Acute Coronary Syndrome (ACS) Myocardial Infarction (MI)
JoAnn Smith, 68 years old
Primary Concept
Perfusion
Interrelated Concepts (In order
... [Show More] of emphasis)
1. Fluid and Electrolyte Balance
2. Clinical Judgment
3. Communication
4. Collaboration
UNFOLDING Reasoning Case Study-STUDENT
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:
3 days of progressive weakness
Denies chest pain, reports epigastric pain with nausea radiating to her neck and shortness of breath Women can present with alternative symptoms than men when experiencing a myocardial infarction so it is important to consider them in this context as opposed to ruling out MI since it is not the “typical” presentation
RELEVANT Data from Social History: Clinical Significance:
Lives with a spouse
Heavy smoker, 40 year history Anxious appearing Patient has a support person who lives with her and can help provider care which is important to keep them involved in the care as appropriate (and legally - patient gives consent to share information). Significant smoking history means patient has had prolonged vasoconstriction and diminished lung capacity; smoking also leads to heart disease. Anxiety can alter vital
signs like increased heart rate and blood pressure.
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:
● Diabetes mellitus type II
● Hypertension
● Hyperlipidemia
● Cerebral vascular accident (CVA) with no residual deficits
● Gastro-esophageal reflux disease (GERD)
● Anemia-Iron deficiency 1. Iron Sulfate 325 mg PO daily
2. Lisinopril 5 mg PO daily 3. Simvastatin 20 mg PO daily 4. Aspirin 81 mg PO daily
5. Clopidogrel 75 mg PO daily 6. Omeprazole 20 mg PO daily 7. Metformin 500 mg PO bid 1. Iron supplement
2. ACE inhibitor
3. Antihyperlipidemic (-statin)
4. Salicylate
5. Platelet aggregation inhibitor
6. Proton pump inhibitor
7. Biguanide antidiabetic 1. Replace iron
2. Reduce BP
3. Reduce cholesterol
4. Reduce platelets/prevent clotting
5. Reduce platelets/prevent clotting
6. Reduces stomach acidity
7. Reduces blood glucose levels
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?
● Bold what PMH problem likely started FIRST
• Most likely DMII however this likely took place in combination with HTN and HLD
● Highlight what PMH problem(s) FOLLOWED as domino(s)
• HTN uncontrolled can lead to CVA as well as the vascular effects from DMII and HLD which can lead to plaque build up and clots that can cause a CVA too
Patient Care Begins:
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
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Pulse of 128
Respiratory rate of 24
BP of 108/58 Tachycardia in combination with low blood pressure can be a sign of bleeding or dehydration and in this case is suggestive of diminished cardiac output in which the heart rate is increased to try and compensate but unsuccessfully as evidenced by her low BP. Her increased respiratory rate is likely due to pain and anxiety as well as her shortness of breath. It is always important to assess airway and lung function. She could be having SOB as a result of pulmonary complications from altered cardiac output as well.
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
SKIN: 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:
Coarse crackles in lung bases Pale, diaphoretic
Anxiety and tension Coarse crackles suggests fluid in the lungs which is important to note as we continue to assess the patient’s respiratory status in combination with her other symptoms. This is likely the result of pulmonary complications from MI. Pallor and diaphoresis also support this and should be investigated further as to their exact etiology. Anxiety and tension increase respirations and heart rate and it is important to address the patient’s concerns and provide support to help reduce this. [Show Less]