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Case Study JoAnn Smith (Acute Coronary Syndrome)
NUR1211 (NUR1211)
Keiser University
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RNSG 2539 exam 2Preview text
Acute Coronary Syndrome (ACS)
Myocardial Infarction (MI)
Claudia Gomez
JoAnn Smith, 68 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
- Fluid and Electrolyte Balance
- Clinical Judgment
- Communication
- Collaboration
UNFOLDING Reasoning Case Study-STUDENT
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- 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:
- Three days of progressive weakness
- Shortness of breath that increases with activity
- Denial of chest pain
- Epigastric pain worsening and radiating to neck
-Fatigue with normal daily activity is an indication of a weakening body system -Shortness of breath indicates decreased oxygenation. -Women does not usually show classic signs of MI such as chest pain. -Epigastric pain that radiates towards the neck is a sign of a cardiovascular concern in women. This can also be mistaken for GERD but must not be ruled out for other possible problems. RELEVANT Data from Social History: Clinical Significance:
- Part-time work
- Physical activity
- Lives independently w/ spouse
- Tobacco use 40 pack years
- Appears anxious
-Physical activity can exacerbate a cardiovascular disorder -Independent living is a safety concern especially for the patient age range. -Tobacco use puts the patient at high risk for developing heart disease -anxious behavior increases the body’s demand for oxygenation exacerbating shortness of breath.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99 F/37 C (oral) P rovoking/Palliative: Nothing/Nothing P: 128 ( regular) Q uality: Ache jR: 24 (regular) R egion/Radiation: Left arm that radiates into neck BP: 108/58 S everity: 5/ O2 sat: 99% room air T iming: 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:
12 Lead EKG:
Location of ST Segment Changes (lateral/anterior/inferior) : Use the diagram below to identify the location of the infarction: 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: Scattered bilateral opacities consistent with atelectasis or pulmonary edema
Opacities indicates occlusion or buildup of fluid – which explains the crackles and the shortness of breath. This is caused by tobacco use.
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%
Regional ventricular wall motion abnormalities are suggestive of a myocardial infarction.
Lab Results:
Complete Blood Count (CBC): Current: High/Low/WNL? WBC (4.5-11 mm 3) 10 WNL Hgb (12-16 g/dL) 12 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 lab values are within normal limits; however; Hgb and Platelets must be monitored.
Hgb and platelets are highly significant to the patient’s condition. Hgb is the oxygen carrying protein of the blood which is associated with the report of shortness of breath and the labored breathing.
Platelets should be monitored also. Values lower than normal may indicate a clot.
Basic Metabolic Panel (BMP): Current: High/Low/WNL? Sodium (135-145 mEq/L) 135 WNL Potassium (3.5-5 mEq/L) 4 WNL Glucose (70-110 mg/dL) 184 HIGH Creatinine (0.6-1 mg/dL) 1 HIGH Misc. Labs: Magnesium (1.6-2 mEq/L) 1 WNL
RELEVANT Lab(s): Clinical Significance: Glucose: elevated
Creatinine: elevated
Patient does have history of DM type II – uncontrolled glucose level puts the patient at risk for complications of the cardiovascular system. Creatinine levels must be considered before using a certain class of drug such as ACE inhibitors and if cardiac catheterization is considered.
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:
Establish 2 large bore peripheral IV
Patient line is important for administration of fluids to support circulation and to administer emergency drugs.
Patient will have 2 IV access and will remain patent.
Metoprolol 5 mg IV push x1 now
Beta-adrenergic blockers are of benefit when given intravenously within 4 hours of the onset of pain and continued on a long- term basis.
Patient’s BP will remain with in normal range with an adequate MAP.
Nitroglycerin IV drip-start at 10 mcg and titrate to keep SBP >
Nitrates are vasodilators opening up the blood vessels promoting blood flow and helps with angina.
Patient’s chest pain will be relieved and will maintain a BP within normal range.
Clopidogrel 600 mg po x1 now
Antiplatelet agents inhibit platelet aggregation by irreversibly inhibiting the binding of ATP to platelet receptors.
The patient will be free from formation of additional/new clots
Aspirin 324 mg (81 mg tabs x4) chew x1 now
Giving ASA as soon as possible inhibits platelet activity at the site of plaque rupture (a key mechanism in the unfolding acute MI)
The patient will be free from bleeding and will not develop additional clots.
Heparin 60 units/kg IV x1 now
Thrombolytic therapy prevents the formation of thrombi causing pain and decreased perfusion.
Patient will remain free from adverse effects of thrombolytic therapy such as cerebral hemorrhage.
To cath lab as soon as team ready
Diagnostic imaging can be used to visualize the arteries and chambers of the heart. Surgical treatment may be performed as a primary intervention or after thrombolysis failure.
Patient will be sent to the lab as soon as possible to diagnose and treat the problem.
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders: Order of Priority: Rationale: Establish 2 peripheral IVs Aspirin 324 mg (81 mg tabs x4) chew/po x1 now
The patient must receive immediate anticoagulation and antiplatelet therapy and due to the lack of IV access, PO meds must be administered right away.
Metoprolol 5 mg IV push x1 now Clopidogrel 600 mg po x1 now
Nitroglycerin IV drip-start at 10 mcg and titrate to keep SBP > Establish 2 peripheral IVs
Establishing IV access is necessary aright after PO medication has been administered to prepare patient for IV drug infusion. Clopidogrel 600 mg po x1 now Metoprolol 5 mg IV push x1 now IV medication can now be given to help dilate the blood vessels to promote circulation and blood flow to the heart.
Aspirin 324 mg (81 mg tabs x4) chew/po x1 now
Nitroglycerin IV drip-start at 10 mcg and titrate to keep SBP >
Heparin 60 units/kg IV x1 now Heparin 60 units/kg IV x1 now
Heparin should then be administered to prevent formation of new clots.
To cath lab as soon as team ready To cath lab as soon as team ready
Diagnostic imaging is beneficial to identify problem and treat with surgical therapy accordingly if needed.
Collaborative Care: Nursing
3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Nursing priorities: -Relieve pain -Reduce myocardial workload (cardiac tissue perfusion) -Prevent, detect, and assist in treatment of life-threatening complications
4. What interventions will you initiate based on this priority?
Nursing Interventions: Rationale: Expected Outcome:
-Administer medications as ordered as soon as possible.
-Monitor heart rate & rhythm – review serial ECG
-Pharmacologic therapy to promote blood flow and circulation and anticoagulation and antiplatelet aggregation will prevent further damage or worsening symptoms.
-Close and routine monitoring of ECG will help determine if treatment is effective or if improvement of condition is taking place.
-patient will maintain adequate cardiac tissue perfusion
-patient will restore normal/regular cardiac rhythms
5. What body system(s) will you most thoroughly assess based on the primary/priority concern? The cardiovascular system and the respiratory system must be assessed thoroughly based on the primary/priority concern.
Case Study JoAnn Smith (Acute Coronary Syndrome)
Course: NUR1211 (NUR1211)
University: Keiser University
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