Collecting data is a crucial aspect of providing care. Healthcare workers who acquire complete, accurate, and timely data are more likely to provide better care to patients and thereby achieve more favorable outcomes (Toney-Butler and Unison-Pace, 2018). In other words, comprehensive data collection enables a healthcare worker to see the bigger picture and address concerns that may be overlooked due to incomplete information. Learning how to gather data is a skill, which means that it takes practice. Clinical practice, on the other hand, serves as a training ground for developing this skill. In this nursing paper, comprehensive information on a patient diagnosed with cardiac disease is provided. Data include background information, patient history, vital signs, laboratory and diagnostic procedures, and medications.
The patient, Joe, is a 57-year old white male admitted for chest pain. Initial assessment indicated angina pectoris due to coronary heart disease.
Angina pectoris, also known as stable angina, is defined as chest pain caused by coronary heart disease. According to the American Heart Association [AHA] (2005), angina happens when the cardiac muscle does not receive the amount of blood it requires. This in turn is the result of narrowing or blockage in one or more of the coronary arteries, a process known as ischemia. Angina usually presents as a squeezing or heavy pain in the chest that may radiate to outlying areas such as the back, shoulders, arms, neck, and jaws. Note that the amount of blood the cardiac muscle requires varies depending on the situation. A person at rest may still receive enough blood despite narrowing or blockage in the coronary arteries. However, demand increases due to a variety of factors including physical activity. Thus, an increase in demand results in pain due to the failure of the coronary arteries to let enough blood pass through. Some of angina’s triggers include physical activity, extreme temperature, smoking, heavy meals, and emotional stress. Angina pectoris is usually relieved by rest or medications, but this condition may progress to unstable angina, which is characterized by increased frequency and duration of episodes (AHA, 2015).
Coronary heart disease or CHD is one of the most common types of heart disease and is characterized by the failure of coronary arteries to deliver enough blood to the cardiac muscle. CHD usually results from the narrowing or blockage of coronary arteries due to the presence of plaque, a waxy substance that accumulates inside the lining of these blood vessels (National Heart, Lung, and Blood Institute [NHLBI], n.d.). Plaque is usually caused by deposits of cholesterol among other substances. Over time, this buildup may cause partial or complete blockage. Multiple risk factors are also associated with CHD including obesity, poor diet, lack of physical activity, smoking, and family history of heart disease (Centers for Disease Control and Prevention [CDC], 2021). Coronary heart disease does not always present symptoms and in many cases is left undetected until a person suffers from a heart attack or cardiac arrest. Treatment for CHD involves a comprehensive approach that includes medications, cardiac rehabilitation, and lifestyle modification among others (CDC, 2021).
The patient, named Joe, came into the emergency department complaining of chest pains. He was accompanied by his wife, Lyn. According to Joe, he was carrying grocery bags to their car from the supermarket when he suddenly felt pain in his chest. He described the pain as tightness that extended to his shoulders and the base of his neck. Joe stands six feet tall (6’0) and weighs around 230 pounds. He denied pain extending beyond his shoulders to his arms. He also stated that it had been around 10 minutes since the pain started. He denied shortness of breath. Initial vital signs yielded a blood pressure reading of 155/85 mmHg. Lyn confirmed that previous readings at home were always above 140 mmHg. Joe is currently not taking any medication for his heart or blood pressure.
Chest pain is a common symptom associated with a wide range of health conditions, many of which are non-life threatening. Chest pain can be musculoskeletal in origin (Hoorweg et al., 2017). It may also be due to gastric hyperacidity and gastroesophageal reflux disorder or GERD. This condition is known as heartburn. In this case, pain is caused by the relaxation of the esophageal sphincter, thus causing the reflux of stomach acid to flow back (Yamasaki and Fass, 2017). A small percentage of chest pain, however, may be due to more serious and potentially life-threatening conditions. A study by Hoorweg et al. (2017) showed that around 8.4% of chest pain is due to conditions such as heart attack and angina. As noted, angina is the pain caused by inadequate blood flow to the cardiac muscle. Heart attack, on the other hand, is the result of complete cessation of blood flow to the heart, thus causing tissue death. Angina is widely considered as a warning sign of a possible heart attack in the future (Hoorweg et al., 2017).
The World Health Organization [WHO] (2021) defines overweight and obesity as “abnormal or excessive fat accumulation that presents a risk to health”. By common medical standards, a body mass index or BMI of 25-29.9 is overweight, while a BMI of 30 and above is obese. Obesity is a risk factor for numerous chronic diseases. It has been identified as a factor that increases risk for heart disease, diabetes, hypertension, certain types of cancer, and metabolic syndrome. Metabolic syndrome is characterized by the clustering of three to five factors: high blood glucose, low levels of high-density lipoprotein or HDL, hypertension, abdominal obesity, and high serum triglyceride. Overall, obesity has been associated with a significant decrease in a person’s life expectancy (Engin, 2017). Over the past few decades, there has been a marked increase in the rates of obesity among younger age groups, with around 20% of children aged 6-19 years overweight or obese. One factor is extensive consumption of fast food. Multiple studies have shown negative impacts of fast food on children’s health (Anderson et al., 2019). Obesity is often approached holistically and depending on individual factors may include medications, diet and lifestyle modifications, and in extreme cases surgery (Engin, 2017).
Joe also has a history of smoking (5 pack years), though he claims to have quit three years ago after learning more about the health effects of smoking. Family history shows that his mother and father both had hypertension. His father passed away due to heart attack at the age of 75 while his mother died from complications of diabetes at the age of 78. Given the findings, it is likely that Joe is at risk for or already has some of the conditions associated with angina pectoris and CHD, thus requiring further evaluation.
The following are the physical orders:
- Vital signs every 4 hours.
- Oxygen via nasal cannula PRN.
- Activity as tolerated.
- ECG, chest x-ray, CBC, hemoglobin A1c, lipid profile, AST and ALT, creatinine, urine analysis, and troponin test.
- Start nitroglycerin sublingual tablet 0.4 mg thrice a day or as needed. No more than 3 tablets in a 15-minute period.
- Start metoprolol tablet 50 mg twice a day.
- Discharge to home with following medications: atorvastatin tablet 20 mg once a day, metoprolol tablet 50 mg twice a day, and nitroglycerin sublingual tablet 0.4 mg thrice a day or as needed; metformin 500 mg once a day taken with evening meal. For follow-up checkup in two weeks.
The following laboratory procedures were performed:
- Complete blood count (CBC): CBC was performed to acquire supplementary information that can help a more comprehensive coronary heart disease profile.
- Hemoglobin A1c: Also known as glycated hemoglobin test, HA1c was performed to determine the amount of glucose attached to hemoglobin. This test was ordered in order to look into the patient’s glycemic control given his family history of diabetes.
- Lipid profile: Lipid profile measures cholesterol levels in the blood. Cholesterol such as high-density lipoprotein, low-density lipoprotein, and triglycerides influences risk of health conditions like CHD, heart attack, and stroke. This test was likely ordered on account of the patient’s obesity.
- AST and ALT: Also known as SGOT and SGPT, respectively, these tests assess liver function and determine the presence of injury. This test was likely ordered given the patient’s family history of hypertension and obesity, both of which are associated with damage to the liver.
- Creatinine: This test evaluates the health and functioning of the kidneys. This test was likely ordered given the patient’s family history of hypertension. Hypertension is associated with damage to the kidneys.
- Urine analysis: Also known as urinalysis, this test has a wide range of applications and is associated with conditions such as ongoing infection, diabetes, and damage to the kidneys.
- Troponin test: This test measures the level of Troponin T or Troponin I in the blood. Troponins are released when the cardiac muscle sustains damage, such as in the case of a heart attack. The test was ordered to rule out heart attack.
Abnormal Laboratory Values
Most of the laboratory procedures performed came out normal. However, some of them showed abnormal levels:
- Lipid profile: The patient’s total cholesterol (255 mg/dL) was beyond normal range (<200 mg/dL). Low-density lipoprotein or LDL level (195 mg/dL), in particular, was elevated (<100 mg/dL). This indicates that the patient has an excess of bad cholesterol in the blood, which could contribute to plaque buildup in the arteries.
- Hemoglobin A1c: HA1c results (6%) came was beyond normal range (4%-5.6%). This result suggests that the average blood sugar level was at around 126 mg/dL, which qualifies as prediabetes.
Apart from laboratory procedures, three diagnostic procedures were performed, namely ECG, chest x-ray, and coronary CT scan. The following were the results of the procedures:
- Electrocardiography (ECG): Results came out unremarkable. No ST-T changes were noted, which reinforces initial diagnosis of stable coronary artery disease (Bourque and Beller, 2015). However, the ECG was conducted while the patient was at rest, and thus it did not show if there would be ischemic ST-T changes. Exercise stress testing may be pursued in the near future to determine ischemia.
- Chest x-ray: Chest x-ray was unremarkable and no changes were noted in the size of the heart. Both lungs were clear.
The following medications prescribed to the patient:
- Atorvastatin (Lipitor) 20 mg daily. Atorvastatin is an HMG-CoA reductase inhibitor (statin). It works by slowing down cholesterol production in the body, thus reducing the amount of serum cholesterol that may accumulate along the lining of blood vessels. It is used to treat conditions such as hypercholesterolemia, dyslipidemia, and coronary heart disease. It is also associated with decreased risk for heart attack, stroke, and angina. Usual dose ranges from 10 mg to 80 mg daily, with common initial dose at 40 mg. Some side effects include diarrhea, heartburn, joint pain, bloating, confusion, memory loss, nausea, loss of appetite, chest pain, tiredness or weakness, itching, and stomach pain (MedlinePlus, 2021a).
- Metformin (Glucophage) 500 mg daily. Metformin falls under a type of medications called biguanides. It works by reducing the amount of glucose the body absorbs as well as by reducing the amount of glucose the liver produces. It also improves sensitivity to insulin in order to improve glucose regulation. Metformin is indicated for people diagnosed with prediabetes and type 2 diabetes. It is also prescribed to women diagnosed with polycystic ovary syndrome (PCOS). The usual dose for oral metformin in tablet form is 500 mg to 1000 mg daily, although dosage can be decreased in frequency if administered with other medications such as insulin. Some side effects include stomach pain, bloating, diarrhea, indigestion, constipation, heartburn, headache, change in taste, and muscle pain (MedlinePlus, 2021b).
- Metoprolol (Lopressor) 50 mg twice a day. Metoprolol is a medication that falls under beta blockers. It works by slowing the heart rate and promoting relaxation of blood vessels, which in turn improve circulation and lower blood pressure. Metoprolol is used to treat hypertension and arrhythmia and is also used to lower the risk of heart attack, stroke, angina, and heart disease. Usual dose is at 50 mg to 100 mg once or twice a day. Some of the common side effects include dizziness or lightheadedness, fatigue, nausea, vomiting, constipation, heartburn, bloating, and dryness of the mouth (MedlinePlus, 2021c).
- Nitroglycerin sublingual (Nitrostat) 0.4mg thrice a day or as needed. Nitroglycerin is a vasodilator. It works by relaxing blood vessels, thereby improving circulation of blood. This medication is indicated for patients who experience angina pectoris. The medication is administered by placing it under the tongue. Usual dose ranges from 0.3 mg to 0.6 mg. It is usually given at the first sign of angina or before performing activities that trigger angina. In cases of active angina, the patient may be given up to three tablets with 5-minute intervals between each tablet. Some side effects include experiencing flushing or warm sensation, dizziness or lightheadedness, and sweating, and tingling in the extremities (MedlinePlus, 2021d).
The patient was advised to comply with the medication regimen provided for the treatment of angina pectoris, hypertension, high glucose level, and high cholesterol level. Coronary CT scan is being considered. The patient was informed that treatment will eventually include lifestyle modification including implementing a diet plan and an exercise routine. Referrals were made to a diabetologist and a dietitian, who would provide insight into how to plan meals for diabetics. The patient was also advised to return after two weeks for further evaluation.
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