Acute Coronary Syndrome/Acute Myocardial Infarction Case Study, Exams of Nursing

Download Acute Coronary Syndrome/Acute Myocardial Infarction Case Study and more Exams Nursing in PDF only on Docsity! [Date]  ACUTE CORONARY SYND ROME (ACS) MYOCARDIAL INFARCTION (MI ) CASE STUDY 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? Patient been having left sided weakness for three days, shortness of breath increases with activity, denies chest pain, she also has epigastric pain with nausea that has been intermittent for 2o-30 minutes over the last three days epigastric pain has gotten worse now radiating into her neck and she also feels anxious and she smokes one pack per day for the past 40 years These signs and symptoms are related to a coronary artery disease and she could be having a heart attack [Date] 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 [Date] Interpretation: Clinical Significance: Location of ST Segment Changes (lateral/anterior/inferior): Use the diagram below to identify the location of the infarction: Radiology Report: Chest x-ray What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? Scattered bilateral opacities consistent with atelectasis or pulmonary edema is consistent with heart failure Radiology Report: Echocardiogram AND Chest X ray The ejection fraction of 25% is further indication of heart failure and likely a cause of the pulmonary edema Scattered bilateral opacities consistent with atelectasis or pulmonary edema is consistent with the primary diagnosis of heart failure. This finding explains the patient’s shortness of breath. [Date] What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? The ejection fraction of 25% Lab Results: Complete Blood Count (CBC): Current: High/Low/WNL? [Date] 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? All labs are within normal limits. 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 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? The patient glucose is high and creatine the patient kidney function is decreasing. Cardiac Labs: Current: High/Low/WNL? Troponin (<0.4 ng/mL) 1.8 HIGH BNP (B-natriuretic Peptide) (<100 ng/L) 1150 HIGH [Date] Aspirin 324 mg (81 mg tabs to prevent heart attack or stroke x4) chew x1 now Heparin 60 units/kg x1 now to prevent blood clots from forming To cath lab as soon as team to examine the arteries of the heart and the chambers of the heart and treat any stenosis or abnormality found. ready Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) 4. What interventions will you initiate based on this priority? I will assess patient vital signs , administer anti- angina medications and administer O2 [Date] 4. What body system(s) will you most thoroughly assess based on the primary/priority concern The lungs listen for signs of congestion and check for abnormal sounds, also examine the veins in patient neck and check for fluid buildup in your abdomen. 5. What is the worst possible/most likely complication to anticipate? Death, risk of bleeding, another heart attack, stroke 7. What nursing assessments will identify this complication EARLY if it develops? dyspnea, shortness of breath, fatigue, and edema. 8. What nursing interventions will you initiate if this complication develops? 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Psychosocial needs to meet basic needs includes their emotional and mental well-being [Date] ps 10. How can the nurse address these psychosocial needs? Nurses can provide both care and support with verbal and written advice to patients, by building dialogue with patient’s nurses can begin to understand how patients view themselves as individuals, what is important to them, and how their relationship with others may affect their decisions and their ability to live with those decisions during their treatment and Beyond. Good communication and assessment skills are essential to building a rapport with patients and can help the nurse develop a clinical relationship with the patient and their family.