What is the highest priority problem that you need to address with B.T.?

X scenario
You are a nurse at a freestanding cardiac prevention and rehabilitation center. Your new patient in
risk-factor modification is B.T., a 41-year-old traveling salesman, who is married and has three children. He
tells you that his work does not let him slow down. During a recent evaluation for chest pain, he underwent
a cardiac catheterization procedure that showed moderate single-vessel disease with a 50% stenosis in
the mid right coronary artery (RCA). He was given a prescription for sublingual (SL) nitroglycerin (NTG),
told how to use it, and referred to your cardiac rehabilitation program for sessions of 3 days a week. B.T.’s
wife comes along to help him with healthy lifestyle changes. You take a nursing history, as indicated in
the following.
■ Chart View
Family History
Father died suddenly at age 42 of a myocardial infarction (MI)
Mother (still living) had a quadruple coronary artery bypass graft (CABG × 4) at age 52
Past History and Current Medications
Metoprolol (Lopressor) 25 mg PO every 12 hours
Aspirin (ASA) 325 mg per day PO
Simvastatin (Zocor) 20 mg PO every evening
Lifestyle Habits
Smokes an average of 1½ packs of cigarettes per day (PPD) for the past 20 years
Drinks an “occasional” beer, and “a 6-pack every weekend when watching football”
Dietary history: High in fried and fast foods because of his traveling
Exercise: “I don’t have time to take walks.”

General Assessment
White Male
Weight 235 lb
Height 5 ft, 8 in.
Waist circumference 48 in.
Blood pressure 148/88 mm Hg
Pulse 82 beats/min
Respiratory rate 18 breaths/min
Temperature 98.4 ° F (36.9 ° C

Calculate B.T.’s smoking history in terms of pack-years.
2. There are several risk factors for coronary artery disease (CAD). For each risk factor listed,
mark whether it is nonmodifiable or modifiable.
a. Age
b. Smoking
c. Family history of CAD
d. Obesity
e. Physical inactivity
f. Gender
g. Hypertension
h. Diabetes mellitus
i. Hyperlipidemia
j. Ethnic background
k. Stress
l. Excessive alcohol use

Circle the nonmodifiable and modifiable risk factors that apply to B.T.

BT Lab Values

Laboratory Testing (Fasting)
Total cholesterol 240 mg/dL
HDL 35 mg/dL
LDL 112 mg/dL
Triglycerides 178 mg/d

4. Which lab values are of concern at this time? Explain your answers.

5. B.T. asks you, “So, how is my ‘good cholesterol’ doing today?” Which is considered the “good
cholesterol,” and why? What do his HDL and LDL levels indicate to you?

CASE STUDY PROGRESS
B.T. laughingly tells you he believes in the five all-American food groups: salt, sugar, fat, chocolate,
and caffeine.

6. Identify health-related problems in this case description; the problem that is potentially life
threatening should be listed first.

7. Of all of his behaviors, which one is the most significant in promoting cardiac disease

8. What is the highest priority problem that you need to address with B.T.? How will you
determine this? Identify the teaching strategy you would use with him.

9. What is the second problem you would work with B.T. to change? Identify an appropriate
strategy to resolve the problem

B.T.’s wife takes you aside and tells you, “I’m so worried for B. I grew up in a really
dysfunctional family where there was a lot of violence. B. has been so good to the kids and
me. I’m so worried I’ll lose him that I have nightmares about his heart stopping. I find
myself suddenly awakening at night just to see if he’s breathing.” How are you going to
respond?
CASE STUDY PROGRESS
Six weeks after you start working with B.T., he admits that he has been under a lot of stress. He is walking
on the treadmill and rubs his chest and says, “It feels really heavy on my chest right now.” You feel his pulse
and note that his skin is slightly diaphoretic and that he is agitated and appears to be anxious.

11. What is the first action you are going to do? What other information will you obtain?
Explain.

12. B.T. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL
NTG) tablets. You decide to give him one tablet. After 5 minutes, which is the appropriate
action to take?
a. If the chest discomfort is relieved, call 911.
b. If the chest discomfort is not relieved, give another SL NTG tablet, and wait 5 minutes
more.
c. If the chest discomfort is not relieved, have someone else call 911, while you give B.T.
another SL NTG tablet.
d. If the chest discomfort is not relieved, do a 12-lead electrocardiogram (ECG) to look for
ischemic changes, and call 911

13. What other actions will you take at this time

Five minutes after the first NTG tablet, B.T. states that the discomfort is still there and only
slightly relieved. Explain what you can expect to be doing while waiting for emergency
medical system (EMS) to arrive

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