What is the most appropriate initial nursing intervention for a patient presenting with stable angina?

B) Encourage the patient to rest

C) Initiate cardiopulmonary resuscitation

D) Administer intravenous nitroglycerin

A patient presents with chest pain that is rated as 3 on a scale of 10, which occurs during periods of high stress and resolves with rest. Based on the initial assessment findings, what is the most likely diagnosis?

D) Gastroesophageal reflux disease (GERD)

What is the primary purpose of starting the patient on a beta-blocker as part of her treatment plan for coronary artery disease?

B) To decrease cardiac workload

What is the primary purpose of prescribing a beta-blocker for a patient with mild reversible ischemia?

B) To decrease heart rate and reduce cardiac workload

A) To reduce cholesterol levels

B) To decrease heart rate and reduce cardiac workload

C) To increase oxygen supply to the heart

D) To alleviate gastrointestinal symptoms

A patient reports occasional dizziness when standing up quickly and is advised to increase fluid intake. Which nursing intervention is most appropriate to help prevent orthostatic hypotension for this patient?

C) Advise the patient to rise slowly from a seated or lying position

A) Encourage the patient to take deep breaths before standing

B) Recommend the patient to cross and uncross legs rapidly when standing

C) Advise the patient to rise slowly from a seated or lying position

D) Suggest the patient to perform vigorous exercises immediately after standing

Which lifestyle modification has the patient implemented to help reduce dizziness upon standing?

D) Engaging in high-intensity exercise

Which dietary recommendation would be most appropriate for a patient experiencing occasional heartburn and aiming to manage slightly elevated cholesterol levels?

B) Include more omega-3 rich foods like salmon

A) Increase intake of spicy foods

B) Include more omega-3 rich foods like salmon

C) Consume more high-fat dairy products

D) Add more processed foods to the diet

chest pain - Nursing Case Study

Pathophysiology

• Primary mechanism: Reduced blood flow to the heart muscle, known as myocardial ischemia, often due to atherosclerosis, causes chest pain by depriving the heart of oxygen and nutrients.

• Secondary mechanism: Inflammation or irritation of the chest wall or pleura, such as in costochondritis or pleuritis, can lead to pain due to swelling and pressure on nearby nerves.

• Key complication: If ischemia persists, it can lead to myocardial infarction (heart attack), causing tissue damage and severe complications if not promptly treated.

Patient Profile

Demographics:

45-year-old female, office administrator

History:

• Key past medical history: Mild hypertension, occasional acid reflux

• Current medications: Lisinopril 10 mg daily, Omeprazole 20 mg as needed

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Mild chest pain

• Key symptoms: Dull, intermittent chest pain lasting a few minutes, no radiation, no shortness of breath, no diaphoresis

• Vital signs: Blood pressure 130/85 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F, oxygen saturation 98% on room air

Section 1

Initial assessment findings revealed that the patient appeared slightly anxious but was otherwise in no acute distress. Upon further questioning, she described the chest pain as a 3 on a scale of 10, noting it typically occurs during periods of high stress at work and subsides with rest. Physical examination showed no signs of respiratory distress, and lung auscultation was clear bilaterally. Cardiac auscultation revealed regular rhythm without murmurs, rubs, or gallops. The patient's skin was warm and dry, and peripheral pulses were palpable and symmetric.

An electrocardiogram (ECG) was performed, showing no acute ST segment changes but displaying nonspecific T-wave inversions in the lateral leads, suggesting potential ischemic changes. Laboratory tests were ordered, including cardiac enzymes, which returned within normal limits, indicating no acute myocardial injury. A chest X-ray ruled out any acute pulmonary conditions, and a stress test was scheduled for further evaluation of the patient's cardiac function and to assess for any exercise-induced ischemia.

Given these findings, the primary concern remains stable angina, with secondary consideration for gastrointestinal or musculoskeletal causes. The patient was educated on the importance of managing stress, adhering to her antihypertensive regimen, and recognizing signs of worsening chest pain that would necessitate immediate medical attention. These steps aim to prevent progression to more severe complications, such as myocardial infarction, and to improve overall cardiovascular health.

Section 2

Two weeks after the initial assessment, the patient returns for a follow-up visit. She reports that she has been diligently managing her stress by incorporating daily relaxation exercises, which have helped reduce the frequency of her chest pain episodes. However, she mentions experiencing mild discomfort in her chest while lifting heavy objects at work, rating the pain as a 4 on a scale of 10. She denies any shortness of breath, nausea, or radiating pain. Her vital signs are stable: blood pressure is 128/78 mmHg, heart rate is 72 beats per minute, respiratory rate is 16 breaths per minute, and oxygen saturation is 98% on room air.

The results from her previously scheduled stress test show mild reversible ischemia, suggesting that the chest pain might be linked to coronary artery disease. In response to these findings, the cardiologist recommends starting the patient on a low-dose aspirin and a beta-blocker to further manage her symptoms and reduce cardiac workload. The patient is also advised to avoid strenuous activities that could trigger the pain and to continue monitoring her symptoms closely.

As part of her ongoing care plan, the patient is educated on the importance of lifestyle modifications, including maintaining a heart-healthy diet and engaging in regular, moderate-intensity exercise. She is encouraged to follow up regularly with her healthcare provider to reassess her symptoms and treatment efficacy. This comprehensive approach aims to stabilize her condition and prevent any potential complications, such as progression to unstable angina or myocardial infarction.

Section 3

Two months later, the patient returns for another follow-up visit. She reports a noticeable improvement in her chest pain since starting the low-dose aspirin and beta-blocker therapy. The pain is now less frequent and has decreased in intensity to a 2 on a scale of 10. She continues to practice her relaxation exercises diligently and has started incorporating light walking into her daily routine, which she finds enjoyable and beneficial. Her vital signs remain stable: blood pressure is 122/76 mmHg, heart rate is 68 beats per minute, respiratory rate is 16 breaths per minute, and oxygen saturation is 98% on room air.

However, the patient mentions a new symptom: occasional dizziness when standing up quickly. This prompts a review of her medication regimen and lifestyle changes to assess potential causes. Upon further discussion, it is discovered that she sometimes forgets to hydrate adequately, especially during her walks. Her blood work, including electrolytes and renal function tests, returns within normal limits, ruling out any significant electrolyte imbalance or renal issues.

The healthcare team advises her to increase her fluid intake and rise slowly from seated or lying positions to prevent orthostatic hypotension. They reassure her that these symptoms are often manageable and encourage her to continue her current treatment plan while monitoring for any changes. The team schedules another follow-up appointment in one month to reassess her symptoms and ensure continued progress. This ongoing monitoring and adjustment of her care plan aim to maintain her stability and prevent any further complications.

Section 4

Response to Interventions:

At her follow-up appointment one month later, the patient reports a further reduction in chest pain episodes, now occurring only sporadically and rated as a 1 on a scale of 10. She expresses confidence in managing her symptoms and notes that the dizziness she experienced when standing has substantially decreased since she began consciously increasing her fluid intake and taking care to rise slowly. Her commitment to her daily walking routine and relaxation exercises remains steadfast, and she feels these activities have positively impacted her overall well-being.

Her vital signs continue to show stability, with a blood pressure of 120/74 mmHg, heart rate of 66 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% on room air. The healthcare team reviews her medication regimen, ensuring she maintains adherence to the low-dose aspirin and beta-blocker therapy, which appear to be effective in managing her condition. The team is pleased with her progress and encourages her to maintain her current lifestyle modifications, emphasizing the importance of consistent hydration and gradual position changes.

Given her positive response to the interventions and stable condition, the healthcare team schedules the next follow-up appointment in two months, extending the interval due to her improved status. They advise her to remain vigilant for any new symptoms and to reach out promptly should concerns arise. This ongoing support aims to empower her in self-management while continuing to monitor her health trajectory closely.

Section 5

Two weeks after her follow-up appointment, the patient contacts the clinic reporting a mild increase in chest discomfort. She describes the sensation as a pressure-like feeling that occurs intermittently, particularly after meals or when she is stressed, though it remains mild and rates it as a 2 on a scale of 10. She denies any associated shortness of breath or radiation of pain. Notably, she mentions experiencing occasional heartburn, which she has not had before. The nurse, during the phone consultation, reviews her current medications and lifestyle, reaffirming the importance of adherence to her current regimen and suggests dietary adjustments to reduce potential triggers like spicy or fatty foods.

Given this new development, the healthcare team advises her to come in for a non-urgent assessment to ensure no significant changes in her condition. At the clinic, her vital signs remain stable with blood pressure at 118/72 mmHg, heart rate at 64 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation at 98% on room air. An ECG is conducted, showing no new ischemic changes. The team decides to perform a basic metabolic panel and a lipid profile to evaluate her current status further. Her lab results reveal slightly elevated total cholesterol at 210 mg/dL and low-density lipoprotein (LDL) cholesterol at 130 mg/dL, which, although mildly elevated, does not warrant immediate pharmacological intervention.

The healthcare team discusses the importance of dietary modifications to manage her cholesterol levels and suggests incorporating foods rich in omega-3 fatty acids and soluble fiber. They also provide educational materials on managing stress effectively, given its role in her symptomatology. Reassured by the absence of significant findings, the patient feels confident in continuing her current health practices, with the added dietary focus, and is scheduled for her next follow-up in six weeks. This approach aims to not only address the current symptoms but also to empower the patient in her ongoing journey towards optimal cardiovascular health.