Case Study 16 Acute Coronary Syndrome
Difficulty: Advanced
Setting: Emergency department, hospital, home care
Index Words: heart failure (HF), coronary artery disease (CAD), arm fracture, communication deficit, cultural diversity, geriatric, laboratory values, therapeutic nutrition, medications, electrolytes
Giddens Concepts: Care Coordination, Communication, Culture, Fluid and Electrolyte Balance, Perfusion
HESI Concepts: Assessment, Care Coordination, Communication, Cultural/Spiritual, Fluid & Electrolyte, Perfusion
You are just getting caught up with your work when you receive the following phone call: “Hi, this is Deb in the emergency department. We’re sending you M.M., a 63-year-old Hispanic woman with a past medi- cal history of coronary artery disease (CAD). Her daughter reports that her mom has become increasingly weak over the past couple of weeks and has been unable to do her housework. Apparently, she has had complaints of swelling in her ankles and feet by late afternoon ‘she couldn’t wear her shoes’ and has nocturnal diuresis× 4. Her daughter brought her in because she has had heaviness in her chest off and on over the past few days but denies any discomfort at this time. The daughter took her to see her family physician who immediately sent her here. Vital signs are 146/92, 96, 24, 99 ° F (37.2 ° C). She has an IV of D5W at 50 mL/hr in her right forearm. Her laboratory results are as follows: Na 134 mEq/L, K 3.5 mEq/L, Cl 103 mEq/L, HCO3 23 mEq/L, BUN 13 mg/dL, creatinine 1.3 mg/dL, glucose 153 mg/dL, WBC 8300/mm3, Hct 33.9%, Hgb 11.7 g/dL, platelets 162,000/mm3. PT/INR, PTT, and urinalysis are pending. She has had her chest x-ray and ECG, and her orders have been written.”
· Scenario
1. What additional information do you need from the emergency department (ED) nurse?
2. How are you going to prepare for this patient?
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3. M.M. arrives by wheelchair. As she transfers to the bed, what observations will you make? Why?
4. Given the previous information, you can anticipate orders for M.M. Carefully review each order to determine whether it is appropriate or inappropriate as written. If the order is appropriate, mark it as A; if the order is inappropriate, mark it as I and change the order to make it appropriate. Provide any other orders that might be appropriate for M.M.
1. Routine VS
2. Serum magnesium (Mg) STAT
3. Up ad lib
4. 10 g sodium (Na), low-fat diet
5. Change IV to a saline lock
6. Cardiac enzymes on admission and q8h × 24 hr, then daily every morning
7. CBC, BMP, and fasting lipid profile in morning
8. Schedule for abdominal CT scan for am
9. Heparin 10,000 units subcut q8h
10. Docusate sodium (Colace) 100 mg/day PO
11. Ampicillin 250 mg IV piggyback q6h
12. Furosemide (Lasix) 200 mg IV push STAT
13. Nitroglycerin (NTG) 0.4 mg 1 SL q4h prn for chest pain
14. Schedule echocardiogram
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5. Which interventions are appropriate for administering subcutaneous heparin? Select all that apply.
a. Rotate injection sites with each dose.
b. Monitor activated partial thromboplastin time (aPTT) levels daily.
c. Massage the area after the injection.
d. Give the injection at least 2 inches away from the umbilicus.
e. Do not aspirate the syringe before injecting the heparin.
CASE STUDY PROGRESS
Shortly after admission, M.M.’s call light comes on. When you respond to M.M.’s call light, you observe she is talking rapidly in Spanish and pointing to the bathroom. Her speech pattern indicates she is short of breath; she is having trouble completing a sentence without taking a labored breath. You help her use a bedpan and note that her skin feels clammy. While sitting on the bedpan, she vomits.
6. On a scale of 0 to 10 (0 being no problem, 10 being a code-level emergency), how would you rate this situation, and why?
7. Identify at least four actions you should take next, and state your rationale.
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8. M.M.’s physician calls your unit to find out what is happening. Using SBAR, what information would you need to convey at this time?
9. The hospital’s staff physician is coming to the floor immediately to evaluate the patient. In the meantime she orders furosemide (Lasix) 40 mg IV push STAT. You have only 20 mg in stock. Should you give the 20 mg now, and then give the additional 20 mg when it comes up from the pharmacy? Explain your answer.
10. M.M. continues to experience vomiting and diaphoresis that are unrelieved by medication and comfort measures. A STAT 12-lead ECG reveals ischemic changes, and she is transferred to the coronary care unit (CCU). As you give the report to the receiving registered nurse, what laboratory value is the most important to report, and why?
11. You are monitoring while a new nurse prepares to administer IV potassium to M.M. Which technique is correct? Explain why the other answers are incorrect.
a. Give the IV potassium by slow IV push.
b. Add potassium to a hanging IV bag as needed.
c. The rate of IV administration should not exceed 10 mEq/hr.
d. Administer the IV potassium by gravity drip.
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CASE STUDY PROGRESS
While recovering in the CCU, M.M. tried to get up out of the bed, fell, and fractured her right humerus. Because of the surgical risks involved, M.M. was treated conservatively and put in a full arm cast. She is transferred back to your floor.
CASE STUDY PROGRESS
A case manager (CM) has been asked to evaluate M.M.’s home to see whether she can be discharged to her own home or will need to stay in a long-term care facility.
12. Identify at least eight things that the CM would assess.
13. M.M.’s nutritional intake over the past few weeks has been poor. She also has increased nutritional needs because of her fractured arm. What are some of the nutritional needs that should be met? What would you recommend to help her with this?
CASE STUDY PROGRESS
Because the case manager determined that M.M. lived in an apartment with poor access, M.M. elects to stay with her daughter and five grandchildren in their small home. A home care nurse comes three times a week to check on her. M.M. is easily fatigued, and the children are quite lively. School is out for the summer.
14. Suggest some ways for M.M.’s daughter to ensure that her mother is not overwhelmed and does not become exhausted in this situation.