Download Answers to Cardiac Diagnostics Case Study

Answers to Cardiac Diagnostics Case Study
Group 1
What can you do independently for Mr. Harvey’s oxygen saturation? What order would you expect from
Dr. Shermer?
Answer: We can sit Mr. Harvey up to allow for greater lung expansion. You would expect an order for
oxygen from Dr. Shermer.
You need to start an IV, what gauge angiocath should you use?
Answer: You should start a large bore peripheral IV, at least an 18g.
Dr. Shermer orders labwork. When should this be drawn and how would you do it? What labs would you
expect to be ordered? Why?
Answer: When you go to start the IV, attach a 10cc syringe to INT tubing. When the IV is inserted and
threaded, connect the INT tubing and pull back on the syringe until full. You may need to use two 10cc
syringes to get enough blood for all the different tubes required. Then flush the catheter immediately
with 10cc of NS and clamp off. Put an 18g needle on the syringes of blood and fill the required tubes. Put
client labels on all tubes with date, time and your initials and send them to the lab. You should expect a
cardiac panel, CBC, coag panel and electrolytes, either a BMP or a CMP. Since he has DM, the physician
will probably order a CMP so BUN and Cr will be included. Low or high sodium levels do not directly
affect cardiac function but potassium does. A decreased potassium can cause life-threatening
dysrhythmias. An elevated potassium can cause heart block, asystole, and other life-threatening
dysrhythmias. Calcium is needed for automaticity of the SA and AV node. Low calcium can slow nodal
function and impair myocardial contractility. High calcium can increase the risk for heart block and
sudden death from V-fib. Low magnesium predisposes the client to atrial or ventricular tachycardias.
High magnesium levels depress contractility and excitability of the myocardium, causing heart block or
asystole. The cardiac panel is necessary since Mr. Harvey is complaining of chest pain. Elevations in
isoenzymes related to myocardial cell damage are strong indicators of ischemia or infarction. The CBC
will give an indicator of infection (rule out pneumonia), H&H will help rule out anemia which can have
serious consequences for clients with cardiovascular disease, like more frequent angina episodes or
acute MI. Platelets can give information about coagulation ability. The coag panel will do the same,
especially if the patient needs an invasive procedure. The physician my also order a lipid panel if it has
been long enough since the client ate, this will show risks for CAD.
Radiology comes in to do a portable chest x-ray on Mr. Harvey. What kind of information will this give
you and Dr. Shermer? What do you need to do to get him ready for this test (think clothing)? What kind
of instructions should you give Mr. Harvey?
Answer: The CXR will show size, contour, and position of the heart. It can show cardiac and pericardial
calcifications and alterations in pulmonary circulation. CXR will not diagnose a MI but can identify
complications from heart disease like CHF. It can also rule out pneumonia. To prepare Mr. Harvey, he
needs to be placed in a hospital gown, remove any jewelry he may be wearing like necklaces. Tell him
the test is not painful and will only take a minute or so. Tell Mr. Harvey he will be in a reclining position
right there in his bed, they will put a hard board behind his back, and he will be asked to take a deep
breath and hold it for a few seconds. Tell Mr. Harvey everyone will step out just long enough for the
XRay to be taken and then will be right back in with him.
Group 2
Based on Mr. Harvey’s cardiac panel, do you think his symptoms are related to heartburn or myocardial
damage?
Answer: Mr. Harvey’s symptoms are probably related to myocardial damage since his isoenzymes are
elevated. Heartburn would not cause them to be elevated.
Why do you think your client’s hemoglobin and hematocrit are elevated?
Answer: Mr. Harvey is probably in fluid volume deficit from his HCTZ. This is more than likely an example
of hemoconcentration.
Is your client at risk for bleeding?
Answer: No, Mr. Harvey is not at risk for bleeding. His platelet count and his PT/INR and PTT are all in
normal range. Mr. Harvey is not on any coagulation modifiers either.
Why are Mr. Harvey’s electrolytes imbalanced?
Answer: His electrolytes are imbalanced more than likely because of his HCTZ. He is on a potassium
supplement but it may not be enough. His glucose is elevated because he has DM.
Do the lab values indicate congestive heart failure?
Answer: No, it does not appear Mr. Harvey has CHF. He is in FVD instead of FVE and his BNP was in
normal range.
What kind of teaching should you plan for Mr. Harvey regarding his lipid panel?
Answer: Mr. Harvey will need to be taught measures to reduce the amount of lipids/fats in his diet. He
will also need to be advised about beginning an exercise program to help raise his HDL cholesterol. This
teaching will be postponed until Mr. Harvey is stable and the diagnostics have been finished.
Do you think this was an accurate reading for his lipids? Why or why not? (think timing of test related to
last PO intake)
Answer: Yes, this was an accurate measurement of his cholesterol. Mr. Harvey had not eaten since the
evening of the day before he presented to the ER. It is now well after 0600, so this sample is considered
a fasting blood sample.
Dr. Shermer evaluates Mr. Harvey’s lab work and orders continuous ECG monitoring and a 12 lead ECG.
What is the difference between these two tests and how are they performed? How should you position
Mr. Harvey for the 12 lead ECG? What will a 12 lead ECG diagnose?
Answer: The 12-lead ECG is used to diagnose dysrhythmias, conduction abnormalities, chamber
enlargement, and myocardial ischemia, injury, or infarction. It can also suggest cardiac effects of
electrolyte disturbances and the effects of antiarrhythmic medications. Continuous ECG monitoring
detects abnormalities in heart rate and rhythm, and changes in ST segments. They can monitor more
than one lead simultaneously, can interpret and store information and alarms, and provide graded and
audible alarms based on priority. The 12-lead is a 6 second “picture” of what the heart is doing
electrically from 12 different angles. The client is placed in a supine or low-fowlers position and
electrode stickers are placed on the arms, legs and anterior chest wall. Hair may need to be clipped on
men to enable good contact with the skin. The lead wires are then connected to the stickers and the
client is asked to hold still, he may be asked to take a breath, exhale and hold it for 6-10 seconds. The
client should not cross his legs during the test. Leave the stickers in place for subsequent ECGs that may
be needed. This will ensure a more accurate comparison and will save time. The continuous ECG will
give a constant reading of basic electrical activity in the heart. The client has to be disconnected from
the monitor to use the restroom but is placed on a portable monitor for transport anywhere in the
facility. Any client on continuous monitoring must be accompanied by a RN during transport.
What information is needed to get the most accurate interpretation of the 12 lead ECG?
Answer: The ECG tech will need to know the client’s age, gender, BP, height, weight, symptoms, and
medications. For Mr. Harvey they would need to know about his metoprolol.
Group 3
Based on Mr. Harvey’s 12 lead ECG and his cardiac enzymes, Dr. Shermer orders an echocardiogram.
What should you tell Mr. Harvey about this test? What should he expect?
Answer: This test is non-invasive and painless. It is like an ultrasound for pregnancy only it looks at the
heart. He should expect to be in the non-invasive cardiac lab about 45 minutes for this test and he can
remain on his stretcher from the ER or he can go by wheelchair and rest comfortably on their bed. He
will be monitored by ECG during this test as well.
What kind of information will this give Dr. Shermer about Mr. Harvey’s heart?
Answer: This US procedure is used to evaluate the structure and function of the heart. It can be used to
diagnose pericardial effusion, valvular disease, subaortic stenosis, cardiomyopathy, infarction, and
aneurysm. Hypokinetic areas of the heart may be due to ischemia or infarction.
Is there anything you need to do to take care of him when he comes back from his test? What should he
wear to the test?
Answer: There is no special care needed when the client returns, just ensure he is re-connected to the
ER ECG machine and is comfortable. Keep Mr. Harvey NPO until further notice and ensure he does not
still have ultrasonic gel left on him. He should be sent to the test in a hospital gown open to the front.
Group 4
Based on the result of the echocardiogram, Dr. Shermer calls up to the non-invasive cardiac lab and
orders a stress test on Mr. Harvey. What information will the cardiologist need to interpret the stress
test accurately (think medications since arrival)?
Answer: The cardiologist needs to know about Mr. Harvey’s home medication, metoprolol and the
nitroglycerin SL he has had since arrival in the ER. This is in addition to age, gender, height, weight etc.
The cardiologist probably has access to all Mr. Harvey’s basic information or he can ask him.
What items from his personal belongings will you need to take to Mr. Harvey for the stress test?
Answer: You should take Mr. Harvey his pants, socks and shoes. The stress test is performed on a tread
mill so clients need to be in comfortable clothes they can walk in. He should still wear his hospital gown
so the ECG can be connected and his BP can be monitored easily during the test.
What kinds of foods/drinks should be avoided before a stress test?
Answer: Mr. Harvey should be fasting for 4 hours prior to the test. He has been fasting for around 10 to
12 hours. He should not have any stimulants prior to the test like caffeine or nicotine.
How will the nurse in the cardiac lab explain what is expected of Mr. Harvey during this test?
Answer: The nurse will describe the way the test will be performed. Mr. Harvey will walk/jog on a
treadmill. Other options would be stationary bike or arm crank. Exercise intensity is increased by a set
protocol until he reaches his target heart rate. His ECG, BP, skin temperature, physical appearance,
perceived exertion, and symptoms will be monitored during the test. He will be asked questions
requiring short answers during the test as well.
What will he have to do?
Answer: Mr. Harvey will have to walk and jog on the treadmill and answer questions about his tolerance
as honestly as possible.
What will he be hooked up to while the test is going on?
Answer: ECG, BP and skin temp probe.
Who will be in the room with him during this test?
Answer: Cardiac lab nurse or tech and the cardiologist. An OR must be on standby in case the patient
has to have emergency heart catheterization or heart vessel bypass.
If Mr. Harvey is unable to complete the exercise stress test, what other option for stress testing is there?
Answer: If Mr. Harvey was unable to do any of the forms of physical exercise, they could give him a
medication that would pharmacologically stress his heart and achieve the same result.
Group 5
During the test, the cardiologist decided Mr. Harvey needed a myoview of his heart. Which one of Mr.
Harvey’s home medications could cause a problem with this test?
Answer: Mr. Harvey should not take his metformin before this test. There are two reasons for this: first,
Mr. Harvey has been NPO and we don’t want his blood sugar to get too low. Second, metformin should
be held before any test requiring contrast media and for 48 hours after the study is completed.
What kind of substance is thallium? Why is it injected in the middle of the test?
Thallium is a radionuclide substance used to assess myocardial ischemia. When the heart is stressed,
evidence of myocardial ischemia can become quite obvious and is easily detected. The thallium is
injected at the point of maximal cardiac stress and will accumulate in the myocardium in direct
proportion to the myocardial blood flow. Normal myocardium will have much greater radionuclide
activity than the ischemic myocardium will.
Will Mr. Harvey experience any kind of side effects from this substance?
Answer: No. There are no side effects or discomfort associated with this dose level of radioactive media.
The cardiac lab staff place Mr. Harvey in the scanner for immediate images. What position will Mr.
Harvey be in? How long will he have to remain in this position? Will this test be painful? Will it be
repeated? In how long?
Answer: Mr. Harvey will be placed in the scanner usually supine, but on occasion prone. He may have to
put one or both arms over his head. He will be in the scanner for about 30-45 minutes. The test itself is
non-invasive and not painful unless he becomes uncomfortable staying in the same position for that
long. Tell Mr. Harvey to let the technician know if he cannot remain in that position. The test will be
repeated in 3-4 hours.
Group 6
It appears Mr. Harvey has a perfusion abnormality that is easily visualized on the myoview scan. Why
does the blood flow look normal while Mr. Harvey is at rest?
Answer: When the heart is at rest ischemic cells will take up the thallium the same as healthy cells will,
but when the heart is stressed it won’t because the blood flow is impaired to those cells. If the cells
were infarcted or dead, they wouldn’t take up the thallium at rest or in stress.
Mr. Harvey has finally made it back to you and is hungry. Should you order him a tray? If you did, what
kinds of food/beverages should be avoided?
Answer: Because Mr. Harvey’s myoview shows abnormalities in blood flow it will be reported to Dr.
Shermer as a positive scan. Positive, in this case, does not mean good. Keep Mr. Harvey NPO because he
may require further intervention. If he had been allowed to eat, he would need a heart healthy diet with
no caffeine. This means no colas, tea, or chocolate.
He also wants to go smoke, should you allow him to go? What should you tell him about this?
Answer: Mr. Harvey should be encouraged to quit smoking and teaching can be started at this time for
that. Nicotine is a vasoconstrictor so since his blood flow to his heart is already impaired, he shouldn’t
do anything to make it worse.
Dr. Shermer consulted with the cardiologist and they have decided to do a left heart catheterization on
Mr. Harvey. How will you prepare him for this test? What should he be wearing? Do you need to
prepare his skin?
Answer: You should have Mr. Harvey remove all clothing and any metal jewelry, he should be wearing
nothing but a hospital gown. He should remain NPO. The cath lab personnel will tell you if you need to
clip any hair and where they plan to insert the catheter. Usually they use a femoral artery for a left heart
catheterization.
What kinds of sensations should you tell Mr. Harvey to expect during the test? Will it be painful? Will he
be awake?
Answer: Tell Mr. Harvey the room will be cold and very brightly lit. There will be large equipment near
him and over him as he lays on the OR table. The staff will cover him with blankets as much as possible
to keep him warm. Explain to him there will be a nurse, cardiologist, and one or two technicians in the
room with him and they will be talking to him throughout the procedure. The only discomfort Mr.
Harvey should feel is a small “bee sting” sensation when the cardiologist numbs up the site over the
artery he will access. After that, he won’t feel any pain at all. Reassure Mr. Harvey that they will give
some medicine in his IV to help him relax and be more comfortable but he will still be awake. When the
contrast media is injected, he may feel a warm sensation all over. Some patients think they have
urinated on themselves because of it. Reassure Mr. Harvey that this sensation is normal and expected.
Tell him all of the staff will have surgical gowns and masks on so if he doesn’t understand something
they say to him he should let them know.
Mr. Harvey wants to empty his bladder, can you let him?
Answer: Yes, Mr. Harvey should empty his bladder before going to his heart catheterization.
His wife wants to come back in and visit with him. Can she or is he radioactive after the thallium?
Answer: Mrs. Harvey can come back in and stay with him. He is not radioactive.
Does Mr. Harvey need to sign a consent for the heart cath? Who should explain the procedure with the
risks and benefits to him? How long will the heart cath take?
Answer: Yes, Mr. Harvey will need to sign a consent for this procedure after the cardiologist that will be
doing the cath has explained it to him along with the risks and benefits. The whole procedure usually
takes less than an hour if there are no complications.
Teach Mr. Harvey about post-procedure care for a heart cath. How often should he be assessed by the
nurse? What kinds of things should the nurse look for? What position will Mr. Harvey need to stay in?
For how long? What is the time frame dependent upon? What kind of vessel will be accessed for a left
heart cath, vein or artery? How will we make sure the vessel is hemodynamically stable after closure?
Answer: Mr. Harvey will go to recovery for a short time after his procedure and then he will be
transferred to a hospital room on the telemetry unit. Tell him during recovery and the first 3 hours after
he gets to his hospital room the nurses will be checking on him frequently, every 5 minutes in recovery
and then every 15 minutes for an hour, every 30 minutes for 2 hours. The nurse will be checking his vital
signs, assessing for bleeding from the site, and checking the extremity below the site to ensure blood
flow is normal. Explain to Mr. Harvey that he will have to lie flat for several hours on his back. He may
have a sandbag on his site to provide pressure to the artery. There are other new closure devices the
cardiologist may use that will lessen the time he has to stay flat and he may not need the sandbag. The
vessel accessed for a left heart cath is an artery so the risk for hemorrhage is substantial. We use
pressure dressings and devices along with keeping the patient flat to ensure hemodynamic stability.