JoAnn Smith _ Acute Coronary Syndrome_ Myocardial Infarction (MI)_Case_Study | Acute Coronary Syndrome (ACS) _ UNFOLDING Reasoning Case Study-STUDENT

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. CollaborationChristina 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- - - - - - - - - - - - - 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