Case Study Acute Coronary Syndrome and Myocardial Infarction Part 2

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College of the Sequoias *

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Nursing

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Apr 29, 2024

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docx

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Case Study Acute Coronary Syndrome and Myocardial Infarction Part 2 HPI: 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). 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. PMH: Type 2 DM, Hypertension, Hyperlipidemia, CVA with no deficits, GERD. Anemia Home Medications : Iron 325 mg daily, Lisinopril 5 md daily, Simvastatin 20 mg daily, Aspirin 81 mg daily, Clopidogrel 75 md daily, Omeprazole 20 mg daily, Metformin 500 mg twice a day Evaluation Two Days later Mrs. Smith 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 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. Vital Signs and Physical Exam Temp 97.2 F/36.2 C HR 76 Regular/irregular Resp 20 Regular BP: 122/58 02 Sats: 95% on room air

Pain: Denies pain General Appearance: Resting comfortably, appears in no acute distress Resp: Denies SOB, Non labored, breath sound equal with faint crackles in both bilateral bases Cardiac: Pink, warm and dry 1+ pitting edema in lower bilateral extremities, S1 S2 regular, pulses strong and equal Neuro: A/O x 4 GI: Bowel Sounds x 4 Abdomen soft/non tender GU: 50 ml urine output since Furosemide IV administration 2 hours ago, urine clear/yellow Skin: Skin intact, femoral puncture site soft, non-tender with no drainage, redness or bruising EKG: NSR with frequent PVC’s Bladder Scan: shows no residual urine LABS: NA+: 135 K+: 5.9 Glucose: 152 BUN: 58 Creatinine 2.9 (increased from 2.1 from the last set of labs) 1. What are your concerns? Mrs. Smith's elevated creatinine level (2.9 mg/dL) and increasing trend despite receiving furosemide raise concerns about acute kidney injury (AKI) or worsening renal function. The presence of frequent premature ventricular contractions (PVCs) on EKG may indicate cardiac irritability or electrolyte imbalances, particularly with the elevated potassium level (K+ 5.9 mEq/L). Persistent symptoms of fatigue and basilar crackles on lung auscultation suggest potential fluid overload despite diuretic therapy. 2. What is the relationship between the K+, BUN and Creatinine? Elevated potassium (K+) levels can result from impaired renal function, as seen with elevated creatinine and BUN levels. The kidneys play a crucial role in maintaining electrolyte balance, and impaired renal function can lead to potassium retention. Elevated BUN (blood urea nitrogen) and creatinine levels indicate decreased kidney function, likely due to renal hypoperfusion secondary to cardiac issues or nephrotoxicity from medications like furosemide. 3. Based on this current evaluation, what are your 3 Nursing priorities for your patient?

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