Instructions: Read through the case study, answering

Instructions: Read through the case study, answering the questions asked in bold. The objective is to use critical thinking skills to work through the possible problems the patient is having as well as treatments and expected outcomes. Answer each as it comes along before proceeding to the next. . I’m looking for critical thinking and working through an organized process to determine what you think is happening and what should be done. If you put your answers in a different color it helps me to find them easier! Case Study A 54-year-old male presents to the ED with a history of a syncopal episode while out walking his dog just prior to arrival. He also states that he has retrosternal chest pain that radiates to his jaw rated 8/10. He is alert and oriented. His airway is patent and he’s able to speak in full sentences though somewhat short of breath. The respiratory rate appears to be normal rate but slightly labored. Skin is somewhat pale and slightly diaphoretic. He is sitting up and his wife is at the bedside with him. What are your initial actions? What assessments do you want to complete? What do you want to ask? An 18 gauge IV was initiated, labs drawn, EKG completed, chest xray completed and assessment information as follows: Assessment findings: PMH: History of smoking ½ pack/day, Hypertension, Diabetes Mellitus Type II Medications: Amlodipine, metformin and baby aspirin Allergies: Penicillin VS: T 36.5, P 120, BP 210/100, RR 20, SpO2 93% on RA, RR 20, pain 8/10 Focused assessment: Lungs are clear on auscultation. Heart sounds are normal with S1 & S2. No adventitious sounds noted on chest auscultation. Skin is pale and diaphoretic. No edema noted to extremities. Capillary refill <2 seconds. Pulses are palpable. Pt complains of nausea. EKG: Unremarkable with sinus tachycardia Chest xray: Widened Mediastinum, lungs clear-no infiltrate Labs: Test Result Units Reference Range CBC WBC 9.0 X10E3/uL 4.0-10.5 Hemoglobin 14 X10E3/uL 12.5-17 Hematocrit 34 % 36-50 Platelets 260 X10E3/uL 140-415 CMP Glucose 125 mg/dL 65-99 Sodium 137 mmol/L 135-145 Potassium 4.9 mmol/L 3.5-5.0 Chloride 101 mmol/L 97-108 Lactate 2.9 Troponin 0.35 <0.02 ABG pH 7.33 7.35-7.45 HCO3 24 22-26 CO2 33 35-45 A differential diagnosis is the process of differentiating between two or more conditions which share similar signs or symptoms. This is where you come up with all the possibilities of what is wrong with the patient. This is the doctors job technically, but before long, if not already, you will start doing this as well. You cannot officially diagnose the patient, but the better you become at anticipating what is wrong, the better care for the patient. What are your differential diagnoses? Come up with at least 3 and explain what assessment information above makes you think this is a possibility. What additional tests/procedures etc need to be completed to determine the diagnosis. Your patient starts complaining of a "tearing" sensation in their chest that has become more intense. Current VS: P: 123, SPO2 95% on 3 lpm NC, BP left arm 213/104, right arm 160/80, RR 22, pain 10/10 Repeat EKG shows no changes, and no ST elevation noted What diagnosis is becoming more likely? I can't really continue with the case without giving you the answer so if you're reading ahead, make an educated guess before you move to the next paragraph. Even if you're wrong. This patient is experiencing an aortic dissection. What assessment data supports this diagnosis? Are there any definitive ways to test this diagnosis? What are the risk factors that make a patient more likely to develop this condition? In patients with dissecting aortic aneurysms, it is important to control blood pressure and heart rate. We want the heart rate low and the blood pressure low as to not place extra pressure on the part of the aorta that is tearing apart. Goals may be as low as a HR of 50 and a MAP of 65-75 What medications are options for controlling blood pressure and heart rate? Choose at least 2. Hint: use IV medications. Look at drugs.com in the professional section if you need help. What are you going to do for pain control? How will that affect the above medications and VS? Where does this patient need to go? What procedure needs to be done? How soon should it be done? If this patient had been having a heart attack (and lets say we saw EKG changes including ST elevation): What are the tests and assessment that confirm STEMI What are the immediate interventions? Name 3 medications that would be used for a STEMI and what their purpose is in STEMI. Where should the patient go next? Also read this portion after completing the questions above: According to the Merck Manual (paying attention to the mortality of this disease process): Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and creation of a false lumen (channel). The intimal tear may be a primary event or secondary to hemorrhage within the media. The dissection may occur anywhere along the aorta and extend proximally or distally into other arteries. Hypertension is an important contributor. Symptoms and signs include abrupt onset of tearing chest or back pain, and dissection may result in aortic regurgitation and compromised circulation in branch arteries. Diagnosis is by imaging tests (eg, transesophageal echocardiography, CT angiography, MRI, contrast aortography). Treatment always involves aggressive blood pressure control and serial imaging to monitor progression of dissection. Surgical repair of the aorta and placement of a synthetic graft are needed for ascending aortic dissection and for certain descending aortic dissections. Endovascular stent grafts are used for certain patients, especially when dissection involves the descending thoracic aorta. One fifth of patients die before reaching the hospital, and up to one third die of operative or perioperative complications. (Farber & Ahmad, 2019, para 1). Up to 80% of patients with a dissection aortic aneurysm will not survive. The half of patients who survive making it to the hospital need to be rapidly assessed and diagnosed and sent to surgery. The closer they are to a facility that can do the surgery the more likely the other 50% are to make it. Farber, M & Ahmad T. S. (2019). Aortic Dissection. Retrieved from https://www.merckmanuals.com/professional/cardiovascular-disorders/diseases-of-the-aorta-and-its-branches/aortic-dissection SCIENCE HEALTH SCIENCE NURSING NURS 4471

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