Acute Coronary Syndrome (ACS)/Acute Coronary Syndrome (ACS), Study Guides, Projects, Research of Nursing

Download Acute Coronary Syndrome (ACS)/Acute Coronary Syndrome (ACS) and more Study Guides, Projects, Research Nursing in PDF only on Docsity! Christina Hammack and Cash Thomas Acute Coronary Syndrome (ACS) Myocardial Infarction (MI) JoAnn Smith, 68 years old Primary Concept Perfusion Interrelated Concepts ​(In order of emphasis) 1. Fluid and Electrolyte Balance 2. Clinical Judgment 3. Communication 4. Collaboration Christina Hammack and Cash Thomas 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 20-30 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? RELEVANT Data from Present Problem: Clinical Significance: d3 days of progressive weakness Denies chest pain, reports epigastric pain with nausea radiating to her neck and shortness of breath dWomen can present with alternative symptoms than men when experiencing a myocardial infarction so it is important to consider them in this context as opposed to ruling out MI since it is not the “typical” presentation RELEVANT Data from Social History: Clinical Significance: Lives with a spouse Heavy smoker, 40 year history Anxious appearing Patient has a support person who lives with her and can help provider care which is important to keep them involved in the care as appropriate (and legally - patient gives consent to share information). Significant smoking history means patient has had prolonged vasoconstriction and diminished lung capacity; smoking also leads to heart disease. Anxiety can alter vital signs like increased heart rate and blood pressure. What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medications treat which conditions? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: ● Diabetes mellitus type II ● Hypertension ● Hyperlipidemia ● Cerebral vascular accident (CVA) with no residual deficits ● Gastro-esophageal reflux disease (GERD) ● Anemia-Iron deficiency 1. Iron Sulfate 325 mg PO daily 2. Lisinopril 5 mg PO daily 3. Simvastatin 20 mg PO daily 4. Aspirin 81 mg PO daily 5. Clopidogrel 75 mg PO daily 6. Omeprazole 20 mg PO daily 7. Metformin 500 mg PO bid 1. Iron supplement 2. ACE inhibitor 3. Antihyperlipidemic (-statin) 4. Salicylate 5. Platelet aggregation inhibitor 6. Proton pump inhibitor 7. Biguanide antidiabetic 1. Replace iron 2. Reduce BP 3. Reduce cholesterol 4. Reduce platelets/prevent clotting 5. Reduce platelets/prevent clotting 6. Reduces stomach acidity 7. Reduces blood glucose levels One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology (if applicable), which disease likely developed FIRST that created a “domino effect” in her life? Christina Hammack and Cash Thomas 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 ​The chest x-ray confirms that there is fluid in the lungs likely as a result of pulmonary complications (most likely pulmonary edema) due to decreased cardiac function leading to pulmonary congestion. 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% ​Significantly reduced ejection fraction (normal is ~65%) meaning that the left ventricle is having a very hard time ejecting blood to the rest of the body due to myocardial ischemia and therefore reduced cardiac capabilities. Lab Results: Complete Blood Count (CBC): Current: High/Low/WNL? 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? RELEVANT Lab(s): Clinical Significance: All within normal limits No signs of infection (WBC), anemia/blood loss (HgB), clotting issues (platelets) or infection/immunity issues (neutrophils). Christina Hammack and Cash Thomas 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 Elevated Creatinine (0.6-1.2 mg/dL) 1.5 Elevated Misc. Labs: Magnesium (1.6-2.0 mEq/L) 1.8 WNL RELEVANT Lab(s): Clinical Significance: Elevated blood sugars and creatinine Electrolytes normal Important to monitor blood sugars as stress can lead to higher blood sugars and this still needs to be managed even though her DMII is not the primary concern right now. Creatinine is very significant in assessing kidney function and elevated creatinine is definitely concern as it can be indicative of kidney failure or poor renal perfusion in the setting of decreased cardiac output. Electrolytes should continue to be monitored as these can change quickly and impact patient’s overall fluid status (sodium) and cardiac function (potassium). What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Cardiac Labs: Current: High/Low/WNL? Troponin (<0.4 ng/mL) 1.8 ​High BNP (B-natriuretic Peptide) (<100 ng/L) 1150 High What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: Troponin and BNP ​Troponin is a cardiac marker present in MI and peaks a few hours after the MI begins and BNP is specifically related to heart failure which in the setting of MI is indicative of cardiac decompensation. Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Troponin Value: 1.8 ​ng/mL Critical Value: Over 1.5 ​Troponin is a cardiac biomarker that is highly indicative of cardiac muscle injury. This occurs when there is reduced oxygen supply to the cardiac muscle tissues, resulting in troponin levels to rise. ​Especially close monitoring of cardiac rhythm (telemetry monitoring and EKG). MI means that patient needs to go to the catheterization lab as soon as possible to re-establish cardiac blood flow. MONA (morphine, oxygen, nitroglycerin, aspirin) to reduce cardiac O2 demands. Christina Hammack and Cash Thomas Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Acute STEMI with pulmonary manifestations. Patient is also at risk for cardiogenic shock due to significantly reduced LV ejection fraction and her dropping BP and tachycardia. 2. What is the underlying cause/pathophysiology of this primary problem? Underlying cause of a myocardial infarction is the occlusion of the coronary arteries leading to ischemia of the myocardial tissue and subsequent cardiac decompensation and diminished output. Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Establish 2 large bore peripheral IVs Metoprolol 5 mg IV push x1 now Nitroglycerin IV drip-start at 10 mcg and titrate to keep SBP >100 Clopidogrel 600 mg po x1 now Aspirin 324 mg (81 mg tabs x4) chew x1 now Heparin 60 units/kg IV x1 now To cath lab as soon as team ready ​2 large bore peripheral IVs will be needed in order to deliver a large amount of drugs to the patient in the initial stages of the patient’s acute condition. Metoprolol is needed to reduce the patient’s HR Nitroglycerin is needed in order to vasodilate the patient’s vessels in order to increase the amount of blood and oxygen to reach the cardiac muscles Clopidogrel is used in order to prevent any clots that may have caused the reduced blood flow to the cardiac muscles from forming and causing more damage Aspirin is used with clopidogrel to increase the anticoagulant effects Heparin will reduce the further risk of clotting considering the patient has a history of stroke and is showing signs of a acute MI Patient’s vessels need to be looked at and possibly stented in order to treat the cause of the patient’s presenting problem ​Drugs will be delivered through a patent IV site HR decreases Patient’s HR and chest pain is reduced Prevents clot formation Prevents clot formation Prevents clot formation Patient has blockage removed by increased circulation, and cause of presenting symptoms has been identified Christina Hammack and Cash Thomas creatinine increased from 1.7 to 2.1 today. The last dose of furosemide was given four hours ago. She has had 100 mL urine output the past four hours. She fatigues easily, but tolerates being up in the chair for short periods of time. Faint basilar crackles persist bilaterally and her O2 is at 2 liters per n/c. What data from this history are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Data from History: Clinical Significance: Increasing creatinine and Lasix administration q12 Persistent crackles Fatigue Creatinine continues to rise which is indicative of renal dysfunction. Given the patient’s history this is likely related to fluid overload which also explains her persistent crackles in her lungs. It is important to continue furosemide and monitor urine output closely (may need a change in dose to achieve a more therapeutic effect? Report to provider) Fatigue is normal following a MI, but providing support and advocating for patient to participate with PT/OT/Rehab is important in preventing further complications Current VS: Most Recent: P-Q-R-S-T Pain Scale: T: ​97.2 F/36.2 C (oral) T: ​97.5 F/36.4 C (oral) P​rovoking/Palliative: P: ​76 ​(​regular/irregular) P: ​82 ​(​regular) Q​uality: Denies pain R: ​20 (regular) R: ​20 (regular) R​egion/Radiation: BP: ​122/58 BP: ​116/68 S​everity: O2 sat: ​95% room air O2 sat: ​94% room air T​iming: Current Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Denies SOB, non-labored respiratory effort, breath sounds equal aeration bilaterally with faint crackles in both bases CARDIAC: Pink, warm & dry, 1+ pitting edema in lower extremities, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants GU: 50 mL urine output since furosemide IV administered two hours ago, urine clear/yellow SKIN: Skin integrity intact, femoral puncture site soft, non-tender with no drainage, redness, or bruising 1. What clinical data are RELEVANT and must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Christina Hammack and Cash Thomas Denies pain 95% O2 sats ​All vitals are WNL, and it is especially important that the patient denies pain and has a appropriate O2 saturation. This indicates that the cardiac muscles are receiving adequate oxygenation and the cardiac system is most likely functioning at an acceptable level. RELEVANT Assessment Data: Clinical Significance: 1+ pitting edema BLE Faint crackles ​1+ pitting edema indicates that there is excess fluid in the patient’s system, this is indicative that the diuretic is not working properly d/t the peripheral edema being newly assessed and not present on the last assessment. Faint crackles indicate that the pulmonary edema is improving, but possibly indicating that the fluid is shifting from the lungs to other parts of the body. 2. Has the status improved or not as expected to this point? While her trip to the cath lab was successful, the continued rise and creatinine paired with crackles and edema is still indicative of ongoing cardiac ineffectiveness as well as renal issues secondary to this. If this is not addressed and the additional fluid removed, she will likely experience more severe cardiac and renal complications due to the issues in perfusion related to fluid volume overload. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Our priorities of close monitoring and medication administration would remain the same. It is important to communicate and advocate for the patient and let the provider know of the changes in patient condition. Monitoring, assessing, and trending vitals and labs are important to determine changes and what is/isn’t working. Monitoring closely prevents further decompensation while the regimen is adjusted to better support the patient’s needs and reduce fluid overload. Two hours later… JoAnn is resting quietly in bed. Foley catheter assessment reveals no new urine in bag from previous assessment two hours ago. Bladder scan reveals no residual urine. Review of labs reveal increased creatinine. The primary nurse gives the following SBAR to the on-call cardiologist: S​ituation: Name/age: ​Joann 68YO Female BRIEF summary of primary problem: ​Day of admission/post-op #: Presented to ED with nausea, epigastric pain radiating to back, SOB, and progressively worsening weakness. Tachycardic, low BP, tachypnea. EKG demonstrated STEMI. Cath lab success but now with ​renal concerns and no urine output in last 2 hours. B​ackground: Christina Hammack and Cash Thomas Primary problem/diagnosis: STEMI RELEVANT past medical history: HLD, DMII, HTN, Smoking history of 40 years, history of CVA A​ssessment: Vital signs: Current VS: T: 97.2 F/36.2 C (oral) P: 76 (regular/irregular) R: 20 (regular) BP: 122/58 O2 sat: 95% room air RELEVANT body system nursing assessment data: ​Cardiovascular and respiratory TREND of any abnormal clinical data (stable-increasing/decreasing): ​Creatinine trending upwards INTERPRETATION of current clinical status (stable/unstable/worsening): ​Worsening R​ecommendation: Suggestions to advance plan of care: ​Speak with provider regarding diuretic therapy (needs more aggressive approach) and continue to closely monitor urine output, lung sounds, and vital signs. Continued monitoring of creatinine. Priority is need for diuresis. The physician addresses your concern and orders a repeat basic metabolic panel (BMP and repeat x1 furosemide (Lasix) 40 mg IV push. You obtain the following results one hour later: Basic Metabolic Panel (BMP): Current: High/Low/WNL? Most Recent: Sodium (135-145 mEq/L) 135 WNL 132 Potassium (3.5-5.0 mEq/L) 5.9 High 4.1 Glucose (70-110 mg/dL) 152 High 184 Creatinine (0.6-1.2 mg/dL) 2.9 High 2.1 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: