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W. R., a 48-year old construction worker with a 36-pack/year smoking history, is admitted to your floor with a diagnosis of rule out myocardial infarction (R/O MI). He has significant male-pattern obesity (“beer belly, high WHR), a barrel chest, and reports a dietary history of high-fat food. His wife brought him to the ED after he complained of unrelieved “indigestion.” His admission VS were 202/124, 96, 18, 36.8oC. W. R. was put on O2 2L/nc, an IV of D5W at KVO was started, and he was given sublingual nifedipine (Procardia) in the ED. He was admitted to Dr. Adam’s service. He tells you he’s just fine in a loud and angry voice and demands a cigarette. 

 

Are these VS reasonable for a man his age? If not, which one(s) concern(s) you. State your reasons why?
His BP is dangerously high, and his pulse is rapid for a 48-year-old man who is at rest. Both of these can contribute to myocardial ischemia.
Identify 5 priority problems associated with the care of a patient like W. R.

 

List 3 relevant nursing diagnoses for a cardiac patient like W. R.

 

Which of the following laboratory tests might be ordered to investigate W. R.’s condition? If the order is appropriate, place an “A” in the space provided.

 

 

      CBC –
      EEG in the AM
      Chem 7 (electrolytes)-
      PT/PTT –
      Bilirubin q AM
      Urinalysis –
      STAT 12-lead ECG –
      Type and cross (T & C) for 4 units PRC’s (packed red cells

 

What significant laboratory tests are missing from the above list?
Serial cardiac enzymes; the order should read CK, troponin T and I q8h
How are you going to respond to his angry demands for a cigarette? He also demands something for his “heartburn”. How will you respond?
Address his feelings of loss of control by acknowledging his legitimate issues of craving (cigarettes) and pain or discomfort.
Assure him you will call the physician and get something to help him feel more comfortable.  Explain that smoking could cut off O2 to his heart and increase his pain, burning, or discomfort (use his choice of words).
Reassure him that you will be available if he needs help.  Offer him a choice by asking him whether he would like some milk of magnesia (MOM, magnesium hydroxide) for his heartburn while you contact the physician (you may offer him 30 ml Maalox per your unit protocol).
Ask whether there is anything else you can do to make him more comfortable. (And no, he still can’t smoke!)
Professional confidence and competence communicate themselves to people experiencing fear and help meet their needs for security

You call Dr. Adam’s resident who prescribes 10 mg morphine sulfate IV push q 1 h prn for pain (burning, pressure, angina). You notified the RN.

Explain 2 reasons for this order.

• Morphine sulfate, a narcotic analgesic, will make him more comfortable and help reduce his stress. (With narcotics, be sure to institute a bowel care program to prevent constipation.) 

• Morphine sulfate also functions to dilate pulmonary vessels and decrease preload on the heart. 

• Morphine sulfate also dilates the coronary arteries to increase blood flow and O2 delivery.

 

What special precautions should the nurse follow when administering morphine sulfate IV push?

• Ask about prior allergy, hypersensitivity reaction to morphine sulfate, or impaired liver function.

• Assess VS, especially respirations; LOC with narcotic use; and location and intensity of pain before and 30 to 60 minutes after administration. 

• Administer IVP slowly over a 30-second period. 

• Start with the smallest dose ordered and titrate to eliminate pain.

 

What safety measures/ instructions would you give him before you leave his room?

• He should press the nurses’ call light as soon as he starts to experience any uncomfortable feelings (the word pain may be misunderstood), becomes nauseated, or experiences more “indigestion.” 

• Inform him of his activity status, for example, “The doctor has placed you on bed rest with bathroom privileges. That means if you need to use the bathroom, you need to turn on your call light and someone will assist you. Do not try to get up by yourself.” 

• It is against the law for him to smoke in the hospital. Have his wife take his cigarettes and lighter or matches home. 

• It’s very important that he let you know whether he has to have a bowel movement because during a bowel movement, Valsalva’s maneuver (you may have to explain this) can contribute to sudden death.

 

One of the housekeeping staff asks you, “If the poor guy can’t smoke, why can’t you give him a nicotine patch?” How will you respond?
Explain that use of the nicotine patch should be avoided in patients with severe angina or uncontrolled HTN and for 8 weeks following an MI. Nicotine in the patch will constrict his coronary arteries and may decrease blood flow and O2 to his heart
Before leaving for the night, Mrs. R. approaches you and asks, “Did W. have a heart attack? I’m really scared. His father died of one when he was 51. “How are you going to respond to her question?
It is important to recognize and address Mrs. R.’s anxiety. Reassure her that he is getting excellent care and he will be closely monitored.
Explain that no one can tell whether he’s had a heart attack until the test results come back.
Thank her for the additional information, and tell her you will pass it along to the physician. Tell her that he is going to need her help when he goes home so that he can begin to live a more healthy lifestyle.
When you come to W. R.’s room at 2200 to answer his call light, you see he is holding his left arm and complaining of aching in his left shoulder and arm? What information are you going to gather? What questions will you ask him?
Take his VS.
Evaluate his level of anxiety.
Perform a focused assessment: observe his color; feel for diaphoresis.
Ask about the presence of pain and symptoms: quality; intensity (have W.R. rate his pain on a scale of 1 to 10, with 1 being no pain and 10 being the worst possible pain); location (where did it start and has it traveled anywhere?); and duration.
Ask about nausea
Based on your assessment findings, you decide to call the physician. What information are you going to report to her?
Identify yourself and give information about the patient: W.R. in room ; was admitted to Dr. A.’s service with a diagnosis of R/O MI; arrived at PM; report anything unusual that happened on admission.
Report the most recent set of VS and whether the signs have changed since admission.
Briefly explain the signs you observed on entering the room and report his symptoms.
Report the information given by the wife in case the physician was not informed.
Make sure you have the medication sheet and chart with you when you call so that you can knowledgeably address questions.

It was determined that W. R. has coronary artery disease (CAD). The physician suggested it would be best to treat him medically for now. He was discharged with a referral for a follow-up visit to the cardiologist in 1 week.

Before discharge, what 4 educational issues are you going to discuss with W. R. and his wife?

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 150

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