Case Study Acute Coronary Syndrome and Myocardial Infarction Part 1

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Case Study Acute Coronary Syndrome and Myocardial Infarction Part 1 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 for 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 Vital Signs and Physical Exam Temp 99.2 F/37.3 C HR 128 Regular Resp 24 Regular BP: 108/58 02 Sats: 99% on room air Pain: 5/10 Left arm that radiates into neck General Appearance: Anxious, uncomfortable, body tense Resp: Labored, coarse crackles in bases bilaterally anterior/posterior Cardiac: Pale, diaphoretic, no edema, S1 S2 normal, pulses strong Neuro: A/O x 4 GI: Bowel Sounds x 4 Abdomen soft/non tender GU: Voiding without difficulty, urine clear/yellow Skin: Skin intact
EKG: ST elevation in the inferior leads of II, III, and AVF (Inferior STEMI is usually caused by occlusion of the right coronary artery, or less commonly the left circumflex artery, causing infarction of the inferior wall of the heart. Upon ECG analysis, inferior STEMI displays ST-elevation in leads II, III, and aVF.) Chest X-ray: Scattered bilateral opacities consistent with atelectasis or pulmonary edema Echo: EF of 25% (heart failure) LABS: WBC 10.5 NA+: 135 Hgb 12.9 (slightly low) K+: 4.1 Plt: 225 Glucose: 184 (high-normal for DM2) Neutrophils: 70% Creat: 1.5 (elevated) Mag 1.8 BNP 1150 (high) Troponin: 1.8 (high) Discussion Questions: 1. Based on the information given to you, what Medical Diagnosis do you suspect? What clinical manifestations led you to this conclusion? In this case, I suspect the medical diagnosis of Mrs. Smith is Acute Coronary Syndrome (ACS) with Myocardial Infarction (MI). These clinical manifestations have led me to this conclusion: ST elevation in the inferior leads of II, III, and AVF Elevated BNP and Troponin Intermittent nausea HR 128 Resp 24 Pale, diaphoretic Intermittent epigastric pain that is radiating to neck MI and going into cardiogenic shock 2. What is the underlying cause of Mrs. Smith’s primary problem? The underlying cause of Mrs. Smiths primary problem is likely a myocardial infarction. The ST elevation indicates ischemia or injury to the heart muscle, which is commonly caused by a blockage in the coronary arteries. Diabetes or hypertension leading to ACS 3. What concepts will you focus on for this patient? What are the top 3 priorities you will have for this patient? List 3 Nursing Diagnosis for this patient? Priority concepts: Oxygenation (assess lungs, ABGs, give oxygen)
Perfusion Comfort (emotional support) Teaching and Learning Top 3 Priorities: o Restore blood perfusion (MONA, diuretics, beta blockers) o Relieve pain o Cardiac rehabilitation 3 Nursing Diagnosis: Decreased Cardiac Output Ineffective Tissue Perfusion Impaired Gas Exchange Acute Pain Anxiety 4. Identify interventions you need to implement based on the findings for Mrs. Smith based on the EKG and Echo results. Interventions to implement based on the Echo and EKG results o Administer Metoprolol 5mg IV push, this beta-blocker will reduce the heart rate and the myocardial oxygen demand to help alleviate ischemia. o Monitor for signs of HF and decreased cardiac output. A reduced EF indicates compromised cardiac function, so close monitoring is important to detect and manage potential complications. o Administer Heparin 60 units/kg IV to prevent further clotting in the coronary arteries, reducing the risk of additional ischemic events. 5. What complication would you anticipate on the cardiac monitor regarding the patient’s rhythm? What nursing assessments will identify complications EARLY if it develops? In this case, I would anticipate any ventricular arrhythmias as potential complications, so it is important to continuously monitor EKG for any new arrhythmias and continue regular assessment of vital signs and signs of worsening distress. 6. What Nursing assessments will identify complications for Cardiogenic Shock with pulmonary edema? Rapid breathing Severe shortness of breath Sudden, rapid heartbeat (tachycardia) Loss of consciousness Weak pulse Low blood pressure (hypotension) Sweating Pale skin
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Cold hands or feet Urinating less than normal or not at all 7. What are the goals of care? The client will maintain stable hemodynamics (e.g., normal blood pressure, cardiac output) and report reduced dyspnea and angina, while demonstrating improved activity tolerance. The client will verbalize relief/control of chest pain within the appropriate time frame for administered medications, display reduced tension, a relaxed manner, and ease of movement, and demonstrate the use of relaxation techniques. The client will recognize and verbalize feelings, identify causes and contributing factors, verbalize the reduction of anxiety, demonstrate positive problem-solving skills, and identify and use resources appropriately. Medications ordered by the provider Metoprolol 5 mg IV push Heparin 60 units/kg IV 8. What are the mechanisms of actions for these medications? What are the nursing considerations while giving these medications? Metoprolol is a beta-blocker, used to reduce the heart rate and blood pressure, thereby decreasing myocardial oxygen demand. It is important for nurses to monitor vital signs, especially heart rate and blood pressure before and after administering. It is almost important to educate the patient on the purpose and the potential side effects of the drug. Heparin is an anticoagulant that is used to further prevent clot formation in the coronary arteries. It is important for nurses to monitor for signs of bleeding and to follow heparin protocol per facility. It is also important to educate the patient about the use and potential side effects to be aware of. References Whalen, D., Dunne, C., Dubrowski, A., Mohamed, L., & Parsons, M. H. (2019). Diagnosis and Management of an Inferior ST-elevation Myocardial Infarction: A Simulation Scenario. Cureus, 11(2), e3995. https://doi.org/10.7759/cureus.3995 Salvador, MSN, RN, K. (2023, March 23). Myocardial infarction: Nursing diagnoses, care plans, Assessment & Interventions . NurseTogether. https://www.nursetogether.com/myocardial-infarction- nursing-diagnosis-care-plan/ Mayo Foundation for Medical Education and Research. (n.d.). Cardiogenic shock. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cardiogenic-shock/symptoms-causes/syc- 20366739

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