Acute Coronary Syndrome (ACS) Myocardial Infarction (MI) Case Study - Macomb Community College

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 ● Bold what PMH problem likely started FIRST • Most likely DMII however this likely took place in combination with HTN and HLD ● Highlight what PMH problem(s) FOLLOWED as domino(s) • HTN uncontrolled can lead to CVA as well as the vascular effects from DMII and HLD which can lead to plaque build up and clots that can cause a CVA too Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.2 F/37.3 C (oral) P rovoking/Palliative: Nothing/Nothing P: 128 ( regular) Q uality: Ache R: 24 (regular) R egion/Radiation: Left arm that radiates into neck BP: 108/58 S everity: 5/10 O2 sat: 99% room air T iming: Intermittent-20-30" at a time What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Pulse of 128 Respiratory rate of 24 BP of 108/58 Tachycardia in combination with low blood pressure can be a sign of bleeding or dehydration and in this case is suggestive of diminished cardiac output in which the heart rate is increased to try and compensate but unsuccessfully as evidenced by her low BP. Her increased respiratory rate is likely due to pain and anxiety as well as her shortness of breath. It is always important to assess airway and lung function. She could be having SOB as a result of pulmonary complications from altered cardiac output as well. Current Assessment: GENERAL APPEARANCE: Anxious, appears uncomfortable, body tense RESP: Respirations labored, coarse crackles present in bases bilaterally anterior/posterior CARDIAC: Pale, diaphoretic, no edema, heart sounds regular S1S2 with no abnormal beats, 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: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Christina Hammack and Cash Thomas Coarse crackles in lung bases Pale, diaphoretic Anxiety and tension Coarse crackles suggests fluid in the lungs which is important to note as we continue to assess the patient’s respiratory status in combination with her other symptoms. This is likely the result of pulmonary complications from MI. Pallor and diaphoresis also support this and should be investigated further as to their exact etiology. Anxiety and tension increase respirations and heart rate and it is important to address the patient’s concerns and provide support to help reduce this. 12 Lead EKG: EXTRA CREDIT Interpretation: ST elevation - STEMI Clinical Significance: This EKG is indicative of a myocardial infarction with ST elevation and must be addressed immediately to prevent further damage to the heart. EXTRA CREDIT SECTION-- Location of ST Segment Changes (lateral/anterior/inferior) : Use the diagram below to identify the location of the infarction: Though this content on basic 12-lead EKG interpretation may be above the scope of knowledge required for most programs, take advantage of the APPLICATION of the principle that ischemia causes distinct EKG changes . This is relevant when a patient on routine cardiac telemetry monitoring begins to have NEW ST-T wave changes. If the nurse understands the significance of these changes, a RESCUE of a patient with a change of status can begin! 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 PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1.Establish 2 peripheral IVs 1. Metoprolol 5 mg IV push x1 now 2. Nitroglycerin IV drip-start at 10 mcg and titrate to keep SBP >100 3. Clopidogrel 600 mg po x1 now 4. Aspirin 324 mg (81 mg tabs x4) chew/po x1 now 5. Heparin 60 units/kg IV x1 now 6. To cath lab as soon as team ready Clopidogrel and Aspirin PO Establish IV access Metoprolol IV push Nitro drip Heparin drip Cath lab PO meds should be started first which address the clotting and are quick to administer. Prevents further clots from forming due to decreased cardiac effectiveness and flow. IV push medication given before drips are started so that they are not interrupted. Metoprolol essential to reduce heart rate and cardiac workload. Nitro drip also decreases cardiac workload by vasodilation. Heparin also prevents further clotting. Cath lab is the most important to address MI. PTCA procedure to open the occluded coronary artery. Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Metoprolol 5 mg IV push (5 mg/5 mL vial) Selectively blocks beta1 adrenergic receptors IV Push: 5 mL over 1 minute Volume every 15 sec? 1.25 mL Vitals, especially BP and HR need to be assessed before administration. Contact provider if systolic BP is under 90 or a HR under 60. Patient should be educated to not get out of bed without assistance, and to rise from laying/sitting to standing slowly to prevent orthostatic hypotension. Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Heparin 60 units/kg Weight: 62 kg (1000 units/mL) Inactivates factor Xa and inhibits conversion of prothrombin to thrombin IV Push: 3.7 mL (3720 mLs) Volume every 15 sec? 0.9 mLs Assess for signs/symptoms of bleeding such as dropping blood pressure, hematuria, hematochezia, bruising, petechiae, tarry stools, epistaxis Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) The main priority in the care of this patient is to prevent further complications and prepare the patient to get to the cath lab as soon as possible. Administering the above medications is priority in order to prevent further clotting and to decrease demands on the already damaged heart and secondary is very close monitoring of patient’s vital signs while cath team is assembled. 4. What interventions will you initiate based on this priority? Christina Hammack and Cash Thomas Nursing Interventions: Rationale: Expected Outcome: Close monitoring of vital signs and assessing for complications Medication administration Regular vitals monitoring, close monitoring of telemetry and cardiac rate/rhythm. Monitor for changes in BP and rate especially once medications are initiated. Medication administration is especially important to decrease cardiac demands and prevent further cardiac decompensation. Starting two IVs is important in case of emergency and since she has multiple drips running. Patient will remain stable and can get to the cath lab in stable condition as soon as possible for procedure Medications will reduce demand on the heart and keep the patient stable until cath lab can start PTCA 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Respiratory and cardiac body systems 6. What is the worst possible/most likely complication to anticipate? Patient can go into V-Tach which can progress to V-Fib if there isn’t correct and immediate interventions 7. What nursing assessments will identify this complication EARLY if it develops? Correctly identifying VTach and VFib rhythm on cardiac monitoring. If patient is in VTach, assess for pulse and LOC. If patient has VFib, move immediately to life saving interventions. 8. What nursing interventions will you initiate if this complication develops? If patient is in VTach and has a pulse, patient will need to be cardioverted. If patient is in VTach with no pulse or in VFib, patient will need to be hooked up to a defibrillator. Pulseless VTach and Vfib interventions will also include high quality chest compressions, positive pressure oxygenation, and calling a code. 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Patient and family will need immediately emotional support due to the patient’s condition rapidly deteriorating. 10. How can the nurse address these psychosocial needs? The nurse can address this by quickly getting them in contact with emotional support staff offered by the facility, such as a chaplain. Evaluation: Two Days Later… JoAnn had an angiogram that revealed an occluded proximal right coronary artery (RCA). She received two bare metal stents with 0 percent residual stenosis. She has been in the intensive care unit (ICU) the past two days and is now transferring to the cardiac telemetry floor. She has been receiving scheduled furosemide 40 IV mg every 12 hours. Her 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: Christina Hammack and Cash Thomas Potassium Glucose Creatinine The rise of potassium and worsening of the creatinine is indicative that the kidneys are compromised and not able to properly excrete the K. The glucose is still high, but improving. The high glucose to be due to the high amount of stress that is being put on the body from its attempts from recovering from an acute MI. Worsening Improving Worsening Current Assessment: GU: One hour post furosemide administration IV, continues to have no urine output. 1. Has the status improved or not as expected to this point? Status of the patient has worsened due to the lack of urine output after the furosemide was given. 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Nursing priority should be modified to include assessment of kidney function (urine output, creatinine monitoring), but otherwise priorities remain the same to implement medication administration for diuresis and maintain close monitoring. Additional choices regarding diuresis and plan of care will come from the provider, but given the continued decline in her condition it is very important to communicate effectively between transitions of care between shifts and make sure to advocate for the patient and communicate needs when working interprofessionally so that more aggressive management can take place and turn her condition around. 3. Based on your current evaluation, what are your nursing priorities and plan of care? Nursing priorities would be to identify the cause of kidney failure, communicate immediately with the provider, and identify interventions to lower the patient’s potassium levels. The rising levels can cause cardiac arrhythmias and cause further damage to the cardiac system. The plan of care would possibly be to increase the dosage of furosemide, change to a different type of diuretic, and to put in a stat order for a nephrology consult. With the rising K, the patient will need to be put hooked up to tele, and respiratory status should be closely evaluated, the fluid could possibly begin to be retained in the lungs again. What health promotion needs does this patient have? (make a bullet point list of needs) -Patient needs to be educated on the importance of smoking cessation -Nutrition counseling - low sodium diet (avoid frozen, processed foods and added salts), low potassium (avoid melon, avocado, leafy greens, and salt substitutes) -Gradually increasing exercise tolerance - discharge planning should have referral for cardiac rehabilitation -Important to follow up with nephrology and cardiology appointments -Extensive education regarding medications at discharge as normal regimen will likely change