Answer KEY-ACS-MI Unfolding Reasoning PDF

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Keith RN - Unfolding Reasoning. Acute Coronary Syndrome/Myocardial Infarction...

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Acute Coronary Syndrome (ACS) Myocardial Infarction (MI)

JoAnn Smith, 68 years old

Answer Key © 2016 Keith Rischer/www.KeithRN.com

UNFOLDING Reasoning Case Study-ANSWER KEY

Acute Coronary Syndrome/Acute MI History of Present 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. What data from the histories are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Three days of progressive weakness Though weakness is a generalized complaint, it must be recognized as clinically significant by the nurse because it is NOT uncommon for women, the elderly, and those with diabetes to have atypical presentations with acute coronary syndrome (ACS) that do not always include chest pain. Denies chest pain, but admits to SOB that increases with activity as well as epigastric pain that has been intermittent for 20-30 minutes over the last 3 days

The combination of SOB, and epigastric pain must be recognized as an atypical variant of ACS. Dyspnea is a common feature associated with MI due to pulmonary congestion from diastolic dysfunction [Epocrates].

Her epigastric pain has become worse and is radiating into her neck

When clustered with weakness and SOB, the significance of an atypical presentation of ACS must be considered by the nurse. Though referred ischemic pain is most commonly seen with chest pain, it can be the ONLY physical complaint for women, the elderly, and those with a history of diabetes. For this scenario, JoAnn has two of these three risk factors. Clinical Significance: Cigarette smoking is the most significant modifiable risk factor that contributes to heart disease.

RELEVANT Data from Social History: She has smoked 1 pack per day the past 40 years

JoAnn appears anxious and immediately asks Anxiety INCREASES the workload of the heart. Therefore the nurse must repeatedly for her husband upon arrival. do all that is possible to decrease her anxiety. Find her husband and his presence will likely decrease her anxiety! What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medications treat which conditions? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: 1. Iron Sulfate 325 mg daily 1. Iron supplements 1. Increase Hgb  Diabetes mellitus type II 2. ACE inhibitor 2. Lower BP/protect 2. Lisinopril 5 mg daily  Hypertension 3. Simvastatin 20 mg daily 3. Lipid lowering agents kidneys in DM  Hyperlipidemia (statins) 3. Lower cholesterol  Cerebral vascular accident 4. Aspirin 81 mg daily 4. Inhibit clots 5. Clopidogrel 75 mg daily 4. Salicylates (CVA) with no residual 6. Omeprazole 20 mg daily 5. Platelet aggregation 5. Inhibit clots deficits 7. Metformin 500 mg PO inhibitors 6. Decrease gastric acid  Gastro-esophageal reflux 6. Proton pump inhibitors 7. Lower blood glucose bid disease (GERD) 7. Antidiabetics  Anemia-Iron deficiency (biguanides) © 2016 Keith Rischer/www.KeithRN.com

What medications treat which conditions?     

Diabetes mellitus type II>>>glyburide Hypertension>>>lisinopril Hyperlipidemia>>>simvastatinCerebral vascular accident (CVA) with no residual deficits>>>ASA/Clopidogrel Gastro-esophageal reflux disease (GERD)>>>omeprazole Anemia-Iron deficiency>>>iron sulfate

One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?  Circle what PMH problem likely started FIRST o Diabetes mellitus type II…likely started the domino effect, though hypertension and hyperlipidemia are close seconds that worked together to cause the vascular complications that JoAnn also has experienced 

Underline what PMH problem(s) FOLLOWED as domino(s) o Hypertension o Hyperlipidemia  Once the trifecta of diabetes, hypertension, and hyperlipidemia have had time to work together, vascular complications such as CVA and PVD will manifest in just a matter of time! o Cerebral vascular accident (CVA) with no residual deficits

Patient Care Begins: Current VS: T: 99.2 F/37.3 C (oral) P: 128 (regular) R: 24 (regular) BP: 108/58 O2 sat: 99% room air

P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Nothing/Nothing Ache Quality: Left arm that radiates into neck Region/Radiation: 5/10 Severity: Intermittent-20-30" at a time Timing:

What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: JoAnn is tachycardic, therefore the nurse must step back and ask WHY? P: 128 (regular) Could be due to anxiety, or, knowing that she may be having an acute coronary syndrome, she could be compensating for decreasing cardiac output. Remember the relevance of this essential formula from A&P that must be applied to practice…CO=SVxHR. This tachycardia can also be due to high sympathetic output [Epocrates]. R: 24

Remember that with any patient with possible ACS, your goal is to DECREASE THE WORKLOAD OF THE HEART! Tachycardia in this context is a clinical RED FLAG because it increases the workload of the heart and increases O2 demands that are currently compromised. Tachypnea could be due to anxiety or SOB that may be due to pulmonary edema with ACS. Recognize the need to thoroughly assess breath sounds and cluster assessment findings with tachypnea.

BP: 108/58

In the context of ACS, this blood pressure is too low. Depending on how the physician manages the case, you will need to be cautious with any medications that can lower BP. In ACS or MI, afterload must be reduced, The goal in acute MI is generally a systolic BP (SBP) of around 120. This is typically done through beta blockers such as metoprolol or nitroglycerin sublingual or IV drip.

© 2016 Keith Rischer/www.KeithRN.com

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN:

Anxious, appears uncomfortable, body tense Respirations labored, coarse crackles present in bases bilaterally anterior/posterior Pale, diaphoretic, no edema, heart sounds regular S1S2 with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants Voiding without difficulty, urine clear/yellow Skin integrity intact, skin turgor elastic, no tenting present

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: This could be the result of anxiety due to her current condition and/or GENERAL APPEARANCE: Anxious, difficulty breathing. Anxiety increases myocardial oxygen demand, elevates appears uncomfortable, body tense systolic BP, and increases the workload of the heart. Therefore it must be addressed and not allowed to continue. Emotional support and education can help decrease this immediately, but she may need medications such as lorazepam or morphine to effectively decrease her blood pressure. RESPIRATORY: Respirations labored, coarse crackles present in bases bilaterally

This cluster of data confirms impairment of diffusion. The alveoli are filling with fluid (crackles) from likely pulmonary edema due to cardiogenic shock in acute MI. Reinforce that the first choice to more accurately assess breath sounds is POSTERIOR —there is less tissue to auscultate through compared to anterior -- especially with women and additional breast tissue. Pay close attention to the BASES as gravity will pull any secretions/fluids downward and is usually the first place that adventitious breath sounds are auscultated. Be sure to listen for full inspiration and expiration in each lung field.

CARDIAC: Pale, diaphoretic, no edema, heart sounds regular S1S2 with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

Pale, and being diaphoretic confirms that the sympathetic nervous system stimulation is present and is there for a reason! The nurse must step back and ask WHY? Fight or flight is now a reality with a life-threatening presentation!

12 Lead EKG:

Interpretation: The ST elevation is clearly present in the inferior leads of II, III, and AVF. This is classic diagnostic criteria for an acute myocardial infarction (MI) that is also referred to as a ST elevation myocardial infarction (STEMI) vs. a non-ST elevation myocardial infarction (non-STEMI). A STEMI is more concerning because it involves the FULL thickness of the myocardium and more muscle is at risk of loss. This is reflected by the ST segment elevation. In contrast, a non-STEMI is PARTIAL thickness infarction of the © 2016 Keith Rischer/www.KeithRN.com

myocardium and is reflected by a ST segment depression on a 12-lead EKG instead. Clinical Significance: This must be recognized as an inferior STEMI that requires immediate intervention! Time is muscle! Inferior wall infarction occurs with occlusion of the right coronary artery. This infarction manifests by ECG changes in leads II, III, and aVF. Conduction disturbances are expected with an inferior wall MI because of the anatomy of the coronary arterial supply. The right coronary artery (RCA) perfuses the sinoatrial (SA) node in slightly more than half of the population and supplies the proximal bundle of His and the atrioventricular (AV) node in more than 90 percent of individuals. Heart block and other conduction disturbances should be anticipated with an inferior MI (Urden, 2014). Location of ST Segment Changes (lateral/anterior/inferior): Use the diagram below to identify the location of the infarction: Though this content on basic 12-lead EKG interpretation may be above the scope of knowledge required for most programs, take advantage of the APPLICATION of the principle that ischemia causes distinct EKG changes. This is relevant when a patient on routine cardiac telemetry monitoring begins to have NEW ST-T wave changes. If the nurse understands the significance of these changes, a RESCUE of a patient with a change of status can begin!

Radiology Report: Chest x-ray What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Scattered bilateral The chest x-ray and echocardiogram confirm the ominous development of severely opacities consistent with depressed left ventricle (LV) function due to inferior MI and pulmonary edema. This report atelectasis or pulmonary confirms what you already suspect and are seeing clinically, pulmonary edema secondary edema to cardiogenic shock in the context of an acute MI. This should not delay implementation of reperfusion therapy. [Epocrates]

Radiology Report: Echocardiogram What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Global left ventricle Reflects severely damaged left ventricle due to inferior MI. Remember a normal ejection hypokinesis with ejection fraction of 55-65 percent and what this represents. An EF of 10-15percent is end-stage fraction of 25% heart function because only 10-15 percent of the blood volume of the LV is being ejected into circulation. In the context of acute MI, an initial low ejection fraction is not necessarily where the patient will remain with their heart muscle, due to zones of injury with an acute MI that are similar to a target and bullseye. The bullseye is the infracted zone that will not return to life, but there is a ring around this zone that is “stunned myocardium.” With reperfusion and time (usually 3-7 days,) this stunned tissue is viable but not yet able to contract. This is similar to when your arm falls asleep when you lie on it wrong at night. It is viable, but initially does not move well. When this echo is repeated in 7 days–this is more telling of what the long-term function will be. © 2016 Keith Rischer/www.KeithRN.com

Lab Results: Complete Blood Count (CBC): WBC (4.5-11.0 mm 3) Hgb (12-16 g/dL) Platelets(150-450x 103/µl) Neutrophil % (42-72)

Current: 10.5 12.9 225 70

High/Low/WNL? WNL WNL WNL WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Though some of the following lab values are WNL, because they are ALWAYS RELEVANT, they must be intentionally noted by the nurse!

Clinical Significance:

WBC: 10.5

ALWAYS RELEVANT based on its correlation to the presence of inflammation or infection. Will usually be increased if infection present, though it may be decreased in the elderly or peds...