Case Study 2: High Risk for Coronary Artery Disease As an occupation nurse at a free-standing HMO clinic, one of your

primary responsibilities is providing information to all employees about healthy lifestyles. While you are waiting in the supermarket checkout line, one of the employees, an accountant named K.N., sees you and says he would like some advice. He tells you he recently had a physical and was given a clean bill of health. He says he want to limit his risk factors but doesnt know what to do. You agree to an appointment o see him later in the week to guide him in identifying lifestyle changes he can make. During your initial interview, you learn that K.N. is 55 years old and reports no chronic medical problems. His family history is significant for CAD in both his father and mother. His father, a heavy smoker, experienced a fatal MI at the age 49 and his mother died of an MI at the age of 60. His paternal grandfather died at age 35 in a farm accident, his paternal grandmother died at 64 of what sounds (from the story) like cancer. His maternal grandfather died at age 55 of what seems to have been sudden cardiac death. K.N.s maternal grandmother died at age 68 with complications related to the flu (pneumonia?). His fathers brother had childhood-onset diabetes and died of complications at age of 23. K.N. had an older brother who was killed at age 24 in Vietnam War. He has no other brothers or sisters. K.N. has never smoked and denies any hypertension, diabetes or other medical problems. He is 510 and weighs 200 lb. His VS are 138/86, 72, 16. He has a sedentary job and gets no routine exercise. He gives you a lipid profile laboratory analysis that reveals the following values: total cholesterol 243 mg/dl, LDL 165 mg/dl, HDL 31 mg/dl, triglycerides 240 mg/dl. His waist circumference is 48.5. Symbols, terms and abbreviations 1. Risk factor Meaning/ definition 1. Something that increases a person's chances of developing a disease. (www.medterms.com) 2. is currently defined as systolic pressure of > 140 mmHg and/or a diastolic pressure of >90 mmHg. This is based upon the average of two or more properly measured readings at each two or more visits following an initial screen. Can perhaps be better described as a progressive cardiovascular syndrome characterized by the presence of BP elevation to a level that places patients at increased risk of target organ damage in multiple vascular beds (Washington Manual of Internal Medicine) 3. is characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, etc. Cardiovascular risk factor

2. hypertension

3. diabetes

Diagnoses/medical conditions (+ current and Description/ meaning of diagnosis or medical past) problem (include possible significance) 1. +family history of MI Myocardial infarction- is the death of heart muscle from sudden blockage of coronary artery by a blood clot. (www.medicinenet.com)

Independent risk factor of coronary artery disease (www.ncbi.nlm.nih.gov) 2. +family history of CAD Coronary artery disease- is a condition in which plaque builds up inside coronary arteries. Positive is considered an independent risk factor of developing CAD (content.karger.com) if Class, indications, contraindications, significant side effects, food and drug interactions

Medications applicable) None Treatments, procedures

(brand

and

generic

name

interventions

and

None therapeutic Method of delivery, purpose/ desired outcome, indications, contraindications, and precautions (include supplemental oxygen, tube feedings, therapeutic beds etc.) None What is it, when was it done, and why? What is a lipid profile? The lipid profile is a group of tests that are often ordered together to determine risk of coronary heart disease. They are tests that have been shown to be good indicators of whether someone is likely to have a heart attack or stroke caused by blockage of blood vessels or hardening of the arteries (atherosclerosis). The lipid profile typically includes: total cholesterol, HDL (good cholesterol), LDL (bad cholesterol) and triglycerides When is it ordered? It is recommended that healthy adults with no other risk factors for heart disease be tested with a fasting lipid profile once every five years. You may be screened using only a cholesterol test and not a full lipid profile. However, if the cholesterol test result is high, you may have follow-up testing with a lipid profile. If you have other risk factors or have had a high cholesterol level in the past, you should be tested more regularly and you should have a full lipid

None Laboratory tests and diagnostic procedures Lipid profile

profile. For children and adolescents at low risk, lipid testing is usually not ordered routinely. However, screening with a lipid profile is recommended for children and youths who are at an increased risk of developing heart disease as adults. Some of the risk factors are similar to those in adults and include a family history of heart disease or health problems such as diabetes, high blood pressure (hypertension), or being overweight. High-risk children should have their first lipid profile between 2 and 10 years old, according to the American Academy of Pediatrics. Children younger than 2 years old are too young to be tested. A lipid profile may also be ordered at regular intervals to evaluate the success of lipid-lowering lifestyle changes such as diet and exercise or to determine the effectiveness of drug therapy such as statins. (www.labtestsonline.org) Cultural issues and their significance None Pathophysiology Coronary arteries are blood vessels that supply the heart muscle with blood and oxygen Blockage of a coronary artery deprives the heart muscle of blood and oxygen, causing injury to the heart muscle. Injury to the heart muscle causes chest pain and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to die for six to eight hours at which time the heart attack usually is "complete." The dead heart muscle is eventually replaced by scar tissue. 1. Are K.N. lipid levels within normal limits? No. total cholesterol 243 mg/dl , Varies with age, generally < 200 mg/dl No. LDL 165 mg/dl (50-130 mg/dl), < 100 optimal, 100-129 near or above normal, 130-159 borderline high, 160-189 high, > 190 very high No. HDL 31 mg/dl Male (45-70 mg/dl), Female: (45-90 mg/dl) No. triglycerides 240 mg/dl < 150 mg/dl 2. According to current guidelines, how would you evaluate K.N for overweight as a risk factor? List two methods and brief explanation for each None

BMI is a number calculated from a person's weight and height. it is used to evaluate if someone is underweight, healthy size, overweight or obese. Formula: BMI = wt/ht (m)2

Waist circumference A high waist circumference and too much abdominal fat puts you at high risk for type 2 diabetes, high blood pressure, high cholesterol, and heart disease. It means you need to lose weight. By measuring your waist circumference, doctors can track your body composition before, during, and after your weight loss efforts. A high-risk waist circumference is:

A man with waist measurement over 40 inches (102 cm). A woman with waist measurement over 35 inches (88 cm).

To measure your waist circumference, use a tape measure. Start at the top of the hip bone, then bring it all the way around -- level with your navel. Make sure it's not too tight and that it is parallel with the floor. Don't hold your breath while measuring it!

3. According to either methods you have chosen in question 3, is K.N considered to be overweight? Explain your rationale. He is overweight because his BMI, which is 28.76, is above the normal range (18-25) 4. Identify all the cardiac related risk factors in K.N. previous information. Place a check mark next to those that are modifiable risk factors Family history of CV disease and diabetes Age Gender Weight, waist circumference / Sedentary lifestyle, (poor exercise) / smoking / lipids profile / blood pressure /

5. Based on the information you received in the initial interview, what lifestyle modifications would you consider for K.N Diet/ exercise to ideal BMI (23) Lipids and glucose control Blood pressure control Supplemental medications, as required Low salt diet

6. What about K.N VS? is he hypertensive? Are his VS considered abnormal? No but he is close being hypertensive. 7. What information would you give to K.N. regarding a healthy diet?
Balancing Calories Enjoy your food, but eat less. Avoid oversized portions. Foods to Increase Make half your plate fruits and vegetables. Make at least half your grains whole

grains. Switch to fat-free or low-fat (1%) milk. Foods to Reduce Compare sodium in foods like soup, bread, and frozen meals and choose the foods with lower numbers. Drink water instead of sugary drinks. http://www.choosemyplate.gov/ 8. Prior to the beginning of an exercise program, what precaution would you want K.N to take

Exercise Precautions For A Heart Healthy Exercise Program There are many precautions you must keep in mind when developing an exercise program. Here are some tips.

Stop the exercise if you become overly fatigued or short of breath; discuss the symptoms with you doctor or schedule an appointment for evaluation. Do not exercise if you are not feeling well or have a fever. You should wait a few days after all symptoms disappear before restarting the exercise program, unless your doctor gives other directions. If you experience shortness of breath or increased fatigue during any activity, slow down or stop the activity. Elevate your feet when resting. If you continue to have shortness of breath, call your doctor. The doctor may make changes in medications, diet, or fluid restrictions. Stop the activity if you develop a rapid or irregular heartbeat or have heart palpitations. Check your pulse after you have rested for 15 minutes. If it's still above 120-150 beats per minute, call the doctor for further instructions.

If you experience pain:

Don't ignore it. If you have chest pain or pain anywhere else in the body, do not allow the activity to continue. Performing an activity while in pain may cause stress or damage to the joints.

Stop the exercise and rest if you:

Have chest pain Feel weak Are dizzy or lightheaded Have unexplained weight gain or swelling (call the doctor right away) Have pressure or pain in the chest, neck, arm, jaw, or shoulder Have any other symptoms that cause concern
http://www.medicinenet.com/fitness_exercise_for_a_healthy_heart/page6.htm

9. K. N wants to know why he shouldnt have eaten for 12 hours before his lipid profile was drawn. What would you tell him? Hint: if the test is drawn as part of a total lipid profile, it requires a 12-hour fast (no food or
drink, except water) http://my.clevelandclinic.org/heart/services/tests/labtests/lipid.aspx