Group discussion. Acute coronary syndrome

Setting: Hospital emergency department

Scenario

The time is 1900. 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 plumber 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 reports a dietary history of high-fat food. His wife brought him to the emergency department after he reported unrelieved indigestion. His admission vital signs (VS) were BP 202/124, pulse 106, respirations 18, and oral temperature 98.2F (36.8 C). W.R. was put on oxygen (O2) by nasal cannula (NC) titrated to maintain SpO2 over 92% and started on an IV nitroglycerin (NTG) infusion. He was given aspirin 325 mg to chew and swallow 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 must deal with limited lab and pharmacy resources. The minute W.R. comes through the door of your unit, he announces hes just fine in a loud and angry voice and demands a cigarette. He also says he has no time to fool around with hospitals.

1. What is the priority in his care?

2. Are these VS typical for a man of his age? If not, which one(s) concern(s) you? Explain why or why not.

3. Identify 5 priority problems associated with the care of a patient such as W.R.

4. Several diagnostic and lab have been ordered. Which of these would you anticipate for W.R.? Use an X to indicate if the tests below are Anticipated (appropriate or necessary) or Unnecessary (makes no difference).

5. What significant lab tests are missing from the previous list?

6. How are you going to respond to W.R.s angry demands for a cigarette? He also requests something for his heartburn. How will you respond?

7. Mrs. R. asks you, If he cant smoke, why cant you give him one of those nicotine patches or some nicotine gum? How will you respond?

8. Are there any alternatives to help him with his nicotine cravings? Would they be helpful now?

CASE STUDY PROGRESS

At 2000, you phone Dr. A.s partner, who is on call. She prescribes morphine sulfate 4 mg STAT IV push (IVP), then 2 to 4 mg IVP q1h prn for pain (burning, pressure, and angina).

9. Explain 2 reasons for this order.

10. What special precautions will you follow when administering morphine sulfate via IVP?

11. The pharmacy supplies morphine for injection in vials of 5 mg/mL only. For the first dose, you will be giving 4 mg of morphine. How many milliliters will you give for this dose?

12. What will you do with the rest of the morphine in the vial?

13. Angina is not always experienced as pain as many people understand pain. How would you describe symptoms you want him to warn you about? Why is this important?

14. What safety measures or instructions would you give W.R. before you leave his room?

CASE STUDY PROGRESS

When you come into W.R.s room at 2230 hours to answer his call light, you see he is holding his left arm and states that he has aching in his left shoulder and arm.

16. What information will you gather? What questions will you ask him?

CASE STUDY PROGRESS

You titrate the NTG drip up, assess whether he is using the oxygen cannula, and assess his vital signs. In addition, you administer a dose of morphine, but his pain is not relieved. Based on your assessment findings, you decide to call the physician.

17. Using SBAR (Situation, Background, Assessment, Recommendation), what information would you provide to the physician when you call?

18. W.R.s chest pain subsides after the dose of morphine and he settles down for the night. You monitor him closely and watch for side effects of the NTG infusion. Side effects of NTG include which of these? Select 3 options.

1. Pruritus
2. Headache
3. Tachycardia
4. Constipation
5. Dysrhythmias
6. Postural hypotension
7. Decreased respirations

CASE STUDY PROGRESS

In the morning, W.R. is transferred by helicopter to the medical center, and a cardiac catheterization is performed. It is determined that W.R. has coronary artery disease (CAD) but has not had an MI. The cardiologist suggests it would be best to treat him medically for now.

19. What does it mean to treat him medically? What other approaches might be used to treat CAD?

20. A new order for atenolol (Tenormin) is added to his medication list. Which is/are the rationale for starting a beta blocker at this time? Select all that apply.

1. Reduction of myocardial stimulation
2. Increased force of cardiac contractions
3. Decreased myocardial oxygen demand
4. Prolonged sinoatrial (SA) node recovery
5. Increased conduction through the atrioventricular (AV) node

CASE STUDY OUTCOME

The physician orders follow-up counseling regarding risk factor modification, especially smoking cessation, hypertension management, weight loss, and lipid (cholesterol) management. W.R. is discharged with a referral for a follow-up visit to his local internist in 1 week.

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