R M. G
Dr. S
P. A., a 56 year old Italian male that identifies with the Italian culture with no significant past medical history presents to the emergency department with the chief complaint of recurrent chest burning. P.A. says his wife believes that he is showing symptoms of having GERD but he has never been diagnosed. P.A states that “the chest burning and discomfort began five days ago and just got progressively worse despite his self medicating with TUMS” he presented to the emergency department on 05-31-16 and felt “some improvement” after a GI cocktail was administered. One set of biomarkers was negative and he was discharged with Esomeprazole Magnesium (Nexium). The next morning 06-01-16 he developed the same symptoms while sleeping with an increase of stated “10/10 pain”. On arrival to the emergency department he was hemodynamically stable with active chest pain and hyperacute anterior ST elevation with reciprocal changes for which a cardiac alert was called and patient was rushed to the cardiac catheterization lab where one DES was placed in the mid left anterior descending coronary artery. The patient tolerated the procedure with no signs of complications and transferred to the MICU in stable condition.
Demographics:
Age: 56 years old
DOB: 08/12/1960
Sex: Male
Weight: 70.761 (156 lb) BMI 21.15 kg/m2
Race: White
Marital Status: Married
Occupation: Car salesman
Religion: Christian
No prior personal or family history of present illness
Past Medical History: No medical conditions
Past Surgical History: No surgical history
Allergies: No known allergies
Smoking: Current everyday cigarette smoker, half a pack a day for the past 25 years
Drug Use: Patient denies any illicit drug use
Admitting Diagnosis:
Chief Complaint: Recurrent chest burning
Review of System:
General Appearance: Alert, awake, oriented x3. In no distress, cooperative and appears stated age
Eyes: PERRLA, EOMI
Throat: Lips, mucosa, and tongue normal, teeth and gums normal
Neck: Supple, symmetrical, trachea midline, no adenopathy; Thyroid: no enlargement, nodules
No carotid bruit or JVD
Lungs: Clear to auscultation bilaterally, good air entry, respirations unlabored. No wheezing, crackles or rhonchi
Chest wall: No tenderness or deformity
Heart: Regular rate and rhythm. Normal S1 and S2. No murmurs, no rub and no gallop. Absent JVD and absent abdominojugular reflux
Abdomen: Soft, non-tender, no rebound tenderness, bowel sounds active all four quadrants. No bruits. No masses, no distention, no lesions, scars or hernias
Extremities: Warm temperature, 2+ pulses, no clubbing, cyanosis or edema bilaterally
Pulses: 2+ and symmetric all extremities
Skin: Skin color, texture, turgor normal, no rashes or lesions
Neurologic: Cranial nerves II-XII are normal. Reflexes are normal and symmetrical bilaterally in both extremities
Vitals: 06-06-16 BP 145/96, Pulse 88, Temperature Oral 36.2C (97.2F), Respiratory 17, SpO2 100%
The labs were drawn on the admission date,
Medications:
Nursing diagnoses
Diagnosis I: Acute pain due to cell/tissue ischemia as a result of arterial blockage
Nursing outcomes
-Verbalize control or relief of chest pain
-Exhibit reduced tension and relaxation
-Exhibit the use of relaxation techniques
Nursing interventions
-Administer pain relievers
-Monitor and document pain characteristics including patient-reported intensity, locality and nature of the pain. Ask the patient to report the pain levels on a scale of 1-10
-Instruct patient to using relaxation techniques such as guided imagery; approach the patient in a calm manner, provide comfortable environment and encourage calming activities
Diagnosis II: Reduced cardiac output due to a reduction in miocard characteristics
Nursing outcomes
-Maintenance of hemodynamic stability
-Verbalize decrease in shortness of breathe
-Exhibit improvement in activity tolerance
Nursing interventions
-Monitor urine output, fluid balance, blood pressure and heart rate/rhythm
-Auscultation of breathe sounds and monitoring of heart rhythm through telemetry
-Monitor patient’s response to activity and provide ample resting
Diagnosis III: Risk of fluid retention due to impaired renal perfusion
Nursing outcomes
-Maintenance of a fluid balance
-Clear pulmonary sounds
-Free from venous/peripheral distention
Nursing interventions
-Maintain fluid intake at 2000 Ml/daily and calculate fluid balance
-Auscultation to detect presence of crackles in pulmonary sounds
-Monitor JVD and monitor swelling/edema
Routine nursing management
Routine nursing management would involve activities intended for assessing the patient condition during all the phases of care. Routine nursing management of STEMI involves monitoring various vital signs such as oxygenation levels, heart rhythm, heart rates, respiratory rates and blood pressure (Van de Werf et al., 2008). Assessment findings of these vital signs on a routine basis not only help in proactively addressing severity but also form a basis for assessing/evaluating the effectiveness of interventions undertaken. Other routine nursing management include; cardiac rehabilitation, adherence to medications and post-discharge advice as well as the routine patient check-ups to monitor recuperation.
Collaborative management
Providing a comprehensive care that helps meet the care needs of the patient both in the short term and in the long term requires a collaborative approach that utilizes an interdisciplinary team. As such collaborative management of the patient would require the services of a cardiologist, heart failure nurse, dietician and a physical therapist. The cardiologist together with the heart failure nurse would help in meeting the cardiac interventions while the dietician would help in the dietary management of the condition (White & Chew, 2008). On the other hand, physical activity is quite essential in promoting cardiac function during the post-discharge phase of care, hence warranting the services of a physical therapist.
Therapeutic modalities
Therapeutic modalities for STEMI are essentially determined by the primary cause and the severity of the condition. Therapy is short-term and long-term and takes both pharmacological and non-pharmacological approaches.
Surgery (coronary artery bypass surgery)
This involves stitching of the arteries and veins past the blocked or narrowed area as a way of ensuring effective blood flow to the heart. Alternatively stenting or coronary angioplasty may be done after catheterization for the purposes of opening the blocked artery on a long term basis.
Pharmacological
Pharmacological approaches are purposely intended to prevent blood clotting in the arteries, dissolve an existing clot and to reduce the workload for the heart. Interventions such as the use of anticoagulants (aspirin or coumadin), thrombolytics (for the purposes of dissolving the clot) and beta-blockers for the purposes of relaxing the heart muscles fits into the first line therapeutic approaches for STEMI (Thygesen et al. 2012).
Lifestyle modification
STEMI is associated with various risk factors that predominantly feature in the pathophysiology of the disease. These risk factors include; smoking, diabetes, obesity and hypertension. All these risk factors are pretty modifiable and can be managed through lifestyle modifications; which should be a long term way of fostering healing (Thygesen et al. 2012). As such dietary approaches-eating foods less in fats, carbohydrates and salt and increasing vegetable and fruit intake can promote healing in the long-term. Weight management and physical activity together with cigarette smoking cessation are equally significant as therapeutic approaches.
Nursing role reflection
STEMI patients and patients having cardiac problems have multi-faceted care needs due to the debilitating effects of the condition on several systems as illustrated in this patient scenario. This means that the nursing role is believably huge in terms of bringing on board all the care resources and skills as a way of ensuring the achievement of the desired patient outcomes. STEMI is an emergency condition and as such, the nurse has a role in conducting a rapid patient assessment so as to unearth the underlying cause and pursue the necessary interventions as a proactive way purposely intended to arrest the condition of the patent before it progresses to severe levels. Reflecting on this case there is an accentuation for a nurse to possess sound assessment skills, notably, critical thinking, analytical thinking and proper judgment skills. Additionally, after undertaking emergency care approaches, there is the need for the nurse to constantly check the progress of the patient, particularly, taking readings of the vital signs such as oxygen concentration, blood pressure and heart rate so as to gain a vantage ground in terms of understanding patient’s response to interventions and also to address pitfalls before progressing to severity (Steg et al., 2012).
As afore-mentioned, patient care in this line of nursing care requires a collaborative approach in order to ensure the desired outcomes are achieved at the end of the day. This makes it the role of the nurse to bring on board an interdisciplinary team that encompasses physicians, nutritionists and nurses so as to ensure that every patient need is achieved. To effectively co-ordinate all the care activities for a STEMI patient, a nurse should possess adequate interpersonal, organizational and planning skills. Working in a collaborative manner requires the ability to communicate effectively and operate within a pre-designed frame-something that underscores the need for having effective interpersonal and planning skills.
Complete therapy and achieving an optimal health is a long term goal for a STEMI patient and in this regard, it is equally the role of the nurse to undertake patient education on various lifestyle issues such as diet, smoking cessation and physical activity (Steg et al., 2012). This is in a bid to equip the patient with self-care abilities that would go a long way in promoting the quality of life in the post-discharge phase of care.
References
Steg, P. G., James, S. K., Atar, D., Badano, L. P., Lundqvist, C. B., Borger, M. A., & Gershlick, A. H. (2012). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.European heart journal, ehs215.
Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., & White, H. D. (2012). Third universal definition of myocardial infarction.Circulation, 126(16), 2020-2035.
Van de Werf, F., Bax, J., Betriu, A., Blomstrom-Lundqvist, C., Crea, F., Falk, V., & Rosengren, A. (2008). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. European heart journal, 29(23), 2909-2945.
White, H. D., & Chew, D. P. (2008). Acute myocardial infarction. The Lancet,372(9638), 570-584.
