Cardiovascular Alterations Case Study

Cardiovascular Alterations Case Study S.P., a 65y.o. female presented to the ED with complaints of headache, nausea, vomiting, and chest discomfort. The patient reports not taking her medications prior to coming to the ED. Her antihypertensive were administered in the ED. She was admitted to the telemetry floor with the diagnosis of “Rule out MI and hypertension.” Past Medical History 1. DM type 2 2. HTN 3. GERD Medication’s: Glipizide 5mg daily p.o Lisinopril 5mg daily p.o Protonix 40mg daily p.o Admission Vitals and labs Vital Signs B/P 190/105 mmHg HR 72 bpm Respirations 20 breaths/min Temperature 38.6 degrees Complete Blood Count Hgb 12.1 g/dL Hct 36% RBC’s 4.5 x 106 WBC’s 7,000/mm3 Cardiac Enzymes Troponin 0.01 ng/mL CK 170 U/L CK-MB 1.2 ng/mL Myoglobin 56ng/mL BNP 65 pg/mL Electrolyte Panel Na+ 135 mmol/L K+ 4.8 mmol/LCl- 100 mmol/L Ca++ 8.5 mg/dL Creatinine 0.7 mg/dL Laboratory results and vital signs were telephoned to her physician. Her physician order’s included the following: 1. Resume home medications- Lisinopril, Glipizide, and Protonix 2. Start Aspirin 325mg p.o, Plavix 75 mg p.o, heparin 5,000 units subcu. every 8 hours, and Toprol XL 100mg p.o BID hold if systolic BP 90 or diastolic pressure of 60 and HR 60. 3. PRN medications: give NTG 0.4 mg sublingual x3 for CP, Diltiazem 10 mg IV PRN for SBP of 160 every 4 hours. 4. Cardiac enzymes and EKG q 6 hours x3 5. Vital signs q 4 hours 6. Repeat vital signs in 1 hour Repeat vital signs are taken: Vital Signs B/P 220/115 mmHg HR 72 bpm Respirations 20 breaths/min Temperature 38.6 degrees The patient complaints of a worsened headache. You call the physician with the S.P.’s vital signs and assessment findings. The physician diagnoses that S.P. is in Hypertensive Urgency. The patients is transferred to the ICU with orders to begin a Nitroglycerin gtt at 5mcg/min. The order is to titrate to a goal blood pressure of 160/90 in the first hour. 1. What is the mechanism of action of Nitroglycerin? How does it treat hypertension/hypertensive urgencies? 2. Why did the physician choose to only lower the blood pressure to 160/90? What would happen if the blood pressure would be lowered to “normal” within the first hour? What organs are at highest risk of being affected by too rapid of a change in blood pressure?. Intensive Care Unit Admission After S.P.’ admission to the ICU, the blood pressure was lowered per the physican orders. S.P’s headache improved. She continues to complain of chest discomfort. EKG was done revealing: ST elevation in leads II, III, and AVF (Inferior wall) Repeat cardiac enzymes are below: Cardiac Enzymes Troponin 1.5ng/mL CK 270 U/L CK-MB 2.0 ng/mL Myoglobin 59ng/mL BNP 85 pg/mL You call these findings to the physician. The physician orders that the patient is prepared for the cath lab. 3. Discuss the pathophysiology of Acute Coronary syndrome. What is done in the cath lab to relieve the pathological mechanism of coronary injury. S.P. returns to the ICU after undergoing PTCA and receiving a stent to her Left Anterior Descending (LAD) coronary artery.Post Cath orders include: 4. Explain what is the rationale behind each one of these orders? 1. HOB 30 degrees for the next 12 hours 2. Vitals and ECG q 15x4, then q 30x2, then q hour x4 3. Assess femoral artery site q 15x4, then q 30x2, then q hour x4 4. Check dorsalis pedis and posterior tibial pulses q 15x4, then q 30x2, then q hour x4 5. ReoPro 0.125 mcg/kg/minDuring your third 15min check post- cath, the patient begins to complain of lightheadedness. You check vital signs and the ECG. Vital Signs B/P 80/50 mmHg HR 38 bpm Respirations 24 breaths/min Temperature 38.6 degrees ECG= Complete heart block You call the physician with these new assessment findings. The physician instructs you to call a Rapid Response, administer 0.5mg IV Atropine, and to prepare for transcutaneous pacing. 5. What is transcutaneous pacing? What are the indications for transcutaneous pacing? 6. What important patient teaching should the nurse give about transcutaneous pacing? 7. What put this patient at risk for complete heart block? The patient is hemodynamically stable with transcutaneous pacing. She is taken to the Electrophysiology lab for insertion of a permanent pacemaker. 8. What are the indications for permanent pacemakers? (provide 3 indications)9. What important patient teaching should the nurse give about permanent pacemakers? (provide 3 patient teachings) 10. What are important assessments to be done after the patient returns from the electrophysiology lab after a permanent pacemaker insertion? (provide 3 assessments)