Melody Dixon Fallticket 2021-1 PDF

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Patient Name: Melody Dixon SIM Visit: #2 Diagnosis and Demographic information: Acute Coronary Syndrome (ACS), African American, Female Allergies: NKDA DOB: April 22 Age: 71

Simulation Lab Admission Ticket Goals: • Performs safe patient care using DCN protocol (CO 1, 2. 3, 4, 5, 6, 7, 8, 9) • Performs a head to toe assessment and recognizes normal and abnormal findings (APPLYING) (CO 1, 2, 8) • Designs an individualized nursing plan of care based on subjective/objective assessment data (CREATING) (CO 1, 2, 3, 4, 5, 6, 7, 8) • Performs safe medication administration (APPLYING) (CO 9) •Uses therapeutic communication to actively engage patient and family in plan of care (APPLYING) (CO 1, 3, 7, 8) •Demonstrate teamwork and collaboration skills, including delegation (APPLYING)(CO 8) •Evaluates the patient’s responses to nursing interventions (EVALUATING) (CO 1, 3, 5) Review (skills):  Basic environmental safety assessment and measures to maintain a safe environment (SWIPE/BRowN COW)  Safe medication administration process  Head to toe assessment  Review EKG interpretation  Pain assessment  Lab interpretation  IV push medications Complete the following questions prior to simulation:

1. Explain the pathophysiology of ACS, including the role of plaque formation and rupture; the 3 sub-conditions of ACS, and the differing manifestations of each sub-condition. 1. Acute coronary syndrome is caused a rupture of an atherosclerotic plaque. What happens is lipids Attach themselves to a coronary vessel wall and overtime the body encapsulates that plaque in a fibrogen cap. as more of the vessel is obstructed the blood becomes more coagulative because it's being blocked or “squeezed” because there's only a percentage of that vessel that is able for it to flow through. Once that encapsulated plaque ruptures it leases all that fat in the blood stream and this also

causes platelet aggregation and formation of a thrombose which will further block the amount of healthy blood that can get passed (Harding et al., 2020) 2. The three sub-conditions of ACS are unstable angina(UA), Non-St-segment- elevation-myocardial infraction (NSTEMI), and Stsegment- elevation-myocardial infarction (STEMI). 1. unstable angina: new onset of chest pain, pain that happens at rest, or pain that is worsening because of a nonocclusive thrombus (Harding et al., 2020). UA are very unpredictable and they need to be treated immediately. EKG changes could be seen as ST depressions and/ or inversions of T waves AKA ischemic changes (Harding et al., 2020). Treatment for a UA is aspirin, low flow O2, nitrates and a heparin drip. 2. The base pathology for a STEMI and NSTEMI is the same. They are caused by sudden occlusion of blood flow in the coronary artery by either a thrombus that is blocking blood flow or not. a. NSTEMI: caused by a partial occlusive thrombus. does not show any ST elevation on an EKG but may show ST depression and/or T wave inversion. The treatment for NSTEMI is aspirin, low flow O2, and nitrates. A cardiac catherization which can be done anywhere from 12-72 hours of onset. NSTEMI’s should not be treated with thrombolytic therapy (Harding et al., 2020, P 718). b. STEMI: caused by an occlusive thrombus. ST segment elevation by at least 1mm or more on an EKG. It has to be treated within 90 minutes of onset of pain to limit any damage done to the heart. it can be either treated by PCI (first line of treatment) or thrombolytic therapy (Harding et al., 2020). 2. Outline the role of 12-lead ECG and serum cardiac biomarkers in the diagnosis and risk stratification of ACS. 1. 12-lead ECG: is a primary tool to diagnose any electrocardiogram changes. it is used to diagnose/ rule out UA or a MI (Harding et al., 2020). 2. cardiac biomarkers: are proteins that are released into the blood stream after the heart suffered some type of ischemic attack causing necrosis of the heart. There are a couple of biomarkers that can be tested, they are cardiac specific Troponin(cTnT, and Ctnl), and Creatine Kinase MB (Harding et al., 2020). Troponin are more specific, and sensitive to myocardial injury. Cardio biomarkers are drawn over a 24 hour period roughly about every six hours. Ponent levels increase at about four to six hours after the original onset of MI, they peak at about 10 to 24 hours, and they returned to normal baseline at about 10 to 14 days post attack. Cardio markers can diagnose if it's a NSTEMI or a UA. Positive cardio markers are indicative of having NSTEMI, while negative cardio markers are more likely to diagnose a UA (Harding et al., 2020). 3. Which of the three sub-conditions of ACS require immediate PCI? Why does this sub-condition require immediate intervention? 1. A STEMI requires immediate PCI because there is an actual blockage of the blood flow and that needs to be “busted” open as soon as possible (within 90 min of onset of pain) (Harding et al., 2020). 4. Explain the process of the cardiac catheterization lab with possible percutaneous coronary interventions (PCI) in the management of ACS and possible complications that may arise. 1. During percutaneous transluminal coronary angioplasty (PTCA) the goal is to open up the blockage within that 90 minutes, that's why in hospitals they say “door to balloon time” and they always try to beat that 90 min because the longer the ischemia is

going on the more damage is done to the heart. While in the cath lab the doctor will determine which artery they will want to enter whether it be the femoral artery or the radial artery, once an artery has been chosen (the most common one is the femoral artery). The doctor numbs the area with a local anesthetic, insert the needle into the artery, then insert the first guidewire into the needle, then the doctor removes the needle. Then an instrument called the introducer is inserted above the original guidewire, then at this point the doctor removes the original guidewire and replaces it with a thinner guidewire. At this point the doctor is ready to insert a diagnostic catheter and guides it up to the aorta. once the doctor is at the opening of carotid artery, he will inject dye and look at a live CT scan to determine where the blockage is located, how big the blockages what is the best course of treatment. If the doctor believes that he can open up the blockage he will insert an even smaller catheter with a balloon on it which they can expand and collapse to push the blockage outwards towards the vessel wall. Once the doctor feels like he cannot push the plaque any further they may wish to place a stent in to help keep the vessel open (Vorvick, 2019).

5. Review the following videos: https://youtu.be/10y4gRdnCy8

https://youtu.be/VzapqLiXbU4 6.

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ACS

Complete the following ADPIE/AAPIE/ Clinical Judgement template on your patient

Priority Problem Nursing Diagnosis (NANDA approved)

R/T (Pathophysiology of diagnosis, cannot be medical diagnosis)

AEB (of diagnosis) Refers to the problem/risk, NOT the R/T. This is

activity intolerance Assessment Data (Include at least three to five [total] objective, subjective, and/or historical pieces of data that would lead to the nursing diagnosis

R/T atherosclerosis Goal Nursing Interventions (One goal that is patient (List three nursing focused and SMART; and/or order driven Specific, Measurable, interventions that relate Attainable, Reasonable, to your goal) and Time specific)

Subjective… patient complains of fatigue

Patient will… able to walk down the hall with no complaints of chest pain/ major vital sign changes before discharge.

patient complains of severe indigestion without relief from antacids

Objective… weak and needing assistance with transfers

1. RN will… position the patient in an upright position and attempt to perform some type of range of motion techniques couple of times a day

2. RN will… monitor the patients vital signs while performing any type of activity

3. RN will… educate on the

assessment data AEB Fatigue Rationale (Provide a reason why each intervention is indicated and/or therapeutic, and provide reference for each in APA format, DO NOT COPY AND PASTE) 1. if the patient stays inactive during the hospital stay the patient will deconditioned and have a harder time getting back to normal (Ackley et al., 2019).

2. the nurse needs to monitor the patients’ vital signs before, during and after an activity to determine any physiological changes (Ackley et al., 2019). 3. Cardiac rehab centers improve the ability to

Outcome Evaluation (How will you know when the goal has been met? Provide specific data you will be assessing; what will your evidence be?) the only way to know that this goal is done his by having the patient walk down the hallway and monitor her vital signs as she is doing the six-minute walk. Her respirations, heart rate, pain will be assessed prior, during, and post wak.

importance of a cardiac rehab

complete ADL’s, as well as improve quality of life (Ackley et al., 2019).

Please complete your medication log on the following medications: Fentanyl IV Direct, Metoprolol IV Direct, Aspirin, Nitroglycerin SL. Medication Log

Drug Name and Patient Example (include reference) Drug Name: Fentanyl

Targeted Use: decreased pain

Action, Use & Metabolism (Onset, peak & duration) Action: binds to opioid receptors in the central nervous system does altering perception of pain and response to it Use: pain control

Classification: opioid analgesics

Administration Dosage/Route/Frequenc y

Side effects/ Nursing Contraindications/ Considerations Precautions (Targeted)

Patient Teaching

Dosage: 25 mcgs- 100

Side effects: respiratory depression

this medication can cause dizziness and drowsiness and please call the nurse if you're going to get out because this medication can cause orthostatic hypotension

mcgs.

Route: IV Direct Frequency: prn q 2hrs

Contraindications: possibly being opioid naive

give medication undiluted inject slowly over 3 minutes

Precautions: DM 2

Metabolism: liver Onset: one to two minutes Peak: three to five minutes

Duration: 30min1hr The information above was collected with the Davis Drug guide (Vallerand & Sanoski, 2021) Drug Name and Action, Use & Administration Side effects/ Nursing Patient Example Metabolism Dosage/Route/Frequenc Contraindications/ Considerations (include (Onset, peak & y Precautions (Targeted) reference) duration) Drug Name: Action: blocks blood glucose Dosage: 5mg Side effects: Metoprolol beta1 receptors needs to be bradycardia from being Route: IV Direct checked frequently Contraindications: stimulated

Patient Teaching

this medication can cause dizziness and drowsiness and

Targeted Use: MI prevention,

Classification antihypertensive, antianginal

Use: decrease mortality impatience with recent MI Metabolism: liver

Frequency: QAM (in the morning)

heart block but otherwise no contraindications Precautions: DM2 b/c this medication may block signs of hypoglycemia

Onset: immediate Peak: 20 minutes Duration: 5-8 hours The information above was collected with the Davis Drug guide (Vallerand & Sanoski, 2021)

medication should not be diluted medication should be administered over one minute Y-site compatible w/ fentanyl

please call the nurse if you're going to get out because this medication can cause orthostatic hypotension

Drug Name and Patient Example (include reference) Drug Name: Aspirin

Targeted Use: Prophylaxis of TIA and MI

Action, Use & Metabolism (Onset, peak & duration) Action: decreases the ability to form blood clots

Administration Dosage/Route/Frequenc y

Side effects/ Nursing Contraindications/ Considerations Precautions (Targeted)

Patient Teaching

Dosage:325mg

Side effects: GI bleed, nausea

if tablet taste like vinegar patient should not take this medication

Use: blood thinner

Frequency: Q.D( daily)

Route: PO

Metabolism: the liver Classification: antiplatelet agent

Contraindications: patient does not have any contraindications to his medication Precautions: increased risk for GI bleed in geriatric patients

Onset: 5 to 30 minutes Peak: one to three hours

(BEERS DRUG) Due to major risk for bleeding Should take with food due to minimize GI upset If enteric coated tablet: do not take antacids with in 12 hours post administration Take with full glass of h2o

Duration: three to six hours The information above was collected with the Davis Drug guide (Vallerand & Sanoski, 2021)

Drug Name and Patient Example (include reference) Drug Name: Nitroglycerin

Action, Use & Metabolism (Onset, peak & duration) Action: dilates coronary arteries thus increasing blood flow

Administration Dosage/Route/Frequenc y

Side effects/ Nursing Contraindications/ Considerations Precautions (Targeted)

Patient Teaching

Dosage:0.4mg

Side effects: hypo tension

this medication will give you one of the worst headaches you

Route: SL Contraindications:

medication should be placed on their tongue and allowed to

Targeted Use: acute chest pain

Use: management for chest pain

Frequency: PRN, MR(may repat) every 5 min x3

patient does not have any contradictions to this medication

dissolve completely, NPO until tablet is dissolved

experienced but that is expected

Metabolism: liver Classification: antianginals

Onset: 13 minutes

Precautions: none for this patient

Peak: unknow Duration: 30 to 60 minutes The information above was collected with the Davis Drug guide (Vallerand & Sanoski, 2021) References page Ackley, B. J., Ladwig , G. B., Makic, M., martinez-Kratz, M., & Zanotti , M. (n.d.). (2019). Nursing Diagnosis Handbook. Elsevier.

Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis's Medical-surgical nursing: assessment and management of clinical problems. Elsevier, Inc.

Vallerand, A. H., & Sanoski, C. A. (2021). Davis's drug guide for nurses. F.A. Davis Company.

Vorvick, L. J. (2019, May 10). Percutaneous transluminal coronary angioplasty (PTCA) - health video: Medlineplus medical encyclopedia. MedlinePlus. Retrieved October 17, 2021, from https://medlineplus.gov/ency/anatomyvideos/000096.htm....