmill while his heart rate, blood pressure, and EKG were monitored. The test results showed that the patient's heart rate increased more than expected during exercise, and there was evidence of slight ST-segment depression on his EKG. These findings suggested that the patient's heart might not be getting enough oxygen during exertion, which is a common sign of angina.

The nurse also ordered a complete blood count (CBC) and lipid profile to assess the patient's overall health and risk factors for heart disease. The results showed slightly elevated cholesterol levels with LDL at 145 mg/dL, HDL at 35 mg/dL, and triglycerides at 200 mg/dL. His CBC was within normal range. These results provided further evidence that the patient might be experiencing stable angina and that further interventions were necessary. This new information will guide the nurse in educating the patient about his condition and proposing a more comprehensive treatment plan.

Section 4

Change in Patient Status:

Over the following week, the patient reported experiencing chest discomfort during his daily walks. He described the feeling as a dull ache in his chest that usually came on towards the end of his walks and would resolve with rest. His blood pressure readings at home had been slightly elevated, averaging 140/90 mmHg over the past few days. He also mentioned that he had been feeling more fatigued than usual, even when not exercising.

These changes in the patient's status suggested that his angina was gradually worsening. The increase in his blood pressure could be a response to the reduced oxygen supply to the heart, as the body tries to compensate by increasing the pressure to push more blood through the narrowed arteries. The fatigue could be a result of the heart working harder to pump blood, leading to overall exhaustion. This highlights the need for closer monitoring and adjustment of the patient's treatment plan to manage his symptoms more effectively. The nurse will need to educate the patient on the importance of monitoring his symptoms and reporting any changes promptly.

Section 5

Change in Patient Status:

Over the next few days, the patient reported that his chest discomfort was now occurring even during light activities such as climbing stairs. He also reported a new symptom - shortness of breath during his daily walks. His home blood pressure readings remained elevated, averaging 145/95 mmHg. The patient also reported difficulty sleeping at night due to a feeling of restlessness and anxiety.

These new developments indicate that the patient's angina is becoming less stable and is progressing. The addition of shortness of breath could indicate that the heart is not getting enough oxygen to meet the increased demands during physical activity. The restlessness and anxiety experienced at night could be due to an increase in catecholamines, which are stress hormones released by the body in response to the heart's reduced ability to pump blood effectively. This further emphasizes the need for timely intervention and reevaluation of the patient's treatment plan. The nurse should explain these changes to the patient and encourage him to continue monitoring his symptoms and blood pressure at home. It's crucial that the patient understands the serious implications of his worsening symptoms.