Case Study #1 – Cardiac

 This case study is meant to be completed individually.  Please place questions and answers into a Word document and upload into the drop box when complete.  APA formatting is not necessary, but you must cite your work and avoid copy/pasting from any source…paraphrase!

Mr. Jones is a 52-year-old obese man with a medical history of gastric reflux and degenerative arthritis.  He arrives at the emergency department with his wife. They had been to dinner and a movie. During the movie Mr. Jones began experiencing excruciating chest pain that radiated to his jaw and left arm.  He appears short of breath and diaphoretic. He reaches the registration window when he suddenly collapses. The nurses place him on a stretcher. He has no pulse, and the monitor reveals ventricular tachycardia.  He was successfully converted to sinus rhythm after one minute of CPR and one defib/shock at 300 joules.

Mr. Jones regains consciousness after his rhythm converts.  He has a blood pressure of 130/92, a heart rate of 112, and a respiratory rate of 24.  O2 is immediately started at 3 liters/minute. Three 18 g IV’s are started, lab work is drawn (CPK-MB, Troponin, CBC, PT, PTT, type and screen & Chem 21) and a 12-lead EKG is preformed. He still complains of chest pain (8/10) and nausea. Sublingual NTG 1/150 gr is given.  The 12-lead EKG reveals sinus tachycardia, a PR interval of 0.24, and 3 mm ST-segment elevation in leads V2, V3, & V4. 

After being admitted to the CCU Mr. Jones complains of chest pain continuing at 8/10. Mr. Jones is given IV morphine 4mg and a nitroglycerin gtt.  This drip was started 10 mcg/min and titrated up every 3-5 minutes until the pain was relieved at 50 mcg/min.  His blood pressure drops to 84/40.  He is pale and diaphoretic.  He is prepared for a percutaneous coronary intervention (PCI) and taken to the cardiac cath lab.

Questions

1. What classic signs and symptoms did Mr. Jones experience which would indicate myocardial infarction (MI)? What are the specific pathophysiological reasons for each of these signs and symptoms?
2. What ECG changes indicate myocardial injury? According to the ECG, which coronary arteries were experiencing occlusion and subsequently what area of the heart was being affected? (List the type of change and the coronary artery most often associated with changes in V2, V3, and V4.
3. What are three things the nurse can do to speed up the time between admission and intervention? 
4. How is a heparin drip calculated and what is the nurses’ role in maintaining this medication?
5. If the blood pressure drops while the patient is receiving nitroglycerin, should the nitro be shut off completely?
6. Why is morphine the drug of choice for cardiac pain?
7. With this type of MI, an intra-aortic balloon pump may be inserted.  What are the two main functions of the IABP?
8. What are three differences between CKMB’s and Troponin blood tests?
9. After the angioplasty and stent placement, Mr. Jones is admitted to the CCU for monitoring.  What are the nursing considerations and assessment priorities for a patient with an arterial sheathe in place?
10. Once admitted to the CCU, what nursing diagnosis would be the top priority? (The diagnosis must include the “related to” and “as evidenced by”). 
11. After angioplasty, the patient begins experiencing frequent PVC’s.  What does this indicate and what should be done about it?
12. If the patient begins to experience chest pain post angioplasty, what is the first thing the nurse should do?
13. Patient teaching should consist of education about risk factors and lifestyle modifications.  What are three things the nurse could teach Mr. Jones about prior to discharge?
14. Mr. Jones is going to be discharged on Plavix, Lopressor, Zocor, and Aspirin.  List one teaching point for each of these medications.
15. Discuss the American Association of Critical Care Nurses (AACN) Synergy Model and how this concept would be important in this patient’s care.