Case Study
Henry Brusca is a 68-year-old, married father of 7 who was in relatively good health until 3 weeks ago. At that time, he visited the emergency room with the complaint of “just not feeling right.” His BP on admission was 170/118, so he was admitted to the coronary care unit with the diagnosis of uncontrolled HTN. His BP was controlled with medication, and he was discharged several days later. He is now being seen for follow-up care and management of HTN. Because Mr. Brusca is newly diagnosed with HTN, you will need to complete a history and thorough cardiovascular examination.
Case Study Findings
Biographical data:
■ 68-year-old white male.
■ Married, father of seven grown children.
■ Self-employed entrepreneur; BS degree in engineering.
■ Born and raised in the United States, Italian descent, Catholic religion.
■ Blue Cross/Blue Shield medical insurance plan.
■ Referral: Follow-up by primary care physician.
■ Source: Self, reliable.
Current health status:
■ No chest pain, dyspnea, palpitations, or edema.
■ Complains of fatigue, loss of energy, and occasional dizzy spells.
Past health history:
■ No rheumatic fever or heart murmurs.
■ No history of injuries.
■ Inguinal hernia repair.
■ Left ventricular hypertrophy revealed by electrocardiogram (ECG).
■ Hospitalized 3 weeks ago for HTN.
■ No known food, drug, or environmental allergies.
■ No other previous medical problems.
■ Immunizations up to date.
■ No prescribed medications except Vasotec 5 mg bid and weekly use of antacid for indigestion.
Family history:
■ Positive family history of HTN and stroke.
■ Mother had HTN and died at age 78 of a stroke.
■ Paternal uncle died at age 79 of MI.
Review of systems:
■ General Health Survey: Fatigue, weight gain of 60 lb over past 3 years.
■ Integumentary: Feet cold, thick nails, tight shoes.
■ Head, Eyes, Ears, Nose, and Throat (HEENT): Two dizzy spells over past 6 months.
■ Eyes: Wears glasses, no visual complaints, yearly eye examination.
■ Respiratory: “Short winded” with activity.
■ Gastrointestinal: Indigestion on weekly basis.
■ Genitourinary: Awakens at least once a night to go to bathroom.
■ Musculoskeletal/Neurological: General weakness, cramps in legs with walking.
■ Lymphatic: No reported problems.
■ Endocrine: No reported problems.
Psychosocial profile:
■ States that he does not have time for routine checkups. “I only go to the doctor’s when I’m sick. “Typical day consists of arising at 7 A.M., showering, having breakfast, and then going to work. Returns home by 6 P.M., eats dinner, watches TV till 11:30 P.M., but usually falls asleep before news is over. Usually in bed by 12 midnight.
■ 24-hour recall reveals a diet high in carbohydrates and fats and lacking in fruits and vegetables. Heavy-handed with salt shaker; salts everything. Admits that he has gained weight over the years and is 60 lb overweight.
■ No regular exercise program. States: “I’m too busy running my business.”
■ Hobbies include reading, crossword puzzles, and antique collecting.
■ Sleeps about 7 hours a night, but usually feels he is not getting enough sleep. Lately is more and more tired. Wife states that he snores.
■ Never smoked. Has a bottle of wine every night with dinner.
■ Works at sedentary job, usually 7 days a week. No environmental hazards in workplace.
■ Lives with wife of 45 years in a two-story, single home in the suburbs with ample living space.
■ Has a large, close, caring family.
■ Admits that running his own business is very stressful, but feels he can handle it alone and doesn’t need anyone to help him.
General Health Survey findings:
■ Well-developed, well-groomed 68-year-old white male, appears younger than stated age.
■ Sits upright and relaxed during interview, answers questions appropriately.
■ Alert and responsive without complaint, oriented x 4 (time, place, situation, and person).
■ Affect pleasant and appropriate.
■ Head-to-toe scan reveals positive arcus senilis, positive AV nicking and cotton wool, extremity changes including thin, shiny skin, thick nails, and edema.
■ Vital Signs
■ Temperature, 36.6 °C.
■ Pulse, 86 BPM, strong and regular.
■ Respirations, 18/min, unlabored.
■ BP: 150/90 mmHg.
■ Height: 180 CM.
■ Weight: 124 KG.
Cardiovascular assessment findings include:
■ Neck Vessels
■ Positive large carotid pulsation, +3, symmetrical with smooth, sharp upstroke and rapid descent, artery stiff, negative for thrills and bruits.
■ JVP at 30 degrees <3 cm, negative abdominojugular reflux. ■ Precordium ■ Positive sustained pulsations displaced lateral to apex, PMI 3 cm with increased amplitude. ■ Slight pulsations also appreciated at LLSB and base, but not as pronounced. ■ Negative thrills; cardiac borders percussed third, fourth, and fifth intercostal spaces to the left of the midclavicular line. ■ Heart sounds appreciated with regular rate and rhythm at apex S1 > S2 and +S4,at LLSB S1 > S2.
■ S2 negative split, at base left S1 < 2 negative split, at base right S1 < 2 with an accentuated S2, negative for murmurs and rubs. Questions: 1) What questions might be useful to elicit further details surrounding the Chest pain, using one of the common acronyms in this regard? (5 Marks) 2) From the subjective information you have obtained from Mr. Brusca’s history, what are his identifiable risk factors for heart disease? Which risk factors are modifiable and which are unmodifiable? (5 Marks) 3) List three priority nursing diagnosis for Mr. Brusca’s case, and cluster subjective and objective data that support each diagnosis. (3 Marks) 4) From the previous data, discuss the main issues of health promotion and disease prevention should the nurse discussed during health history and physical examination? (4 Marks). 5) Considering the relationship of the cardiovascular system to the respiratory system, what respiratory problems might Mr. Brusca have as a result of his cardiovascular disease? (3 Marks) _______________________ Answer Guide; 1) Exploring Chest Pain Further Using the PQRST Acronym: To delve deeper into the details of Henry Brusca's chest pain, the PQRST acronym can be employed to comprehensively assess his symptoms: P - Provocation/Palliation: Ask if any specific activities or positions provoke or alleviate the chest pain. Inquire about any associated symptoms like shortness of breath or sweating during these episodes. Q - Quality: Determine the character of the chest pain. Does it feel sharp, dull, crushing, burning, or stabbing? This can provide insights into potential causes. R - Region/Radiation: Ask where the pain is located and if it radiates to other areas like the arms, neck, or jaw. This can help differentiate between cardiac and non-cardiac causes. S - Severity: Quantify the intensity of the pain on a scale from 0 to 10. This helps assess the severity of the symptom and its impact on the patient's daily life. T - Timing: Inquire about when the pain started, how long it lasts, and its frequency. This can aid in understanding the pattern of the symptoms. By using the PQRST approach, clinicians can gather a more comprehensive picture of Henry's chest pain, which is crucial for accurate diagnosis and treatment planning. 2) Identifiable Risk Factors for Heart Disease: Identifiable risk factors for heart disease based on Mr. Brusca's history include: Modifiable Risk Factors: Hypertension (HTN): Mr. Brusca was recently diagnosed with uncontrolled high blood pressure, a significant modifiable risk factor for heart disease. Obesity: He has gained 60 pounds over three years and is 60 pounds overweight, contributing to cardiovascular risk. Sedentary Lifestyle: Lack of regular exercise increases the risk of heart disease. Diet: A high-carbohydrate and high-fat diet, along with excessive salt intake, can exacerbate cardiovascular risk. Stress: The stress from managing his own business might contribute to heart disease risk. Unmodifiable Risk Factors: Age: Being 68 years old increases his risk. Gender: Being male is associated with a higher risk. Family History: Positive family history of hypertension and stroke elevates his risk. Ethnicity: Italian descent might have genetic implications for cardiovascular risk. 3) Priority Nursing Diagnoses and Supporting Data: 1. Ineffective Coping Related to High Stress Levels and Sedentary Lifestyle: Subjective: Mr. Brusca's busy, stressful routine, and lack of exercise. Objective: Lack of stress management activities, sedentary job, and indulging in high-calorie meals. 2. Risk for Imbalanced Nutrition: More than Body Requirements: Subjective: Excessive weight gain, high-carb, high-fat diet, excessive salt use. Objective: Overweight status, poor dietary choices, thick nails and other physical markers. 3. Activity Intolerance Related to Cardiovascular Weakness: Subjective: Fatigue, shortness of breath, cramps with walking. Objective: Positive pulsations, PMI displacement, and cardiac changes detected in examination. 4) Health Promotion and Disease Prevention: The nurse should discuss the following during the health history and physical examination: Heart-Healthy Diet: Emphasize the importance of a balanced diet rich in fruits, vegetables, lean proteins, and whole grains. Educate about salt reduction. Regular Exercise: Stress the significance of regular physical activity to manage weight, improve cardiovascular health, and reduce stress. Stress Management: Provide strategies like deep breathing, mindfulness, and relaxation techniques to cope with stress. Weight Management: Discuss setting achievable weight loss goals through diet and exercise modifications. 5) Cardiovascular-Respiratory Relationship and Potential Respiratory Problems: Cardiovascular and respiratory systems are closely intertwined. With cardiovascular disease, respiratory problems can arise: Dyspnea: Cardiovascular issues can lead to fluid buildup in the lungs, causing shortness of breath. Decreased Tolerance for Physical Activity: Heart disease can impair oxygen delivery, leading to exercise intolerance and breathlessness. Orthopnea: Fluid accumulation in the lungs can worsen when lying down, causing orthopnea. These respiratory issues are primarily consequences of heart-related challenges and can significantly impact Mr. Brusca's quality of life. Monitoring and managing his cardiovascular health are crucial to prevent these respiratory complications. References: World Health Organization. (2016). Cardiovascular Diseases (CVDs). Retrieved from https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) American Heart Association. (2018). Understanding Blood Pressure Readings. Retrieved from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings Mayo Clinic. (2020). Cardiovascular disease. Retrieved from https://www.mayoclinic.org/diseases-conditions/cardiovascular-disease/symptoms-causes/syc-20373124 Centers for Disease Control and Prevention. (2019). Heart Disease Risk Factors. Retrieved from https://www.cdc.gov/heartdisease/risk_factors.htm

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