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Transcript

MINUTES IS MUSCLE

Created by: Becky Fitzgerald 2018

Who is our patient

Case Study

52 year old male

252 lbs (114.5 kg)

Father of 4

Full time construction worker

Chest pain radiating to his left arm and jaw at 0200 hours

Went to a small rural hospital to be assessed first.

  • 0800 hours: Arrived at large tertiary center.
  • Severe sub-sternal chest pain that refers down both arm and into neck
  • Shortness of breath
  • Maalox at home with no relief
  • ST segment elevations with a 12 lead EKG

What is his history

Episodic "chest tightness' for past 6 months

Smokes 1 pack/day for 35 years

Drinks 3-4 beers/day

Father died of a heart attack at 55

Total cholecystectomy 10 years ago

Elevated cholesterol

Gastroesophageal Reflux Disease

NIDDM (Type 2 diabetes)

No known drug allergies

History

Current Vital Signs

BP: 96/50

HR: 62

RR: 14

LABS

K 3.0 mmol/L

Sodium 142 mmol/L

Glucose 16.5

Creatinine 168 umol/L

Troponin 4.2 mcg/L

Current VS

NORMAL VALUES FOR CARDIAC MARKERS

Cardiac Markers

Marker Reference Range

Cardiac troponin < 0.1 ng/mL *

Creatine kinase MB (CKMB) <10 ng/mL

Myoglobin <170 ng/mL (>25% increase over 90 min. suggests AMI)

NORMAL VALUES FOR CARDIAC MARKERS

Nanograms per milliliter, abbreviated ng/mL, is the unit of measure most commonly used to express drug testing cut-off levels and quantitative test results in urine and oral fluid. A nanogram is 10-9 grams

TROPONIN & CK-MB

MYOGLOBIN

Will be elevated 2 hours after MI and remain elevated for 24 hours

Released when cardiac or skeletal muscle is damanged

What are the client's risk factors?

RISK FACTORS

RISK FACTORS

  • Overweight
  • smoker
  • Drinking
  • High Cholesterol
  • NIDDM
  • Male > 45
  • Family History

RISK FACTORS

DO WE GIVE t-PA?

t-PA

Is he a candidate for t-PA

NO

The best results from t-PA occur within the first hour after symptom onset, may be administered within 3 hours.

He suffered his first symptoms at 0200 hours.

Arrived at larger tertiary centre at 0800 hours

Is he a candidate for t-PA

WHAT ARE THE CONTRAINDICATIONS FOR t-PA

CONTRAINDICATIONS

  • HTN >180/110•
  • Ischemic CVA > 3 months ago•
  • Dementia
  • Other intracranial disease
  • Traumatic or Prolonged CPR > 10 minutes
  • Major surgery in the last 3 weeks•
  • Internal bleeding in the last 2-
  • 4 weeks or active peptic ulcer•
  • Noncompressible vascular punctures•
  • Pregnancy•
  • Current anticoagulant therapy
  • Prior exposure to streptokinase
  • Best results within 1 hours of symptom onset.

NURSING PRIORITIES

PRIORITIES

NURSING PRIORITIES

NURSING PRIORITIES

  • Ischemic Chest Pain
  • Decrease workload of the heart
  • Dilation of coronary vessels
  • Anticoagulants to prevent futher blockage
  • Fluid and Electrolyte imbalance
  • Assess for reprerfusion therapy

NURSING ASSESSMENTS

NURSING ASSESSMENTS

NURSING ASSESSMENTS

NURSING ASSESSMENTS

CNS

  • Assess for chest pain not relieved by rest or medications.
  • LOC

CVS

  • Monitor vital signs, especially the blood pressure and pulse rate.
  • Assess IV sites frequently
  • Monitor Labs

RESP

  • Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.

GI

  • Assess for nausea and vomiting.

GU

  • Assess for decreased urinary output.

INTEG

  • Diaphoresis, cool clammy skin, pallor

PSYCH/SAFETY

  • Anxiety
  • Coping
  • Family
  • Nicotine withdrawal

Perform a precise and complete physical assessment to detect complications and changes in the patient’s status.

NURSING ACTIONS

NURSING ACTIONS

NURSING ACTIONS

  • IV fluids
  • M - morphing
  • O - oxygen
  • N - nitroglycerine
  • A - aspirin
  • Position of comfort - HOB elevated to ensure lung expansion and prevent pooling of fluid in the lungs.
  • Minimize patient exertion - Bedrest
  • Promote rest with early gradual increase in mobilization once out of ICU
  • Maintain NPO
  • Manage symptoms
  • Prepare for ICU admission
  • Check skin temperature and peripheral pulses frequently to monitor tissue perfusion.
  • Provide information in an honest and supportive manner.
  • Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, changes in skin color, and laboratory values

EVALUATION

EVALUATION

EVALUATION

EVALUATION

  • There is an absence of pain or ischemic signs and symptoms.
  • Myocardial damage is prevented.
  • Absence of respiratory dysfunction.
  • Adequate tissue perfusion maintained.
  • Anxiety is reduced

DISCHARGE TEACHING

DISCHARGE TEACHING

HOME CARE

HOME CARE

Medication Teaching

Recovery after a heart attack takes time. Plan to rest for at least 4 to 8 weeks. Check with physician on return to work

Cardiac rehabilitation programs

Signs & symptoms of depression.

When to call 911

Ask your family members to learn CPR. This is an important skill that can save lives when it's needed.

Monitor BP and HR at home - talk about monitoring equipment

Keep follow-up appointments

LIFESTYLE CHANGES

LIFESTYLE CHANGES

DIET

  • Consult a dietician
  • Cut back on fats
  • Low cholesterol diet
  • Eat fresh fruit and vegetables
  • Lean proteins - fish, poultry, beans - less red meat
  • Low fat dairy
  • Cut back on fast foods and sugars

EXERCISE

  • Each individual is assessed for exercise tolerance.
  • Recommendations are moderate to vigorous physical activity for at least 40 minutes each day, and for at least 3 to 4 days each week.

SEXUAL ACTIVITY

Sexual activity is reasonable if the patient can exert enough energy to ride a stationary bicycle or walk at a comfortable pace without experiencing angina, excessive breathlessness, ECG changes signifying lack of oxygen to the heart muscle, arrhythmias, or a rise in blood pressure.

SEXUAL ACTIVITY

As well it should take place in a familiar environment where the patient feels comfortable and safe.

Erectile dysfunction drugs interact dangerously with nitrates, which are given for chest pain.These two drugs should never be taken together!

OTHER POINTS

OTHER POINTS

Lose weight

Stop smoking

Drink in moderation

Learn to manage stress

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