HESI Patient Review 3 Mr. Swan PDF

Preview

Summary

Download HESI Patient Review 3 Mr. Swan PDF

Description

HESI Patient Review, Adult Health, Cardiovascular Health, Mr. Swan

You are a nurse working the day shift in the Emergency Department (ED) at a local community hospital. Mr. Swan, age 54, has come to the ED complaining of chest pain. His wife is with him. Mrs. Swan tells the triage nurse that her husband complained of chest discomfort late last evening after a very stressful day. He felt better after sitting down and reading the newspaper and attributed his discomfort to "indigestion." As Mr. Swan was dressing for work this morning, however, chest discomfort returned, and was more intense. Mrs. Swan also mentions that her husband had surgery two weeks ago: transurethral resection of the prostate for obstructing benign prostatic hyperplasia. An initial assessment is completed by the triage nurse. She immediately admits Mr. Swan to the Emergency Department (ED) and assigns him to your care.

Given Mr. Swan's chest pain, it is initially assumed and he is treated as if he is having a heart attack, or myocardial infarction (MI). Signs and symptoms of myocardial infarction (MI) are highly variable. The patient experiencing an MI may present with chest pain, confusion, breathlessness, hypotension, diaphoresis, weakness, nausea, syncope, and/or dysrhythmias. You place Mr. Swan on a stretcher and move him to the cardiac section of the Emergency Department (ED), where monitoring and emergency equipment are available. Chest pain often occurs with myocardial infarction (MI). With MI, chest pain may be located over the precordium or may be substernal -- it may radiate to one or both arms, the neck, the jaw, or other areas. It may be described in many ways, including squeezing, heavy pressure, aching, or a burning discomfort. Pain may not be present at all with MI, especially in elderly and diabetic persons. Women and diabetics often have an atypical presentation, reporting pain in the neck or throat, and/or fatigue and dizziness.

With MI, the onset of pain is usually sudden, and its duration is generally more than 30 minutes. Pain is often severe.The chest pain associated with an MI usually is not relieved with rest, position change, or nitroglycerin. The physician orders aspirin for Mr. Swan. Aspirin is administered as soon as possible when symptoms of a heart attack are present. Aspirin is administered for its antiplatelet effect, which decreases platelet aggregation and clotting. The often-recommended dose of baby aspirin (81 mg) is used for prevention. This preventive dose is not sufficient when a patient has signs and symptoms that suggest acute myocardial infarction (MI). 325 mg is ordered for Mr. Swan. 



It is important that the aspirin you administer to Mr. Swan be in which form? o Enteric-coated  Enteric-coated aspirin is not indicated at this time. Enteric coating would delay absorption of the aspirin. Aspirin effects are needed immediately. Enteric-coated aspirin is used when a person will be maintained on aspirin long-term. Enteric-coated drugs do not dissolve in the stomach. The coating dissolves in the intestine, where the drug is then absorbed. Enteric coating is useful when a drug can be irritating to the stomach, and/or absorption in the intestine instead of the stomach is desirable. o Non-enteric-coated  Mr. Swan should be given non-enteric-coated, chewable aspirin, for fastest onset of action. Aspirin effects are needed immediately, to decrease platelet aggregation and clotting. Drug absorption and action would be delayed if enteric-coated aspirin was given. Enteric-coated aspirin is used when a person is maintained on aspirin long-term. Enteric-coated drugs do not dissolve in the stomach. The coating dissolves in the intestine, where the drug is then absorbed. Enteric coating is useful when a drug can be irritating to the stomach and/or absorption in the intestine instead of the stomach is desirable. o Sublingual  Aspirin is only available as a tablet for oral administration. It is not available in a form for administration under the tongue. o Translingual  Aspirin is only available as a tablet for oral administration. Given Mr. Swan's chest pain, it is initially assumed and he is treated as if he is having a myocardial infarction (MI). This is because: o other causes of chest pain are less serious than acute MI  Chest pain can occur with a variety of health problems other than acute myocardial infarction (MI). Many of these are potentially serious and can be life-threatening. These include anxiety, hyperthyroidism, severe anemia, thoracic aortic aneurysm, and a variety of cardiac (myocardial hypertrophy, severe aortic stenosis or regurgitation, paroxysmal tachycardia),

o

gastrointestinal (esophageal, stomach) and respiratory (pleurisy, pneumonia, pneumothorax, pulmonary embolus) disorders. early identification and treatment of MI increases the chance of preserving myocardium  Although chest pain can occur with a variety of health problems, in the Emergency Department (ED) it is often associated with acute coronary syndrome (ACS) which may involve myocardial infarction (MI). Aggressive emergency treatment is critical in preventing or limiting myocardial damage when ACS with possible MI is evident. Treating Mr. Swan on the assumption that his chest pain is a consequence of acute MI will not preclude a thorough diagnostic work-up to determine the cause of his chest pain. It will, however, increase the chance of preserving his myocardium and insuring his survival, if in fact he is having an MI.

Acute coronary syndrome (ACS) involves either acute myocardial infarction (MI) or unstable angina (UA) that may result in MI. Angina is a signal that the myocardium is being deprived of oxygen. It is usually a consequence of severe ischemia secondary to increasing obstruction from plaque rupture and evolving thrombus (clot) formation in an atherosclerotic coronary vessel. 



In contrast to unstable angina, a myocardial infarction (MI) involves myocardial: o necrosis Correct  Unstable angina is associated with severe ischemia. A myocardial infarction (MI) is a consequence of severe prolonged myocardial ischemia, and injury that initially causes myocardial cell dysfunction, and eventually myocardial cell death (necrosis). o infection  A myocardial infarction (MI) does not involve infection of the myocardium. Infectious processes of the heart include myocarditis, pericarditis, and endocarditis. Given Mr. Swan's current condition and complaints, which of the following interventions is indicated and has priority? o Draw venous blood for serum cardiac biomarkers  Drawing blood for serum cardiac biomarkers is important, but another intervention takes priority. o Teach Mr. Swan relaxation techniques  Relaxation techniques, while important, are not a priority at this time. Another intervention takes priority. o Apply nasal oxygen  Mr. Swan is complaining of chest pain that may be associated with acute coronary syndrome, either angina (myocardial ischemia) or myocardial infarction (tissue injury/necrosis secondary to ischemia). Also, his SpO2 is 92%, which is low. Oxygen is indicated, to improve tissue oxygenation. Oxygen administration takes only seconds to implement. Generally, 2-4 liters





of oxygen per minute is administered by nasal cannula. You administer nasal oxygen to Mr. Swan by nasal cannula at 2 liters per minute, per physician's order. Which of the following positions allows for optimal oxygen-carbon dioxide exchange and is best for Mr. Swan at this time? o Supine  The supine position limits movement of the diaphragm and respiratory excursion. Oxygen-carbon dioxide exchange is hampered by this position. o Fowler's  Mr. Swan is complaining of chest pain that may be associated with acute coronary syndrome, either angina (myocardial ischemia) or myocardial infarction (tissue injury/necrosis secondary to ischemia). Optimal tissue oxygenation is indicated. The Fowler's position, with the head of the bed elevated 45 degrees or more, allows for full lung expansion and optimal oxygen-carbon dioxide exchange. In the Fowler's position, movement of the diaphragm is not restricted, and the lungs can fully inflate. In the Fowler's position, Mr. Swan rests comfortably, with oxygen running. Although still complaining of chest pain, he is less apprehensive. o Side-lying  The side-lying position is not optimal for enhancing oxygen-carbon dioxide exchange.

You connect Mr. Swan to a monitor that displays his ECG, noninvasive blood pressure (NIBP), and arterial oxygen saturation by pulse oximetry (SpO2). Which heart rhythm is displayed? o normal sinus rhythm o sinus bradycardia o sinus tachycardia o atrial tachycardia o atrial fibrilation o atrial flutter o junctional rhythm o ventricular tachycardia o ventricular fibrilation o asystole o 1st degree heart block o 2nd degree heart block (type I) o 2nd degree heart block (type II) o 3rd degree heart bloack o premature atrial contractions o premature junctional contractions







o premature ventricular contractions The physician examines Mr. Swan. He uses a stethoscope to assess Mr. Swan's heart sounds. Which chest piece is used first when auscultating the heart? o Bell  The bell chest piece of a stethoscope is not used first when auscultating the heart. o Diaphragm  The diaphragm, the flat-shaped surface of a stethoscope, is used first when auscultating the heart. The diaphragm is best for assessing high-pitched sounds. The bell is used after the diaphragm, to assess low-pitched sounds. Cardiac auscultation with Mr. Swan is normal. No murmurs, rubs, or gallops are noted. The physician orders nitroglycerin sublingually stat for Mr. Swan. In administering the nitroglycerin, you realize that sublingual administration is indicated because the drug: o will be absorbed quickly when administered sublingually  Quick relief of Mr. Swan's chest pain is desired. Sublingual nitroglycerin is commonly prescribed for quick treatment of chest pain. The mucous membranes in the mouth have a thin epithelium and a rich blood supply that allow for quick drug absorption. Nitroglycerin tablets for sublingual (under the tongue) administration are readily dissolved by saliva and quickly absorbed. Nitroglycerin can also be administered by translingual spray (directed on or under the tongue), or buccal tablets (placed between the gum and upper cheek or upper lip). Nitroglycerin is also available as extended-release capsules and tablets. These are not used to treat chest pain, since drug effects would be delayed. o could make Mr. Swan nauseous if administered orally  Orally-administered nitroglycerin would not be more likely to cause nausea any more than sublingually-administered nitroglycerin. The preferred route is determined by another factor. o is less likely to cause an allergic reaction when administered sublingually  Orally-administered nitroglycerin would not be more likely to result in an allergic reaction any more than sublingually-administered nitroglycerin. The preferred route is determined by another factor. To evaluate Mr. Swan's response to nitroglycerin, which of the following assessments are indicated? o Breath sounds  While breath sounds need to be monitored, they are not specifically affected by the administration of nitroglycerin. o Respiratory rate  While respiratory rate must be monitored, it should not be directly affected by nitroglycerin. o Blood pressure  Nitrates relax vascular smooth muscle, resulting primarily in venous vasodilation and coronary artery vasodilation. Blood pressure should be

o o

monitored in Mr. Swan. Through venous vasodilation, nitroglycerin decreases venous return to the heart (preload). This reduces myocardial oxygen demands. However, this action also causes blood pressure to decrease. Hypotension can aggravate myocardial ischemia. Blood pressure should be closely monitored and maintained. Oral temperature  The administration of nitroglycerin does not affect oral temperature. Chest discomfort  Nitrates relax vascular smooth muscle, resulting primarily in venous vasodilation and coronary artery vasodilation. Assessment of chest discomfort is important. Through coronary artery vasodilation, nitroglycerin should help relieve chest pain by increasing myocardial perfusion and blood flow. It is expected that chest discomfort will be relieved with nitroglycerin.

A chest x-ray is ordered, and blood tests are drawn (cardiac biomarkers, complete blood count (CBC), coagulation studies, electrolytes). Vital signs and SpO2 are recorded, an IV is started, and a 12-lead ECG is done. A 12-lead ECG is needed to determine if Mr. Swan has evidence of myocardial tissue injury that would make him a candidate for reperfusion. With reperfusion, coronary artery patency can be restored, and infarct size (tissue injury) can be limited. Myocardial ischemia (angina) and myocardial tissue injury (infarction) may be characterized by changes in the ECG waveform. The ST-segment of an ECG waveform reflects the heart's ability to repolarize (prepare for the next contraction). ST-segment variations from baseline occur when the myocardium is ischemic or there is myocardial tissue injury. With myocardial ischemia there may be ST-segment depression. Myocardial tissue injury or infarction is generally characterized by ST-segment elevation

An ECG that demonstrates persistent significant ST-segment elevation (greater than 2 mm above the baseline in two contiguous precordial leads and 1 mm in two limb leads) is diagnostic for myocardial injury that could benefit from reperfusion of the injured area.

Mr. Swan does not have ST-segment elevation, and therefore is not a candidate for reperfusion. When a patient is a candidate for reperfusion, reperfusion can be accomplished with primary percutaneous coronary intervention (PCI) or fibrinolytic reperfusion. PCI is preferred for reperfusion, because it is likely to result in more effective reperfusion. However, PCI is preferred only when it can be done quickly (within a few hours of symptoms) and accomplished by a team with a high success rate. PCI usually involves percutaneous transluminal coronary (balloon) angioplasty (PTCA), laser angioplasty, and/or the implantation of intracoronary stents. When PCI is not possible, fibrinolytic reperfusion is implemented. 

If Mr. Swan was a candidate for reperfusion and fibrinolytic reperfusion was being considered, which of the following would be a concern? o Mr. Swan's chest discomfort started last evening  The fact that Mr. Swan's chest discomfort started last evening would not necessarily contraindicate fibrinolytic reperfusion. The greatest benefit from fibrinolytic reperfusion occurs when treatment is initiated within 1-3 hours of the onset of symptoms. Many patients benefit from treatment within 6 hours, and for some, treatment may still be advantageous up to 12 hours or more after onset of symptoms. In general, the earlier treatment is initiated, the better the chance of successful reperfusion. o Mr. Swan had surgery two weeks ago  Recent surgery (less than three weeks prior) might contraindicate fibrinolytic reperfusion. Fibrinolytic therapy increases risk for bleeding. Fibrinolytic agents promote the conversion of plasminogen to plasmin, which breaks down thrombi. Using fibrinolytic therapy in a patient who recently had surgery would predispose the person to bleeding and possibly hemorrhage. Recently-formed clots/fibrin deposits could easily breakdown and bleed. Highly-vascular areas such as the bladder would be especially prone to bleeding. Fibrinolytic reperfusion is done cautiously in patients who had

recent trauma, surgery, or internal bleeding of any kind (such as stroke), those with severe hypertension or currently taking anticoagulants, those with any history of familial bleeding disorders, and those with active peptic ulcer disease. The greatest benefit from fibrinolytic reperfusion occurs when treatment is initiated within 1-3 hours of the onset of symptoms. Many patients benefit from treatment within 6 hours, and for some, treatment may still be advantageous up to 12 hours or more after onset of symptoms. In general, the earlier treatment is initiated, the better the chance of successful reperfusion. Mr. Swan's chest pain is relieved after two doses of nitroglycerin, administered five minutes apart. Mr. Swan is now less anxious. He remains in the Emergency Department (ED) for continued observation.



You note Mr. Swan's ECG. Which rhythm is displayed? o normal sinus rhythm o sinus bradycardia o sinus tachycardia o atrial tachycardia o atrial fibrilation o atrial flutter o junctional rhythm o ventricular tachycardia o ventricular fibrilation o asystole o 1st degree heart block o 2nd degree heart block (type I) o 2nd degree heart block (type II) o 3rd degree heart bloack o premature atrial contractions o premature junctional contractions o premature ventricular contractions

You also note on Mr. Swan's ECG that ST-segment depression is no longer evident. In patients with angina, this is consistent with relief of chest pain and increased myocardial oxygen supply. Mr. Swan had blood drawn for serum cardiac biomarkers. Protocol at your hospital includes serum creatine kinase MB (CK-MB) and troponins: cardiac specific troponin T (cTnT) and cardiac-specific troponin I (cTnI).

Creatine kinase (CK) is an enzyme normally present in the heart, skeletal muscle, brain, and gastrointestinal tract. When tissue injury occurs to these areas, serum CK elevates. Each of the CK isoenzymes, CK-MB, CK-MM, and CK-BB is specific for different sites of tissue damage. CK-MM and CK-BB are specific for damage to skeletal muscle and brain tissue, respectively. CK-MB is sensitive for myocardial necrosis. On average, CK-MB rises 3-6 hours after myocardial tissue injury, peaks at 12-24 hours, and returns to normal in 3-4 days. Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI) were also drawn. Cardiac troponins are proteins that exist in myocardial cells. With myocardial injury, they are released into the serum. Cardiac troponins (especially cTnI) are more specific for cardiac injury that CK-MB. On average, cTnI and cTnT levels rise within several hours after myocardial injury, and remain elevated 10-14 days. Mr. Swan's chest x-ray and ECG are read as normal. His chest pain has been eliminated with nitroglycerin. Clinical signs and symptoms are not consistent with a myocardial infarction (MI). Available lab results are normal. Even though cardiac biomarker results are not yet available, the physician believes that Mr. Swan has stable angina, probably a consequence of coronary artery disease (coronary atherosclerosis). 

Mr. Swan asks you if angina is the same as a heart attack. You correctly teach Mr. Swan and his wife that: o The chest pain of angina is temporary and can be relieved with nitroglycerin and/or rest. The chest pain of MI is long-lasting and not easily relieved.  The pain of angina is temporary and relieved with nitroglycerin and/or rest. The pain of a myocardial infarction (MI) is long-lasting and not easily relieved. It is appropriate to provide Mr. Swan and his wife with this information. o The chest pain of angina is caused by irritation of nerve endings in the heart. The pain of MI is caused by poor blood supply to the heart.  This information would not be correct. The pain of angina AND the pain of a myocardial infarction (MI) are both caused by poor blood supply to the heart. o There is no myocardial damage with angina. There is permanent myocardial damage with an MI.  There is no myocardial damage with angina. There is permanent myocardial damage with myocardial infarction (MI). It is appropriate to provide Mr. Swan and his wife with this information. o Episodes of angina are usually associated with activity or stress. An MI often occurs without a precipitating event.  Episodes of angina are commonly associated with a precipitating event (physical or emotional stress). A myocardial infarction (MI) often occurs

without a precip...