NURS 4521 Cardiovascular Disease Case Study

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NURS 4521 ADULTS WITH COMPLEX NEEDS Cardiac Case Study Assignment Part 1 You are to complete all of the critical thinking questions for each stage and embed typed answers into this document. STAGE 1: Carl Shapiro 64 year old White male admit: 02/15/2021 Height: 71in Weight: 91 kg Allergies: NKDA Chief Complaint & History of Current Illness: Presents to the emergency room with a two-day history of intermittent substernal chest pressure associated with shortness of breath and diaphoresis. The pain had originally awoken Mr. Shapiro from sleep 2 nights ago and has been intermittently relieved with some sublingual nitroglycerin tablets that he had received from his physician 3 years ago. The pain increases with exertion, but now is constant. He rates the pain a “7” on a scale of 0 to 10. Past Medical History: HTN, Type 2 DM Home Medications: Lopressor (metoprolol) 50 mg PO daily Lasix 40 mg PO daily ASA 325 mg PO daily Glucophage 500 mg PO BID Past Surgical History: none Past Social History: denies tobacco, ETOH or illicit drug use. Vital Signs: T-98.9 (O) P 110 R 32 BP 90/60 (70)SpO2 86% on RA Physical Exam: Neuro: Alert and oriented x4, Anxious with a RASS of 2+, GCS 15, PERRLA 4mm Brisk Cardiac: Heart sounds S1, S2, S3 noted rhythmic; point of maximum impulse (PMI) displaced laterally; 2+ pitting edema in lower extremities; 1+ radial and dorsalis pedal pulses, cap refill < 6 seconds with cyanotic nail beds Resp: Breath sounds- rales throughout lung field; effort-labored without use of accessory muscles; chest symmetrical GI: Bowel sounds active x 4 quadrants; abdomen soft/non-tender; liver enlarged; no N/V INTEG: Pale, diaphoretic & intact skin. Lab Results: Chem panel: Na 130 K 5.7 C1 100 CO2 22 BUN 29 Cr 1.8 Glucose183 CBC: WBC 11.2 Hgb 9.2 Hct 27.6 Plt 203 Cardiac panel: BNP 788 LDH 972 Troponin 6 Diagnostic Tests: 12L ECG: Sinus tachycardia with left ventricular hypertrophy & ST elevation leads V1, V2, V3, & V4 Chest XRay: Increased vascular markings in both lungs Critical thinking exercises 1. List ALL OF your primary suspected medical diagnoses and top 5 priority nursing concerns from different body systems with supporting evidence. 2. What area(s) of the left ventricle is affected by this MI? 3. What is your rationale for EACH of the abnormal physical assessment parameters, the abnormal laboratory results, and the abnormal diagnostic tests? List each out by section (VS, physical exam, lab results, diagnostic tests) and explain rationale for why you believe they are abnormal. 4. What are your anticipated nursing interventions for this patient? 5. What patient and family teaching is important? Be specific. STAGE 2: Mr. Shapiro is admitted to the CCU with a diagnosis of Acute MI with acute decompensated heart failure. The following orders are obtained: Vital Signs q1h Continuous ECG monitor Bedrest Foley catheter Heparin IV infusion @ 1000 units/hr PTT q6h and call results if 90 Troponin level q12h x2 O2 at 2 1iters/min per NC—titrate to maintain O2 saturation >91% Lopressor 25 mg PO BID Available form: 25mg immediate release tablet Lovenox 50mg Sub-Q Q 12hrs Available form: 50mg/ml graduated prefilled syringe Bumex 4mg IV Push Daily Available form: 2.5mg/10ml vial Ambien 5 mg PO qHS PRN sleep Available form: 5mg immediate release tablet Dobutamine 2mcg/kg/min (found on IV pump) Range: 2-20 mcg/kg/min Available Form: 500mg/ 500ml D5W Administration Instructions: titrate by 1 mcg/kg/min Q 5 min to maintain CO between 5-6 L/min Nitroglycerin 10 mcg/min (found on IV pump) NURS 4521 Cardiovascular Disease Case Study

Range: 5mcg/min- 50mgc/min Available form: 50mg/250ml D5W in glass bottle Administration Instructions: titrate by 5mcg/min Q 5 min to keep chest pain below a 3 on a scale of 0-10 Precedex 0.4mcg/kg/hr (from IV Pump) Range: 0.1mcg/kg/hr to 0.5mcg/kg/hr Available form: 200mcg/50ml NS Administration Instructions: Titrate by 0.05mcg/kg/hr Q 5 min to keep RASS score 0 to -1 Critical thinking exercises 1. What is your rationale for each of the admitting orders? List out each order and explain why you think they are ordered for this patient. 2. What patient and family teaching is important? Be specific. STAGE 3: Mr. Shapiro’ urine output decreases to 10 ml/hr and he is unresponsive to the IV Bumex. He complains of increased SOB and physical exam reveals increasing rales bilaterally. A pulmonary artery catheter is inserted with the following parameters obtained: CVP 10 PCWP 22 PA pressure 38/20 CO 3.1 CI 1.2 SVR 1872 Critical Thinking Exercises 1. 2. What is the reason for each of the above hemodynamic results and what medication(s) do you anticipate starting? List out each parameter and what you believe caused the result and the medication(s) you believe you will start and specific goal(s) of medication(s). What patient and family teaching is important? Be specific. STAGE 4: You had provided Mr. Shapiro with some IV morphine sulfate for pain. You check on him 30 minutes later and find that he is unresponsive with slow, shallow respirations. He is diaphoretic. An ABG on 2L/NC reveals: pH 7.22 pCO2 50 pO2 82 HCO3 23 SaO2 83% Critical thinking exercises 1. 2. 3. 4. What does the ABG reveal? What is the probable cause? What are the anticipated medical and nursing interventions and why? Separate medical & nursing in list format. What patient and family teaching is important? Be specific. STAGE 5: Mr. Shapiro remains unresponsive is intubated and CXR reveals proper tube placement. His ventilator settings are as follows: Mode: Assist Control rate: 10 Vt: 600ml FiO2: 100% An ABG is drawn 1 hour later and reveals the following: pH 7.13 pCO2 80 pO2 347 HCO3 23 SaO2 100% PEEP: 5 Critical thinking exercises 1. 2. 3. What does the ABG reveal? State Acid-base imbalance & oxygenation status What changes do you anticipate to the ventilator settings and what is the rationale for each change and why? What patient and family teaching is important? Be specific. STAGE 6: You are in Mr. Shapiro’ room and notice that he is unresponsive and does not have a pulse. This rhythm is on his bedside monitor: Critical thinking exercises 1. 2. 3. What is this rhythm? What are the interventions for this rhythm in order of performance and rationale for each intervention? List out in the order they would be performed. What family teaching is important? Be specific. The rhythm changes to this one but he remains without a pulse: Critical thinking exercises 4. 5. What is the rhythm? List ALL the possible treatable causes (Hs & Ts) of this rhythm and what the treatment is for each cause? Mr. Shapiro had return of spontaneous circulation (ROSC) and survives without any neurological deficits but required an internal cardiac defibrillator (ICD) placement prior to discharge to an outpatient cardiac rehab program. Final critical thinking exercises 1. What discharge teaching would this patient/family require? Be specific 2. What additional information would you like to have seen covered in this evolving case study? 3. As you watched this case unfold, how did it make you feel? Provide a list of references utilized to complete this assignment.