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Ruling Out a
Myocardial
Infarction
Jill, Kara, Jenna, Hoda
Scenario
The time is 1900 hours. You are working in a small, rural hospital. It has been snowing heavily all day, and the medical
helicopters at the large regional medical center, 4 hours away by car (in good weather), have been grounded by the weather
until morning. The roads are barely passable. W.R., a 48-year-old construction worker with a 36-pack-year smoking history,
is admitted to your floor with a diagnosis of rule out myocardial infarction (R/O MI). He has significant male-pattern obesity
(“beer belly,” large waist circumference) and a barrel chest, and he reports a dietary history of high-fat food. His wife brought
him to the emergency department (ED) after he complained of (C/O) unrelieved “indigestion.” His admission vital signs (VS)
were 202/124, 96, 18, and 98.2° F. W.R. was put on oxygen (O2) by nasal cannula (NC) titrated to maintain SaO2 (arterial
oxygen saturation) over 90% and an IV of nitroglycerin (NTG) was started in the ED. He was also given aspirin 325 mg and
was admitted to Dr. A.’s service. There are plans to transfer him by helicopter to the regional medical center for a cardiac
catheterization in the morning when the weather clears. Meanwhile you have to deal with limited laboratory and pharmacy
resources. The minute W.R. comes through the door of your unit, he announces he’s just fine in a loud and angry voice and
demands a cigarette.
1. From the perspective of basic
human needs, what is the first priority
of his care?
Maslow’s hierarchy of needs indicates that
physiological needs are priority. For W.R., this
would include his oxygen saturation, blood
pressure and his unrelieved “indigestion” pain
(Potter 43).
2. Are these VS reasonable for a man his age? If not,
which one(s) concern(s) you? Explain why or why
not?
Some of the vital signs are not normal for a man his age. The ones I am concerned with are
the blood pressure (202/124) and needing oxygen to obtain a saturation over 90%. The
pulse is on the higher end (96 bpm), but it may be because he is agitated/anxious.
Respirations and temperature are within normal limits. The blood pressure is concerning
because a normal blood pressure is 120/80. Blood pressure changes in the event of the
cardiac cycle, and a high blood pressure (smoking and eating unhealthily) while having
chest pain would leave me to believe it is a possible MI. I am also concerned about the 90%
because if he is at home and on the job, smoking, etc. he is not getting the correct amount
of oxygen his body needs circulating throughout his blood (Jarvis 121).
3. Identify five priority problems
associated with the care of a patient like
W.R.
1. 36 pack year smoking history (O2/BP)
2. High fat diet
3. High stress work environment
4. Barrell chest (copd)
5. Obesity.
(Potter 2013)
4. Which of the following
laboratory tests might be ordered
to investigate W.R.’s condition? If
the order is appropriate, place an
“A” in the space provided. If
inappropriate, mark with an “I,”
and provide rationales for your
decisions.
1. CBC → A
2. EEG in the morning → I → An EEG is a
test that tracts brain wave patterns. This type of
test would not reveal any information about a
possible MI.
3. Chem 7 (Electrolytes) → A
4. PT/PTT → A
5. Bilirubin every morning → I → Bilirubin
testing reflects the health of the liver. While
studies do show that liver congestion due to an
increase of central venous pressure may
possibly cause elevations of serum bilirubin,
recurrent testing every morning would not
confirm an MI.
6. Urinalysis (UA) → I → While there is a list of
things you can tell from testing a person’s urine,
especially the health of the kidneys and bladder,
a myocardial infarction in not something on that
list.
7. STAT 12-Lead ECG → A
8. Type & Crossmatch (T&C) for 4 units
packed RBCS → A
(Ignatavicius & Workman, 2013)
(Alvarez & Mukherjee, 2011)
5. What significant lab tests are
➔
➔
➔
missing from the previous list?
➔
Cardiac biomarkers/enzymes
Troponin levels
Creatine kinase (CK) levels: CK-MB levels increase within 3-12 hours of the
onset of chest pain, reach peak values within 24 hours, and return to
baseline after 48-72 hours
Myoglobin levels: Myoglobin is released more rapidly from infarcted
myocardium than is troponin; urine myoglobin levels rise within 1-4 hours
from the onset of chest pain
Lipid profile
➔
C-reactive protein (CRP) and other inflammation markers
➔
6. How are you going to
respond to W.R.’s angry
demands for a cigarette? He
also demands something for
I would explain to W.R. that while I understand he is frustrated and
would like a cigarette, the hospital is a smoke-free facility. Also, with
his O2 stats being where they are, smoking would furthermore
decrease the much needed oxygen in his body. Not to mention,
smoking near oxygen is very dangerous. I would also offer to speak
to Dr. A about getting a nicotine patch to help with his cravings. I do
not believe that now would be an appropriate time to talk about
his “heartburn.” How will you
smoking cessation since he is angry and it probably wouldn’t do any
good. As far as his “heartburn” goes, I would calmly and in layman’s
respond?
terms explain the severity of the situation. I would explain that even
though it feels like indigestion, a tums will not fix it. I will tell D.W. that
I will contact Dr. A. right away to see about a getting an order for an
analgesic for the pain.
Case Study
You
phone Dr. A.’s partner, who is “on call.” She prescribes morphine
Progresses
sulfate 4 to 10 mg IV push (IVP) q1h prn for pain (burning, pressure,
angina).
Pain from MI is often intense and requires prompt and adequate
7. Explain two
analgesia. The agent of choice is morphine sulfate. Reduction in
myocardial ischemia also serves to reduce pain, so oxygen
reasons for this
therapy, nitrates, and beta blockers remain the mainstay of
therapy. It is important to consider that morphine can mask
order.
ongoing ischemic symptoms, it should be reserved for patients
being sent for coronary angiography (Ignatavicius & Workman,
2013).
8. What special precautions
should you follow when
administering morphine sulfate
IVP?
➔
Push med slow and monitor patient for
respiratory depression.
➔ Administer 1 mg/minute
➔
Assess BP, Pulse, RR, LOC during
administration.
(Lilley 83)
9. Angina is not always experienced
I would tell W.R. to let me know if he has chest
as “pain” (as many people
discomfort that radiates down his left arm, pain
or discomfort in his jaw, shoulder, abdomen, or
understand pain). How would you
describe symptoms you want him
back, palpitations, shortness of breath,
anxiety, dizziness, etc. This is extremely
important because it could mean that he is
to warn you about? Why is this
going to have an MI.
(Chard 696)
important?
10. What safety measures or
instructions would you give W.R.
Safety measures to include for W.R. would include
keeping his side rails up, bed should be in the
lowest position, having his call light within reach.
before you leave his room?
Instructing him to change positions slowly to
prevent orthostatic hypotension. Instruct W.R. to
call if he needs to use the washroom and to not
get up without assistance. Instruct W.R. to call if
he is having any of the symptoms listed above in
#9.
11. One of the housekeeping
staff asks you, “If the poor
guy can’t smoke, why can’t
you give him one of those
nicotine patches?” How will
“Unfortunately, due to HIPPA laws, I
you respond?
can’t discuss his plan of care with
you.”
12. If the patch were to be used later to help him quit smoking,
how would it be dosed for him?
If W.R. were to use a nicotine patch, such as
Nicoderm CQ, he would use a schedule that tapers the dose of
nicotine. This ultimately weans him off of the drug. If W.R.
smokes greater than 10 cigarettes per day, he would begin by
applying one 21 mg patch transdermally daily for weeks 1-6,
then one 14 mg patch daily for weeks 7-8, and then one 7 mg
patch daily for weeks 9-10.
If W.R. smokes less than 10 cigarettes per day,
he would begin by applying one 14 mg patch transdermally
daily for 6 weeks, then one 7 mg patch daily for 2 weeks
(Micromedex).
13. Before leaving for the
night, Mrs. R. approaches you
and asks, “Did my husband
I would acknowledge Mrs. R.’s fears and
have a heart attack? I’m really
scared. His father died of one
concerns, and explain to her that we are
running various tests to verify if W.R. has in fact
had a heart attack or not. At this time we
when he was 51.” How are you
cannot confirm a heart attack diagnosis but we
will know more once the test results come back.
going to respond to her
14. When you come into W.R.’s
room at 2200 hours to answer his
I will gather vitals, primarily blood pressure, heart
rate, and O2 stat. If possible, I would also place
W.R. on a cardiac monitor and obtain an EKG
call light, you see he is holding his
(look for ST elevation). Also, have someone bring
an AED close by.
left arm and complains of aching
in his left shoulder and arm. What
I would ask W.R.:
➔
To fully describe the pain, including the location,
intensity (1-10 scale), duration, and
information are you going to
characteristics (dull, pressure, crushing,
burning).
gather? What questions will you
ask him?
➔
If he is having any difficulty breathing?
➔
If he is feeling lightheaded?
➔ If he is feeling nauseous?
15. Based on your assessment
BP was 202/124. Heart rate, temp, and respirations were
findings, you decide to call the
WNL. O2 by nasal cannula was started to maintain SaO2
over 90%. Nitroglycerin IV was started in the ED as well
physician. What information are
you going to report to the
physician, and why? Use SBAR.
as aspirin 325mg. He was last given __mg of morphine IV
push at ___time. W. began feeling pain in his left arm and
shoulder about 10 minutes ago. I assessed him personally
and his current vitals are___. He is on __L of O2. Most
recent EKG shows___. W. is alert & oriented but is visibly
Hello Dr. A., this is Jenna, the nurse here in room 10
anxious. We are still waiting on the lab results from earlier.
with Mr. W.R. W. is a 48-year-old who was admitted at
He appears that W. is experiencing a MI. How do you
1900 this evening to rule out a MI after coming into the
recommend we proceed until we are able to transfer him to
ER with complaints of unrelieved indigestion. Upon
admission,
the regional medical center for a cardiac catheterization in
the morning?
Case Study
Progresses
In the morning W.R. is transferred by chopper to the medical center, and a
cardiac catheterization is performed. It is determined that W.R. has coronary
artery disease (CAD). The cardiologist suggests it would be best to treat him
medically for now, with follow-up (F/U) counseling on risk factor modification,
especially smoking cessation. He is discharged with a referral for an F/U visit to
his local internist in 1 week.
16. What does it mean to treat him “medically”
(conservatively)? What other approaches may be used to treat
The doctor means treat his symptoms he is having now
CAD?
and stabilize him when he says “medically.” We are worried
about the patient’s physical condition right now. Later on,
when his chest pain and vital signs are stabilized, we can
move into patient teaching and lifestyle modifications. By
lifestyle modifications, I mean such as quitting smoking,
eating healthier, losing weight, etc (Dechant 832).
17. What personality
A personality characteristic that I observe in W.R.
characteristic do you observe
that places him at high risk for CAD is his
unhealthy lifestyle choices. He has a 36 pack year
in W.R. that places him at high
risk for CAD?
smoking history, eats poorly, and is obese. Even
upon entering the unit the client stated angrily that
he needed a cigarette. This gives me the idea that
he is in denial of his poor health and will continue
to pursue unhealthy lifestyle choices that may
eventually lead to coronary artery disease.
(Dechant 832)
18. What follow up care is needed for him post discharge?
~ Cardiac Rehab can help with:
~ Family counseling: to help
everyone understand his risks and to
➔
Exercise planning
➔
Reducing risk factors
➔
Dealing with stress, anxiety
discuss enabling behaviors. By
cooking poor food choices, the family
is enabling.
~ Home health nurse- build a
and depression
~ Regular Doctor appointments to
therapeutic relationship to educate
~ Dietitian: to help with healthy
ensure W.R. is taking his prescribed
the patient and help him be
food choices.
medications
independent.
(Ignatavicius 840)
References
Alvarez, A., & Mukherjee, D. (2011). Liver abnormalities in cardiac diseases and heart failure.
International Journal of Angiology, 20(3). http://dx.doi.org/10.1055/s-0031-1284434
Ignatavicius, D. D., Workman, L. M., & Dechant, L. M. (2013). Medical-surgical nursing: Patient-centered
collaborative care (7th ed.). St. Louis: Elsevier Saunders.
Jarvis, C. (2012). Physical Examination & Health Assessment (6th ed.). St. Louis, Mo.: Elsevier/Saunders.
Lilley, Linda L., Shelly Collins, Julie Snyder. (2013). Pharmacology and the Nursing Process. (7th ed). St. Louis:
Elsevier Saunders.
Nicoderm CQ. Truven Health Analytics. (2016). Retrieved September 3, 2016, from
http://www.micromedexsolutions.com.
Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. (2013). Fundamentals of Nursing (8th ed) .St. Louis:
Elsevier Saunders.