Chest Pain Evaluation - Essay Example

?Case Study CHEST PAIN CASE STUDY of CHEST PAIN The high incidence of chest pain makes it a common symptom seen in the Emergency Department in acute and primary care centres. This complaint has been found to be the presenting symptom for about 5 million people in the US (Reigle, 2005). The frequency of the symptom has not made things any easier where accurate diagnosis is concerned. The range of diagnoses varies from simple muscle strain to life-threatening illnesses like aortic aneurysm and myocardial infarction. Evaluating the cause is the first step towards management. This can be done mainly through eliciting the history in fair detail. As a nurse practitioner in the community, I will be facing many cases of chest pain. Recently I had to manage such a case and I believe that the experience has equipped me with confidence. I adopted a structured approach to evaluate the case and progress through a mental checklist for eliciting the essential historical details (Reigle, 2005). The collected relevant data helped the decision- making and subsequent management. Case Presentation Respecting the confidentiality and privacy of the patient, I met her in the emergency department where I was working. With her consent, as she was conscious and answering, I elicited the history of the chest pain from Mrs John. Mrs John, 81 years old and weighing 85 kg., had been brought to the Emergency Department by her son. I followed the mnemonic TROCAR for eliciting the history of the presenting complaint of chest pain. She had a sudden but mild chest pain while she was in bed. Time of onset was when she woke up with it at 6a.m. and first dismissed it as indigestion. As it was not giving way after her antacid liquid, she called her son. Also experiencing shortness of breath, the duration of pain had lasted for the past forty minutes. Mrs. John had fatigue since the previous night, something she was not accustomed to. Radiation of the left-sided chest pain was to the back. Onset was sudden. The character of the pain was a dull aching sensation. There was no particular aggravation or relief. The severity remained constant as a dull pain. It was a left sided chest pain. The excessive sweating worsened her fatigue. She was reluctant to go to hospital but her son insisted on it. She had then been brought to my department where I was on duty. Past History revealed that she had been a hypertensive on treatment for the past twenty years. There was a history of irregularity in treatment at times. The mild senile dementia with partial loss of memory that the lady suffered from was the cause of the irregular treatment. Now her son was in charge of giving her the medicine. She became diabetic fifteen years ago and was on oral anti-diabetics since then. Seven years ago she had a fall injuring her left trochanter which was managed accordingly. She now walks with a limp. There was no history of allergies but she had been taking antacids on and off presumably for acid-peptic disease. Smoking was not her weakness and she had not travelled for a long time. Before retirement she was working as a personal secretary in an industrial concern. Family history revealed that two brothers had died of myocardial infarction but at a later age of around 85 years. Obesity was in the family too. Mrs. John’s mother had diabetes and died of renal failure. Nursing care plan This has been elaborated upon the mnemonic ADPIE (assessment, diagnosis, planning, implementation and evaluation). Assessment On inspection, obviously obese Mrs. John appeared dyspnoeic taking short breaths with the respiratory rate being 28 per minute but regular. Her heart rate was 90 per minute and irregular at times due to ectopic beats. Her supine blood pressure was 200/120mm Hg. Palpation of abdomen did not reveal any abnormalities. Percussion ruled out fluid in the chest or abdomen. Auscultation elicited an irregular heart and tachypnea. During the general physical examination, I enumerated and eliminated non-cardiac causes; her symptom details helped me to distinguish her illness as cardiac in cause. Mrs. John did not have the non-cardiac causes of pain of musculo-skeletal pains involving the back, shoulder or arm. The examination of the vital signs of the cardiovascular and respiratory systems pointed to a cardiac cause. The typical dull chest pain with radiation to the back, the history of hypertension, diabetes mellitus, the unexplained exhaustion, the excessive sweating, the tachycardia and her obesity all pointed to a cardiac cause of chest pain. The hypertension and diabetes are the killer illnesses which along with obesity had increased the chances of the occurrence of coronary artery disease. Coronary artery disease is the number one cause of death in the world (WHO Fact sheet, 2007). Investigations 1. ECG was taken on arrival. An elevation was noted in the ST segment. Ectopics were also noted. 2. Fasting blood sugar was 200 mg.%. Normal is 60-90 mg%. 3. Blood urea was 38mg/ 100 ml. Normal value is 20-40mg/100ml. 4. Serum creatinine was 1mg/dl Normal for females is 0.6 to 1.2 mg/dl (NIH, US) 5. Lipid profile : The results were as follows Mrs. John’s results Normal Values Total cholesterol 325 mg/dL 160-240mg/dL LDL 120mg/dL < 100mg/dL HDL 25 mg/dL > 40mg/dL Serum triglycerides 180 mg/dL < 150mg/dL 6. Serum electroltyes Mrs John’s results Normal values Sodium level 140 mEq./L 135-145 mEq./L Potassium 4.2 mEq/L 3.5-5mEq./L Chloride 103mmol/L 98-108mmol/L Bicarbonate 28mmol/L 22-30mmol/L Diagnosis of Mrs John’s condition Mrs. John had presented with myocardial infraction due to coronary artery disease which had been associated with her long term hypertension, diabetes mellitus and dyslipidaemia due to long standing obesity. She had also developed senile dementia as part of her aging process. The chest pain was due to the formation of lactic acid which occurred due to the decreased blood flow to the heart in infarction and reduced oxygen supply so that anaerobic metabolism prevailed to form the lactic acid. Planning The planning was aimed at providing relief to the chest pain and improving the myocardial perfusion. The patient should be able to feel the relief and express it. Implementation A sublingual tablet of isosorbide trinitrate caused coronary vasodilatation and improved the myocardial perfusion. Pain was relieved in Mrs John’s case. Had pain not been relieved, Intravenous Morphine or other analgesics like Demerol could be administered. Administration of oxygen using a face mask was useful to increase the oxygen saturation of the blood. Discomfort due to tissue ischaemia was relieved. Tenormin was used to reduce heart rate, systolic BP and oxygen demand by the myocardium. I ensured that the environment was calm and comfortable during the recovery stage. Evaluation Mrs. John did have her chest pain relieved as I planned it. The experience of caring for Mrs. John provided great satisfaction and increased my confidence. It would remain a feather in my journey through nursing. She helped to bring out behaviours that I never knew existed within me. Preventive education Prevention of a fatal illness like coronary heart disease was targeted. Though Mrs. John should have observed a healthy lifestyle where the following conditions were met, I did not harass her over it. However I instilled in her the need to be careful in future. The cholesterol levels should be less than 200 mg/dL. Blood pressure should be less than 120/80mm Hg. Body mass index is to be less than 25kg./m2. Fasting blood glucose is to be no more than 100 mg/dL. The significance of keeping health was also impressed upon the son. Justification and rationale The main cause of all of Mrs. John’s illnesses is her obesity. The dyslipidaemia that resulted has led to the coronary artery disease (Murphy, 2011). Cholesterol is made in the liver and carried as lipoproteins in the blood (Murphy, 2011). The cholesterol level had risen significantly for the patient. The high cholesterol level that subsequently built up as plaques in the blood vessels to the heart, also known as coronary arteries, tended to block the easy flow of blood to the heart. Too much LDL, 120mg/dL in Mrs John, caused more cholesterol deposition as plaques and this is atherosclerosis. When nourishment to the heart suffered, the functions of the heart faltered. The pumping mechanism was at stake (Murphy, 2011). The HDL is the favourable lipoprotein which extracts the plaque and puts it into circulation ensuring its excretion through the liver. HDL was low in the patient. Triglycerides, 180mg/dL in Mrs John, functioned just like the LDL, negatively. The faulty circulation occurred because of the narrowing lumen of the coronary arteries. If the plaque gets dislodged, thrombi could occur and could cause stroke in the patient. Thankfully, Mrs. John did not have this. Mrs. John may be deemed to have developed secondary dyslipidaemia due to obesity, diabetes and from using anti-hypertensives (Murphy, 2011). This dyslipidaemia had progressed to its complication, coronary artery disease. Hypertension affects 32% of US adults who are older than 20 years (Herman, 2010). Sustained hypertension and poor adherence to anti-hypertensive treatment are two reasons for the setting in of complications (Herman, 2010). However one-third of this figure does not know about the illness and hence not being treated. Mrs. John had a primary systemic hypertension. Irregularity in treatment had produced complications which could be causing concern now. Obesity could again be pre-disposed to hypertension. Statistics indicate that the risks of myocardial infarction, the miserable condition of stroke and renal illness could occur for every 20/10 mm. Hg. rise in BP (Herman, 2010). The carotid circulation could also be narrowed in the pre-hypertensive period. In Mrs. John’s case, the MI could have occurred as a complication of hypertension (Herman, 2010). Mrs. John could also be having the metabolic syndrome as she had hypertension, obesity, diabetes, insulin resistance and high triglycerides (Herman, 2010). Since she had no severe headache, we could safely rule out malignant hypertension. BP measurements needed to be taken frequently. Investigations that were usually prescribed with hypertension had been done for Mrs. John: urine analysis, serum electrolyte levels, serum creatinine, fasting blood glucose levels and HDL levels (Herman, 2010). Left ventricular hypertrophy associated with hypertension was ruled out from the ECG. Management of hypertension was aimed at preventing complications. Salt intake was reduced. BP needed to be maintained below 140/90 mm. Hg and below 130/80 mm. Hg. in diabetics with kidney disease. Lifestyle modifications had to be made. A strict regimen was to be followed to prevent cardiological complications of hypertension. Type II diabetes mellitus, which Mrs. John was suffering from, was definitely associated with coronary heart disease (Ali et al, 2010). The chances of diabetics developing coronary heart disease was 2-fold to 4-fold when compared with people without diabetes. Coronary heart disease accounted for 65-75% of deaths in diabetics (Ali et al, 2010). The pathophysiology of coronary heart disease could be closely related to that of diabetes in that similar predisposing factors producing atherosclerosis and renal dysfunction were seen in both (Ali et al, 2010). Coronary heart disease and its complications were more seen in women than men (Wells, 2011). Thirty eight percent of women died in the first year after the MI while only 25 % of men did so. The significance of educating women in the risks of coronary heart disease is obvious. Most women present with a chest sensation or pain (78%). Fatigue of an unusual nature is experienced by many (67%) (Well, 2011). Breathing problems are found in 58% of women who develop coronary heart disease. Fifty percent exhibit radiating pain to arm or shoulder. Less common are a cold sweat, flushing and giddiness. Mrs. John had chest pain with a characteristic dull ache (Wells, 2011), unexplained fatigue, tachypnoea, radiating pain and sweating. The awakening with pain or pain at rest is typical for women; classical angina is rare in them. References: Ali, MK, Narayan, KMV and Tandon, N., 2010, Diabetes & coronary heart disease: Current perspectives, Indian J Med Res 132, November 2010, pp 584-597. Herman, A., 2010, Hypertension: The pressure's on Hypertension, Nursing made incredibly easy July/August 2010 , Volume 8 Number 4, Pages 40 - 52 Murphy, K , 2011, Cholesterol: The good, bad and the ugly, Nursing made Incredibly Easy! May/June 2011, Liipincott, Williams and Wilkins National Institute of Health, BUN and creatinine, http://www.ncbi.nlm.nih.gov/books/NBK305/ Reigle, J , 2005, Evaluating the Patient with Chest Pain, Foreword, Journal of Cardiovascular Nursing Vol. 20, No. 4, July/August 2005. Wells, M and Kalman, M, 2011, Women and Heart Disease: Symptom treatment and guidelines, Nursing Practitioner, Vol. 36, No. 9 World Health Organisation Factsheet, 2007, The Top Ten Causes of Death, WHO Media Centre. http://www.who.int/mediacentre/factsheets/fs310.pdf Read More