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Presentation: Mrs. Hilary Flutter is a 58yo African American female

Mrs. Hilary Flutter is a 58yo African American female who presents to the ER with dyspnea and pain in
the neck, shoulder blade and jaw. She also notes persistent swelling in her lower extremities x 3-4 weeks.
She rates the pain 8/10 on the pain scale. The pain started abruptly 9 hours ago and appears to be getting
worse. She also notes some nausea without vomiting. She has not had any bowel changes, fevers,
malaise, arthralgias, cough, wheezing, stridor, rales, vertigo, syncope, loss of consciousness or visual
Past Medical History:
Stable Angina
Hypertension (HTN)
Congestive Heart Failure
Diabetes type 2 (T2DM)
Allergies: Shellfish
Nitroglycerin tablets prn chest pain
Metoprolol BID
Lisinopril BID
Digoxin BID
ASA Daily
Plavix Daily
Metformin BID
Atorvastatin Daily
Furosemide BID
Social History:
Tobacco: Smokes 1 Pack Per Day (PPD)
Drugs: Never
ETOH: Quit 4 years ago
Exercise: None
Family History:
Father died of Congestive Heart Failure at the age of 65
Mother still alive, history of HTN and DM



Case Study #1: NUR 324
Spring 2023
Notable exam findings include tachycardia and +2 bilateral lower extremity edema.
No crackles or jugular venous distention (JVD) noted on exam.
HR: 115
BP: 95/85
RR: 20
SPO2: 95%
Temp: 98.7
1. As the ER nurse, what are your initial concerns about Mrs. Flutter’s presentation and what are
your initial priority interventions?
2. Which of the following components of the physical examination are essential to perform and why?
a. Heart Examination
b. Lung Auscultation
c. Evaluation for jugular venous pressure
d. Visual Acuity
e. Evaluation for edema
f. Joint Evaluation
g. Skin assessment
3. While you are completing the medication reconciliation, the patient states that she is unsure why
she takes each medication. Please explain to Mrs. Flutter why she is taking each medication.
Include any special instructions.
4. The physician orders the following test. Mrs. Flutter recognizes one lab as being related to her
heart. She asks why each of these labs were ordered since she is not having any chest pain and
what do these labs look for?
a. Troponin stat
b. CKMB stat
c. BNP
d. Fasting Lipid panel
e. Chemistry Panel
5. Which of the following diagnostic studies would you expect the MD to order for Mrs. Flutter and
why? (More than one may apply)
A. Electrocardiogram (ECG)
B. Chest x-ray (CXR)
C. 24-hour urine protein level
D. Stress Test



Case Study #1: NUR 324
Spring 2023
6. You are reviewing the results of Mrs. Flutter’s current labs. Which lab results are your priority
concern at this time and why?
a. Troponin 1.6 NG/ML
b. CKMB 24 NG/ML
c. BNP 85 pg/mL
d. Total Cholesterol: 240 mg/dL
e. Triglycerides: 180 mg/dL
f. HDL: 45 mg/dL
g. LDL: 195 mg/dL
h. Creatinine: 2.1 mg/dL

7. It was concluded that Mrs. Flutter is having a Myocardial Infarction and will need to be taken to
the cardiac catheter lab (cath lab) immediately. What is meant by a goal of “door to balloon time
of 90 minutes”? Why is it important?

8. What risk factors does Mrs. Flutter have for a Myocardial Infarction and which are modifiable vs
9. Mrs. Flutter asked what the doctor meant by Myocardial Infarction. Explain the pathophysiology
in terms that she can understand. Include what is meant by stable and unstable angina.

10. Mrs. Flutter signs her consent for a coronary angioplasty with stenting. She asks if you could
review what this procedure entails one more time. How would you explain the purpose of this

11. Why does the RN remind the cardiologist that Mrs. Flutter has an allergy to shellfish and that her
creatinine is elevated?

12. Mrs. Flutter’s procedure was a success and she is being transported from the cath lab to the
cardiology floor in stable condition. What are some nursing implications/interventions for patients
who are status post coronary angiogram with entry site through the femoral artery?

13. Mrs. Flutter is now being discharged from the hospital. Please review the following patient
education with Mrs. Flutter

a. What type of diet would you recommend and what foods should she avoid?
b. Instructions for taking Nitroglycerin tablets with stable angina
c. Can she exercise while taking Nitroglycerin tablets?
d. Signs/symptoms of worsening CHF
e. Signs to report while taking Aspirin and Clopidogrel
f. She says thankfully her cholesterol is really not an issue. How would you respond to this