Jose Martinez - Concepts of Nursing III PDF

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Jose Martinez Room 303 Jose Martinez 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. Chest pain became progressively worse, so he called for an ambulance to bring him to the Emergency Department. Once the ambulance arrived, he reported his pain as 10/10. he 12-lead EKG, done within the initial 10 minutes of arrival and ASA was given to chew. Vital signs were HR 160, BP 145/102, Respirations 23, and Pulse Ox 89%. He was given nitroglycerin during transport to the hospital with little relief. He complained of feeling “light- headed” and is anxious. He has been admitted to the unit, and the pain has subsided. He does have a 10-year history of hypertension. He was admitted to the cardiac step down from the ER because no beds were available in the cardiac ICU. The CathLab has been notified for an emergency procedure. Ambulance report: Nitroglycerin SL x 3, 12-lead EKG, Blood drawn for cardiac enzymes, Peripheral IV started to left forearm.

You responded correctly to 5 out of 6 evaluations: Category Educational Needs Fall Risk Health change Neurological

Your response Explanation Increased Mr. Martinez needs further understanding of why he is acuity having chest pains and the risks associated with cardiac injury. Increased Due to Mr. Martinez feeling “light -headed” as well as acuity an increased level in pain, he is at risk for falling. Increased Due to the risk of cardiac injury, possible vessel blockage, and history of hypertension Mr. Martinez is acuity more susceptible for further cardiac injury. Increased low pulse ox and lightheadedness puts the patient at Acuity an increased need.

Your response Explanation Normal Normal, rationale: Patient states the pain has subsided Psychological Increased Patient is anxious Needs acuity Category Pain level

Jose Martinez Jose Martinez 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. Chest pain became progressively worse, so he called for an ambulance to bring him to the Emergency Department. Once the ambulance arrived, he reported his pain as 10/10. he 12-lead EKG, done within the initial 10 minutes of arrival and ASA was given to chew. Vital signs were HR 160, BP 145/102, Respirations 23, and Pulse Ox 89%. He was given nitroglycerin during transport to the hospital with little relief. He complained of feeling “light- headed” and is anxious. He has been admitted to the unit, and the pain has subsided. He does have a 10-year history of hypertension. He was admitted to the cardiac step down from the ER because no beds were available in the cardiac ICU. The CathLab has been notified for an emergency procedure. Ambulance report: Nitroglycerin SL x 3, 12-lead EKG, Blood drawn for cardiac enzymes, Peripheral IV started to left forearm.

You correctly diagnosed 8 out of 10 options: Physiological

Description Acute Pain

Altered body image Anxiety Disturbed thought process, risk for. Impaired gas exchange Impaired tissue perfusion Ineffective health maintenance Powerlessness

Your Respons e Explanation True Angina (chest pain) is the pain associated with decreased blood flow to the heart muscle. False Scenario does not support this. True True

Patient expresses he is experiencing anxiety. Patient is lightheaded and has low pulse ox.

True

Oxygen saturation is 89%.

True

Due to altered cardiac blood flow circulation. High blood pressure, high cholesterol, and high triglycerides.

True

True

This is related to acute illness and inability to control pain. This can also be due to lack of knowledge regarding medical conditions.

Safety Your Respons Description e Explanation Drug therapy True Monitor patients for antithrombotic therapy due to increased risk for bleeding and bruising. Scenario does not support this. Risk for social False isolation

Jose Martinez Scenario 1 You enter the room and Mr Martinez is still waiting to be taken to the CathLab. The patient is now 10/10. Call Rapid response. Rapidly prioritize the following:

You correctly ordered 3 out of 5 actions: Is this order correct Your Correc order t order Step Explanation 1 1 Assess airway, Assessment is always breathing, circulation. the first step in the nursing process. Myocardial oxygen 2 Administer oxygen therapy to make sure demand is increased during an acute event. oxygen saturation is greater than 90%. 3 Ensure continuous Analysis of the EKG is EKG monitoring. essential to ensure appropriate patient care management. 4 4 Provide Morphine Pain relief helps increase the oxygen supply and Sulfate IVP as decrease myocardial prescribed. oxygen demand. 5 5 Assist rapid response Patient is in need of immediate intervention team in taking Mr. Martinez to the cathlab

Scenario 2

Mr. Martinez was taken emergently to the Cath-lab and had 3 stents inserted in his heart. The pain was relieved after the procedure. He has been informed that the stents have been placed and he will be monitored closely for the next 24 hours.

You correctly ordered 5 out of 5 actions: Is this order correct Your Correc order t order Step 1 1 Assess for the abrupt cessation of pain 2 2 Initiate IV Heparin. 3

3

Give ASA.

4

4

Observe for bleeding at the insertion site

5

5

Monitor aPTT

Explanation Indicates that the clot has been dissolved.

Large amounts of thrombin are released increasing the risk for vessel-reocclusion. Maintain the patency of the coronary artery after percutaneous coronary intervention. During thrombolytic administration immediately report any indications of bleeding to the Healthcare Provider. Used for evaluation of Heparin therapy.

Scenario 3 Mr. Martinez will now start taking long term antithrombotic therapy. He is anxious that he will forget to take it or take the wrong dose. He tells you he wished he “had died from the attack…I’ll never be the same.”

You correctly ordered 5 out of 5 actions: Is this order correct Your Correc orde t r order Step Explanation 1 1 Provide emotional Needed to promote a positive learning environment. Allow support. patients to verbalize and express feelings of fear, anxiety, anger, denial, and grief. 2 2 Assess Mr. Assessment of Mr. Martinez’s willingness to learn to know Martinez’s how much information should willingness to be taught at this time. learn. Be specific in education 3 3 Provide efforts to promote introductory understanding and information on compliance. prescribed antithrombotic medication. 4 4 Report Mr. Case Management will Martinez’s identify need for

Your Correc orde t r order

5

5

Step Explanation emotional distress interdisciplinary intervention. to Case Management. Document all Documentation is necessary findings. to validate education was provided and understood. Any conversations with an interdisciplinary team are to be documented in the medical record.

Scenario 4 Mr. Martinez lab work comes back post-stent placement. Rank as most concerning for labs.

You correctly ordered 5 out of 5 actions: Is this order correct Your Correc order t order Step 1 1 Troponin 1.0 mg/mL. 2 2 CPK: 360 mcg/mL.

Explanation Troponin is a sensitive marker for myocardial damage. It may indicate heart damage, but could also be elevated as a result of increased strenuous activity or damage to other parts of the body.

Your Correc order t order Step 3 3 CK-MB6.8 4

4

5

5

Explanation A marker, but not specific for acute MI. Abnormal Potassium Lab values can affect cardiac conduction.

Serum Potassium 4.2 mEq/L. Serum Serum-Sodium level is normal with Sodium 142 lesser adverse cardiac events on cardiac conduction. mEq/L.

Scenario 5 Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. Upon completion of the shift assessment, Mrs. Martinez quietly asked “my husband is telling me he is ready to get me home, that he is missing me. Should I be concerned about having sex with him? Could he have another heart attack?”

You correctly ordered 5 out of 5 actions: Is this order correct Your Correc orde t r order Step 1 1 Clarify with Mrs. Martinez that she is asking if it is okay to resume sexual

Explanation Therapeutic communication involves open discussion and understanding of what the

Your Correc orde t r order

Step relations with her husband upon discharge. Promote open communication between Mr. and Mrs. Martinez.

2

2

3

3

Explain to Mr. and Mrs. Martinez the disease process following a myocardial infarction.

4

4

Discuss physical limitations following a myocardial infarction.

5

5

Provide information to Mr. and Mrs. Martinez regarding support groups.

Explanation other person is attempting to communicate. Open communication after a myocardial infarction is needed for the patient and family to promote positive coping. It is important to explain the disease process in layman’s terms to the patient and family to promote understanding of how this may affect their sexual relationship. Explains to the patient and his wife that sexual relationships may resume when he can walk one block or climb 2 flights of stairs without symptoms. Support groups can be beneficial for patients and families with similar health care concerns....