Acute Coronary Syndrome FUNDAMENTAL Reasoning Case Study History ofPresent Problem • JoAnn Smith is

Acute Coronary Syndrome FUNDAMENTAL Reasoning Case Study History ofPresent Problem • JoAnn Smith is a 68-year-old woman who presents to the emergency department (ED) after having three days of progressive weakness. • She denies chest pain, but admits to shortness of breath (SOB) that increases with activity. She also has epigastric pain with nausea that has been intermittent for 20-30 minutes over the last three days. She reports that her epigastric pain has gotten worse and is now radiating into her neck. • Her husband called 9-1-1 and she was transported to the hospital by emergency medical services (EMS). Personal/Social History • JoAnn is a recently retired math teacher who continues to substitute teach part-time. She is physically active and lives independently with her spouse in her own home. • She has smoked 1 pack per day the past 40 years. JoAnn appears anxious and immediately asks repeatedly for her husband upon arrival. Vital Signs Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.2 F/37.3 C (oral) Provoking/Palliative: Nothing/Nothing P: 128 (regular) Quality: Ache R: 24 (regular) Region/Radiation: Left arm that radiates into neck BP: 108/58 Severity: 5/10 O2 sat: 99% room air Timing: Intermittent-20-30" at a time Nursing Assessment Current Assessment: GENERAL APPEARANCE: Anxious, appears uncomfortable, body tense RESP: Respirations labored, coarse crackles present in bases bilaterally anterior/posterior CARDIAC: Pale, diaphoretic, no edema, heart sounds regular S1S2 with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow Radiology Reports Radiology Report: Chest x-ray RELEVANT Results: Scattered bilateral opacities consistent with atelectasis or pulmonary edema Clinical Significance: Radiology Report: Echocardiogram RELEVANT Results: Global left ventricle hypokinesis with ejection fraction of 25% Clinical Significance: Diagnostic Data Basic Metabolic Panel (BMP) Current: Na K Gluc. Creat. 135 4.1 184 1.5 Complete Blood Count (CBC) Current: WBC HGB PLTs % Neuts Bands 10.5 12.9 225 70 n/a Cardiac Current: Trop. BNP Mg 1.8 1150 1.8 Lab Planning Lab: Troponin Value: 1.8 ng/mL Normal Value: Critical Value: Clinical Significance: Nursing Assessments/Interven tions Required: Pharmacology Home Med: Classification: Mechanism of Action: Nursing Considerations: Lisinopril Atenolol Metformin Omeprazole Simvastatin Pathophysiology 1. What is the primary problem that your patient is most likely presenting? 2. What is the underlying cause/pathophysiology of this primary problem? Identifying Clinical Relationships 1. What is the RELATIONSHIP of the past medical history and current medications? Past Medical History (PMH): Diabetes mellitus type II Hypertension Hyperlipidemia Cerebral vascular accident (CVA) with no residual deficits Gastro-esophageal reflux disease (GERD) Anemia-Iron deficiency Home Meds: Iron Sulfate 325 mg daily Lisinopril 5 mg daily Atenolol 25 mg PO daily Simvastatin 20 mg daily Aspirin 81 mg daily Clopidogrel 75 mg daily Omeprazole 20 mg daily Metformin 500 mg PO bid Identifying Clinical Relationships 2. Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the current problem? PMH: What Came FIRST: Diabetes mellitus type II Hypertension Hyperlipidemia Cerebral vascular accident (CVA) with no residual deficits Gastro-esophageal reflux disease (GERD) Anemia-Iron deficiency Identifying Clinical Relationships 3. What is the RELATIONSHIP between the primary care provider’s orders and primary problem? Care Provider Orders: Establish 2 large bore peripheral IVs Metoprolol 5 mg IV push x1 now Nitroglycerin IV drip-start at 10 mcg and titrate to keep SBP >100 Clopidogrel 600 mg po x1 now Aspirin 324 mg (81 mg tabs x4) chew x1 now Heparin 60 units/kg IV x1 now To cath lab as soon as team ready How it Will Resolve Primary Problem/Nursing Priority: Nursing Priorities 2. What nursing priority(ies) will guide your plan of care? The following are NANDA -I nursing diagnostic statements that can be used to establish a plan of care in this scenario: 3. What interventions will you initiate based on this priority? 4. What are the PRIORITY psychosocial needs that this patient and/or family likely have that will need to be addressed? 5. How can the nurse address these psychosocial needs? 6. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family? Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? 2. What can you do to engage yourself with this patient’s experience and show that she matters to you as a person? Health Science Science Nursing LPN 101 Share QuestionEmailCopy link Comments (0)

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