CASE STUDY #1-ACS-MI Unfolding Reasoning

Acute Coronary Syndrome/Acute MI History of Present Problem: JoAnn Smith is a 68-year-old woman who presents to the emergency department (ED) after having three days of progressive weakness. She denies chest pain b ...

Acute Coronary Syndrome/Acute MI History of Present Problem: JoAnn Smith is a 68-year-old woman who presents to the emergency department (ED) after having three days of progressive weakness. She denies chest pain but admits to shortness of breath (SOB) that increases with activity. She also has epigastric pain with nausea that has been intermittent for 20-30 minutes over the last three days. She reports that her epigastric pain has gotten worse and is now radiating into her neck. Her husband called 9-1-1 and she was transported to the hospital by emergency medical services (EMS). Personal/Social History: JoAnn is a recently retired math teacher who continues to substitute teach part-time. She is physically active and lives independently with her spouse in her own home. She has smoked 1 pack per day the past 40 years. JoAnn appears anxious and immediately asks repeatedly for her husband upon arrival. What data from the histories are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: 3 days of progressive weakness SOB Epigastric pain with nausea Epigastric pain into neck Joanne is presenting with signs and symptoms of angina. Since it has been 3 days it could possible indicate an MI RELEVANT Data from Social History: Clinical Significance: Physically active Smoked 1 pack a day for 40 years Anxious The smoking can lead to CAD What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medications treat which conditions? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: • Diabetes mellitus type II • Hypertension • Hyperlipidemia • Cerebral vascular accident (CVA) with no residual deficits • Gastro-esophageal reflux disease (GERD) • Anemia-Iron deficiency 1. Iron Sulfate 325 mg PO daily 2. Lisinopril 5 mg PO daily 3. Simvastatin 20 mg PO daily 4. Aspirin 81 mg PO daily 5. Clopidogrel 75 mg PO daily 6. Omeprazole 20 mg PO daily Iron summplement ACE INHIBITOR ANTIHYPERLIPIDEMIC SALICYLATE PLATELETE AGGERVATION INHIBITOR PROTEIN PUMP INHIB BIGUNIDE ANTIIDIABETIC REPLACE IRON REUDCE BP REDUCE CHOLESTORL PREVENT CLOT PREVENT CLOT DECRESE STOMACHE ACID DECREASE BLOOD GLUCOSE LEVELE © 2016 Keith Rischer/www.KeithRN.com 7. Metformin 500 mg PO bid One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?  Circle what PMH problem likely started FIRST  Underline what PMH problem(s) FOLLOWED as domino(s) Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.2 F/37.3 C (oral) Provoking/Palliative: Nothing/Nothing P: 128 (regular) Quality: Ache R: 24 (regular) Region/Radiation: Left arm that radiates into neck BP: 108/58 Severity: 5/10 O2 sat: 99% room air Timing: Intermittent-20-30" at a time What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Pulse is 128 Resp- 24 Temp- 99.2 Indication of tachycardia which is paoin ful Indication of tachypenia Low grade fever Current Assessment: GENERAL APPEARANCE: Anxious, appears uncomfortable, body tense RESP: Respirations labored, coarse crackles present in bases bilaterally anterior/posterior CARDIAC: Pale, diaphoretic, no edema, heart sounds regular S1S2 with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Appears uncomfortable Body tense Resp labored crackles present Pale This shows sign of pain or discomfort Possible fluid in the lungs with the crackles and labored breathing is a sign of having a hard time Pale could also be caused by nausea and vomiting or the fever or pain © 2016 Keith Rischer/www.KeithRN.com 12 Lead EKG: Interpretation: ST ELEVATION- STEMI Clinical Significance: This indicates an st elevation and should be taken care of immediately before the heart can be damaged even more Location of ST Segment Changes (lateral/anterior/inferior): Use the diagram below to identify the location of the infarction: Though this content on basic 12-lead EKG interpretation may be above the scope of knowledge required for most programs, take advantage of the APPLICATION of the principle that ischemia causes distinct EKG changes. This is relevant when a patient on routine cardiac telemetry monitoring begins to have NEW ST-T wave changes. If the nurse understands the significance of these changes, a RESCUE of a patient with a change of status can begin! Radiology Report: Chest x-ray What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: © 2016 Keith Rischer/www.KeithRN.com Scattered bilateral opacities consistent with atelectasis or pulmonary edema This would be consistent with the diagnosis of heart failure. It could also explain why joanne is short of breath Radiology Report: Echocardiogram What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Global left ventricle hypokinesis with ejection fraction of 25% This shows further significant signs of heart failure and could possibly show signs of PE Lab Results: Complete Blood Count (CBC): Current: High/Low/WNL? WBC (4.5-11.0 mm 3) 10.5 wnl Hgb (12-16 g/dL) 12.9 wnl Platelets(150-450x 103/µl) 225 wnl Neutrophil % (42-72) 70 wnl What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: All labs are noemal and with in range…showing no signs of infection Basic Metabolic Panel (BMP): Current: High/Low/WNL? Sodium (135-145 mEq/L) 135 wnl Potassium (3.5-5.0 mEq/L) 4.1 wnl Glucose (70-110 mg/dL) 184 high Creatinine (0.6-1.2 mg/dL) 1.5 High Misc. Labs: Magnesium (1.6-2.0 mEq/L) 1.8 wnl RELEVANT Lab(s): Clinical Significance: GLUCOSE CREATININE The blood sugar is high The patients kidneys are declining What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Cardiac Labs: Current: High/Low/WNL? Troponin (<0.4 ng/mL) 1.8 High BNP (B-natriuretic Peptide) (<100 ng/L) 1150 High © 2016 Keith Rischer/www.KeithRN.com What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: Troponin BNP High troponin can indicate a heart attack or a recent heart attack Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Troponin Value: 1.8 ng/mL Critical Value: Elevated n=because progressing MI Monitor the patients vitals Make sure all the patients meds are given Be sure to identify patients wishes with life saving measures Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Acute stemi 2. What is the underlying cause/pathophysiology of this primary problem? CAD THIS CAUSES A BUILDUP IN PLAQUE IN THE ARTERIES WHICH CAUSESN REDUCED BLOOD FLOW CAUSING A HEART ATTACK LEADING TO HEART FAILURE Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: © 2016 Keith Rischer/www.KeithRN.com  Establish 2 large bore peripheral IVs  Metoprolol 5 mg IV push x1 now  Nitroglycerin IV dripstart at 10 mcg and titrate to keep SBP >100  Clopidogrel 600 mg po x1 now  Aspirin 324 mg (81 mg tabs x4) chew x1 now  Heparin 60 units/kg IV x1 now  To cath lab as soon as team ready MEDICCATION ADMIN AND BLOOD DRAWL TREATMENT FOR HIGH BLOOD PRESSURE AND CHEST PAIN TREATMENT FOR CGEST PAIN PREVENTION OF HEART ATTACK FOR THINNING OF BLOOD PREVENTION OF CLOTS PUT IN A STENT NURSE WILL BE ABLE TO ADMIN MEDS AND WITHDRAWL BLOOD PATIUENTS BP WILL LOWER AND CHEST PAIN WILL SUBSIDE CHEST PAIN WILL SUBSIDE PATIENTS TROPONIN LEVELS WILL NOT INCREASE NO CLOTS WILL FORM CREATING A BLOCKAGE PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1.Establish 2 peripheral IVs 2.Metoprolol 5 mg IV push x1 now 3.Nitroglycerin IV drip-start at 10 mcg and titrate to keep SBP >100 4.Clopidogrel 600 mg po x1 now 5.Aspirin 324 mg (81 mg tabs x4) chew/po x1 now 6.Heparin 60 units/kg IV x1 now 7.To cath lab as soon as team ready Establish IV Nitroglycerin IV Make sure to establish an IV because this will be used and referred back to throughout the patients entire stay. After that I would admin nitroglycerin via IV to allivaiate some of the pain the patient is experiencing. © 2016 Keith Rischer/www.KeithRN.com Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Metoprolol 5 mg IV push (5 mg/5 mL vial) Selectively blocks beta 1 recptors IV Push: 5ml/min Volume every 15 sec? 1.25 Follow the cardiac rules of administration Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Heparin 60 units/kg Weight: 62 kg (1000 units/mL) Inactivates factor xa and inhibits conversion of prothrombin to thrombin IV Push: 3.7 ml Volume every 15 sec? 0.9ml Watch for signs and symptoms of bleeding Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) The main priority is to prevent any further damage and get the patients pain under sontrol. Its also super important to get the patient down to the cath lab 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: Put the patient on oxygen Vitals every 30 minutes Administer meds Even though the patients o2 seems okay, they are short of breath. This could help ellivate that By watching the vitals frequently we can get what the patiens base line is This should help relieve some of the patients discomfort and pain they are experiencing Patient will no longet have SOB Vitals will be obtained and docoumentd Admin the meds on time and document appropreaity 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Respiratory and cardiac 6. What is the worst possible/most likely complication to anticipate? Patient will go into V-tech which will progress into V-fib © 2016 Keith Rischer/www.KeithRN.com 7. What nursing assessments will identify this complication EARLY if it develops? Watching the cardiac monitor closely 8. What nursing interventions will you initiate if this complication develops? You should call a code, start chest compressions, and pray to the gods above 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? They will need support mentally due to the patients condition rabidly deterroiating 10. How can the nurse address these psychosocial needs? Listen to them, talk to them, and get them in contact with appropriate services and resourceds that are available. Evaluation: Two Days Later… JoAnn had an angiogram that revealed an occluded proximal right coronary artery (RCA). She received two bare metal stents with 0 percent residual stenosis. She has been in the intensive care unit (ICU) the past two days and is now transferring to the cardiac telemetry floor. She has been receiving scheduled furosemide 40 IV mg every 12 hours. Her creatinine increased from 1.7 to 2.1 today. The last dose of furosemide was given four hours ago. She has had 100 mL urine output the past four hours. She fatigues easily, but tolerates being up in the chair for short periods of time. Faint basilar crackles persist bilaterally and her O2 is at 2 liters per n/c. What data from this history are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Data from History: Clinical Significance: Crackles Fatigue Patient could still have fluid in the lungs Patient has lost a lot of strength and should be sent to the appropriate services to gain strength back © 2016 Keith Rischer/www.KeithRN.com Current VS: Most Recent: P-Q-R-S-T Pain Scale: T: 97.2 F/36.2 C (oral) T: 97.5 F/36.4 C (oral) Provoking/Palliative: P: 76 (regular/irregular) P: 82 (regular) Quality: Denies pain R: 20 (regular) R: 20 (regular) Region/Radiation: BP: 122/58 BP: 116/68 Severity: O2 sat: 95% room air O2 sat: 94% room air Timing: Current Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Denies SOB, non-labored respiratory effort, breath sounds equal aeration bilaterally with faint crackles in both bases CARDIAC: Pink, warm & dry, 1+ pitting edema in lower extremities, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants GU: 50 mL urine output since furosemide IV administered two hours ago, urine clear/yellow SKIN: Skin integrity intact, femoral puncture site soft, non-tender with no drainage, redness, or bruising 1. What clinical data are RELEVANT and must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Denies pain Vitals are WNL This means the meds are working like they should if the patient is no longer having chest pain All vitals are WNL meaning the bloodpressure isn’t high or pulse. Also showing signs of pain decrease. 02 is better meaning there isn’t much signs of SOB RELEVANT Assessment Data: Clinical Significance: Pitting edema +1 Faint crackles This shows that the patient has excess fluid in their system. The patient is on a diuretic and that should be solving this problem Crackles are improving but srill there telling that there is still fluid in the lungs. 2. Has the status improved or not as expected to this point? The patients chest pain has subsided but there is still access fluid which could lead to more serious cardiac issues. © 2016 Keith Rischer/www.KeithRN.com 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? I think it is appropriate to leave the plan of care the same. The only thing we could maybe add is a fluid restriction. Cardiac Telemetry Strip: Interpretation: Clinical Significance: Two hours later… JoAnn is resting quietly in bed. Foley catheter assessment reveals no new urine in bag from previous assessment two hours ago. Bladder scan reveals no residual urine. Review of labs reveal increased creatinine. The primary nurse gives the following SBAR to the on-call cardiologist: Situation: Name/age: Joann 68YO Female BRIEF summary of primary problem: Presented to ED with nausea, epigastric pain radiating to back, SOB, and progressively worsening weakness. Tachycardic, low BP, tachypnea. EKG demonstrated STEMI. Patient seemed to be improving but now with renal concerns and no urine output in last 2 hours. Day of admission/post-op # Keith Rischer/www.KeithRN.com Background: Primary problem/diagnosis: STEMI RELEVANT past medical history: CVA, smoking, HTN Assessment: Vital signs: RELEVANT body system nursing assessment data: Cardiovascular TREND of any abnormal clinical data (stable-increasing/decreasing): CR increasing INTERPRETATION of current clinical status (stable/unstable/worsening): Patient was improving but is now worsening.