Case Study: Myocardial Infarction SCENARIO You are

Case Study: Myocardial Infarction SCENARIO You are working in a small, rural hospital in Central California, when W.R., a 48-year-old plumber with a 36-pack-year smoking history, is brought to your emergency department (ED) shortly after 1330. His wife brought him to the emergency department after he complained of unrelieved “indigestion”, while eating at home. He is being admitted to the ED with a diagnosis of rule out myocardial infarction (R/O MI). His chest pain began at approximately 1300. He has significant male-pattern obesity (a “beer belly,” a 44-inch pant/waist circumference) and a barrel chest. He is 5’10” and weighs 216 pounds. You don’t have any other information on W.R.s risk factors. His admission vitalsigns (VS) are 178/98, 110, 22, and 98.2° F (36.8° C) and he is diaphoretic. The minute W.R. comes through the door of your unit, he demands a cigarette in a loud and angry voice. Looking dyspneic, he states his chest pain is an 8 out of 10 and is experiencing some left arm numbness. Calculate his weight in KG According to the most recent guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, W.R.’s blood pressure (BP) falls under which classification? From the perspective of basic human needs, what is the first priority in his care? Are his admit VS reasonable for a man of his age? If not, which one(s) concern(s) you? Explain why or why not. As the nurse caring for W.R, assuming he is having an MI, what are your next initial actions? (Provide a detailed rationale for each action) Which risk factors are known, and which remain to be determined? How is a pack year calculated? Which laboratory tests might be ordered to investigate W.R.’s condition? If the order is appropriate, place an “A” beside it and provide your rationale. If inappropriate, mark with an “I,” and provide rationales for your decisions. What significant lab tests are missing from the previous list? What do they measure? And how often should they be ordered How are you going to respond to W.R.’s angrydemands for a cigarette? He also demands something for his “heartburn.” How will you respond? What special precautions should you follow when administering morphine sulfate IVP? The pharmacy supplies morphine for injection in vials of 5 mg/mL only. For the first dose, you will be giving4 mg of morphine. How many milliliters will you give for this dose? Mark the syringe with your answer. What will you do with the rest of the morphine in the vial? (Give a rationale for your choice) a. Discard it. b. Save it for the next dose. c. Return to pharmacy d. Discard it with a second witness. Rationale: UPDATE: A witness is necessary to verify that the drug is being disposed of properly. This method prevents the abuse of narcotics by staff (and others) and keeps it from getting into the hands of inappropriate people. You put W.R. on continuous ECG monitoring, and this is the rhythm that you see. 13. What is the rate and what is this rhythm? 14. Does this rhythm need treating at this time? Explain your answer CASE STUDY PROGRESS The cardiac monitor remains in place and soon you see a sinus rhythm with ST elevation (>0.1 mm). It also looks like W.R. might be developing a left bundle branch block (LBBB). Because you know that the closest hospital equipped for invasive cardiac procedures (Angiography, stenting etc.)is 2 hours away, you work closely with your colleagues in the ED along with the ED physician to complete the Fibrinolytic Checklist for STEMI (see CC for checklist) and determined him to be eligible for fibrinolytic therapy-the next best thing for your patient who is exhibiting signs of a STEMI T 15. What is a STEMI? 16. What are the necessary criteria for W.R. to be able to receive fibrinolytic therapy? CASE STUDY PROGRESS At 14:30 pm Mr. R received alteplase, recombinant (tPA) bolus15 mg and then 0.75 mg/kg for 30 minutes and 0.5 mg/kg over the next 1 hour. Calculate the two doses that he will receive. 0.75mg/kg x 98.18 kg = 0.5mg/kg x 98.18 kg = During the fibrinolytic administration, his chest pressure and left arm numbness subsided to 3 out of 10. On the cardiac monitor, his heart rhythm remained in sinus rhythm. However, the ST deviation decreased to less than 0.5 mm, and the LBBB remained the same. Lab results showed elevated troponin I of (150 ng/m) as well as an elevated CK-MB. He stayed in the ICU for 6 hours post fibrinolytic therapy for monitoring prior to admission to the cardiac unit. After the administration of tPA, IV heparin infusion was initiated. While in the ED he also received metoprolol 12.5 mg PO. 17. Why do you think Mr. R was not taken to the urban hospital for an invasive intervention? a. Time b. Physician preference c. Insurance coverage d. Ambulance and acute care center contract Explain your answer 18. Mrs. R. asks you, “If he can’t smoke, why can’t you give him one of those nicotine patches?” How will you respond? 19. Are there any alternatives to help him with his nicotine cravings? Would they be helpful now? 20. Before leaving for the night, Mrs. R. approaches you and asks, “Did my husband have a heart attack? I’m really scared. He eats a lot of fat in his diet and his father died of a heart attack when he was 51.” How are you going to respond to her ? CASE STUDY PROGRESS During day 1 of his hospitalization, 24 hours after the cardiac event, he is placed on a heparin drip. Based on the lab work, the heparin protocol calls for an increase in the drip rate of 1.5 units/kg/hour. Current drip rate: 17 ml/hour. You have: heparin 20,000 units per 500 ml What should the IV pump be set at? (Round to the nearest whole number) Lisinopril 5 mg PO daily was also added to his treatment plan. Labs from Day 1 showed LDL-C of 220 mg/dL, triglycerides of 450 mg/dL, high-density lipoprotein cholesterol (HDL-C) of 30mg/dL, and fasting glucose of 120 mg/dL. His rhythm on the cardiac monitor was stable overnight. He did not experience recurrent chest pain, and his vital signs were stable. During day 2 of his hospitalization, Mr. R was thankful to have survived an AMI. His family was at his bedside, and Mr. R was planning on going home that day. Arrangements were being made for Mr. R to be enrolled in cardiac rehabilitation at the larger urban hospital. His discharge paperwork noted initiation of new medications, including: Metoprolol 25 mg PO daily Lisinopril 5 mg PO daily Aspirin 81 mg PO daily Participate in cardiac rehabilitation for 6 weeks 21. Which of the Acute Myocardial Infarction (AMI) Core Measures were not completed in Mr. R’s care? 22. What teaching would the nurse want to provide for Mr. R? Include medication and disease education. 23. What if they had wanted to treat Mr. R “medically” (conservatively)? What other approaches might be used to treat CAD? THANK YOU!!!! SCIENCE HEALTH SCIENCE NURSING NURSING 1020

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