Section 6
Chapter 36 Cardiovascular Problems
Case Study
A 64-year-old female patient enters the walk-in clinic reporting dizziness and fainting that has been happening off and on for the last 48 hours. The patient reports a 10-year history of hypertension, which she describes as “usually” controlled. The woman reports being recently ill with a “bad case” of influenza but otherwise well, with a history of depression controlled with antidepressant medication. The woman reports taking an ACE inhibitor daily for her hypertension and notes she has taken a dose today. Her vital signs upon arrival are: blood pressure 104/48, heart rate 180, respiratory rate 30, and temperature 99.1F. The woman appears diaphoretic, fatigued, and weak. Physical assessment reveals an irregularly irregular heart rate, weak peripheral pulses, cool, pale skin, and decreased capillary refill. The ECG shows atrial fibrillation. The woman reveals that she is in the United States illegally and is undocumented. The patient expresses concern about her status as you prepare her for treatment.
Case Questions
1. What additional symptoms should you ask the patient if she has experienced?
The patient should be asked if she has palpitations, angina, and signs of stroke including weakness on one side, facial droop on one side, and vision or speech difficulties.
2. Using Table 36.1, calculate the patient’s CHADS2 score and determine whether anticoagulation is recommended based on the score.
The CHADS2 score is 1, for a history of hypertension. Based on the recommendations of the CHADS2 score, the patient does not need anticoagulation therapy.
3. What is the significance of this condition happening off and on for the last 48 hours?
The patient who has had untreated atrial fibrillation for 48 to 72 hours is at an increased risk of stroke. The condition needs to be promptly diagnosed and treated.
4. You, the nurse practitioner, decide the patient needs treatment beyond the walk-in clinic’s resources. What action do you take to ensure that the patient is treated promptly?
This is a new onset of atrial fibrillation, so the patient needs to be seen by a cardiologist for management and needs care in an area where the patient’s response to treatment can be monitored. The patient has been having the symptoms for more than 48 hours, which places the patient at higher risk of stroke. The patient needs further management of her condition without delay. The patient will need to be transported to an emergency room or acute care unit for the level of care needed. If the clinic is attached to a hospital, the patient can be accompanied to the emergency room for treatment. If the walk-in clinic is attached to a hospital where direct admission to an acute care unit is possible, the practitioner can consider direct admission to the acute care unit with a cardiology consultation.
5. Because the patient is an undocumented immigrant, what considerations will be needed while care is provided?
The patient needs urgent medical care. The practitioner needs to ensure the patient’s privacy and ensure that treatment ensures the patient’s safety. The practitioner does not have to report the woman’s immigrant status, and to do so would undermine the trust the woman has in the health-care system, preventing further successful treatment. Health-care facilities have financial counselors who can work with the patient to address financial needs after the patient’s condition is stabilized.
Cardiovascular Emergencies
Case Overview
This 64-year old female patient presents with concerning symptoms of dizziness, fainting, and an irregular heart rate that require prompt attention. Her medical history of hypertension and recent influenza infection are contributing risk factors in her current condition.
Immediate Concerns
Upon assessment, key findings include an irregularly irregular heart rate of 180 bpm, low blood pressure, pale skin and decreased pulse, consistent with an arrhythmia like atrial fibrillation (later confirmed on ECG). As her symptoms have persisted over 48 hours untreated, she is at elevated stroke risk (1). The patient needs emergency treatment beyond the clinic’s scope.
CHADS2 Score and Anticoagulation
Using the CHADS2 criteria in Table 36.1, her lone risk factor of hypertension earns a score of 1, below the threshold for anticoagulation (2). However, given the duration of her arrhythmia, prompt rate/rhythm control is still indicated to reduce her stroke risk.
Ensuring Timely Treatment
As a higher level of monitoring is required, the practitioner should arrange emergency transport to an emergency department or acute care unit for admission and cardiology consult (3). Direct admission may be possible if the clinic is hospital-attached.
Addressing the Patient’s Concerns
While the patient’s immigration status need not be reported per privacy laws, establishing trust is important for continued care (4). Financial counselling can address costs after stabilizing her condition. Her safety and wellbeing should be the top priority in all decisions made.
In summary, this case highlights the need for swift action and consideration of a patient’s whole context to properly treat cardiovascular emergencies. Please let me know if any part of my analysis requires clarification or expansion.
References:
(1) Lip, G. Y., & Lane, D. A. (2015). Stroke prevention in atrial fibrillation: a systematic review. Jama, 313(19), 1950-1962.
(2) Gage, B. F., Waterman, A. D., Shannon, W., Boechler, M., Rich, M. W., & Radford, M. J. (2001). Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. Jama, 285(22), 2864-2870.
(3) January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., … & Murray, K. T. (2014). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 64(21), 2246-2280.
(4) Artiga, S., & Diaz, M. (2019). Health coverage and care of undocumented immigrants. Kaiser Family Foundation.
