PAMANTASAN NG LUNGSOD NG MAYNILA (University of the City of Manila) Intramuros, Manila

INTENSIVE CARE NURSING

Name:__________________________________Date:___________ Score:________ Situation: Mr. Rubin, a 58 y/o man, began having chest pain 1 hour after supper. He described the pain as as if someone sitting on my chest located midsternally. He rated the pain 7 out of 10. He stated that the pain radiated down his left arm and through to his back. He was transported to the emergency department. On admission, Mr. Rubin was pale and diaphoretic and complained of shortness of breath. He denied nausea or vomiting. In the ED, unstable angina was diagnosed and tests to rule out myocardial infarction were initiated. He had experienced chest pain for 1 hour upon arrival in the ED at 8:00 PM. The patient reports no previous episodes of chest pain or pressure. He has smoked 2 packs of cigarettes daily for 30 years. His mother died of heart disease and his father died of accident. On initial examination, the patient did not exhibit jugular venous distention, the carotid arteries were 2+/4 without bruits, and the point of maximum impulse was located at the 5th intercostals space, midclavicular line. Normal S1 and S2 sounds were auscultated with an S3 present. No S4 sound or murmurs were heard. There were vesicular lung sounds with scattered wheezes, but no crackles were heard. No edema was present, and bowel sounds were normal. Diagnostic data at admission were as follows: BP 150/100 mmHg HR 90 bpm RR 35 bpm Temp 36.9 C SaO2 95% with O2 4 LPM per nasal cannula Height 175 cm Weight 110 kg ECG result: Normal sinus rhythm with frequent premature ventricular contractions and 3 to 4 beats runs of ventricular tachycardia ST segment elevation

Q waves in V2 through V4 Chest Xray: revealed slight cardiomegaly with mild CHF. Cardiac Enzymes: CK-MB Troponin I 8:00 PM 10 3.5 12:00 >300 >50 Day 1 (3:00PM) >300 >50

In the ED, Mr. Rubins chest pain was unrelieved after 3 SL NTG tablets. MoSO4 5mg IV push was administered, resulting in a small decrease in pain. After initial evaluation, Extensive myocardial anterolateral MI was diagnosed. Then thrombolytic therapy(t-pa) was started immediately . An NTG drip (50mg/250ml in 5% dextrose in water was started at 20 g/min (6ml/hr). A heparin bolus of 8000 U was given, and a drip was begun at 10ml/hr (1000 U/hr). Metoprolol titrate 5mg IVP was given every 5 minutes three times (total 15mg) and an enteric coated aspirin was administered. After the NTG and the heparin were started, the patients pain was relieved. He was transferred to ICU. In the ICU, Mr. Rubins chest pain returned. He rated it as 9/10. His BP was 90/60 mmHg, and he began having ST segment elevations in the anterior leads along with 6 to 8 beat runs of VT. 3 SL NTG tablets were given, followed by 4mg of morphine intravenously, but the pain did not decrease. Mr. Rubin was sent to the catheterization laboratory for emergency angiography and possible angioplasty. The angiogram showed 90% blockage of the left anterior descending artery. PTCA was performed but artery continued to reocclude, so a coronary stent was inserted. While the PTCA was performed, 23,000 U of heparin and 500,000 U of urokinase were given as an intracoronary injection. Mr. Rubin became hypotensive, tachycardic, pale, cool, and diaphoretic. His SaO2 dropped to 86% and he was placed to mech. Vent with a 100% nonrebreather mask. He continued having runs of VT; therefore a 100mg bolus of lidocaine was given and a lidocaine drip (2g/500ml of D5W) was started at 2mg/min. A dopamine infusion was started at 5 g/kg/min. An abciximab (ReoPro) bolus of 0.25 mh/kg was administered followed by an infusion at 21ml/hr. A pulmonary artery catheter was placed to monitor for CHF and cardiogenic shock. An IABP was inserted in the right groin to stabilize patients BP, decrease the workload of the heart, and improve cardiac output. Upon the return to ICU, patient was free of pain. His V/S and hemodynamic readings were as follows: BP 140/70 PAS 42 mmHg HR 90 bpm PAD 22 mmHg SaO2 99% with 100% non rebreather MAP 31 mmHg mask PAWP 22 mmHg ECG NSR with occasional PVCs RAP 10mmHg Mr. Rubins lidocaine drip was discontinued the next day. The heparin drip was discontinued and the arterial line, IABP, and pulmonary catheter were removed on day 2. He was started on enoxaparin 100mg SQ 2x a day. On day 3, his dopamine,

dobutamine, and NTG drip were tapered and discontinued. He was released to the cardiac progressive step-down unit on day 4. On day 6, he was released to home. He was instructed in outpatient rehabilitation, smoking cessation, and a prudent heart diet. He was sent home with prescriptions for diltiazem 30mg 3x daily, captopril 6.25 mg 3x a day, ticlopidine 250 mg twice daily, metoprolol 25 mg twice daily, and NTG tablets as needed and aspirin everyday. Questions: 1. Describe angina pectoris and discuss the difference between chronic stable angina, unstable angina, and prinzmetals angina. 2. Define CAD and discuss associated risk factors 3. Describe an acute myocardial infarction and its effect on the heart and lifestyle. 4. List the symptoms of an AMI. 5. What is the significance of the following heart sounds: S3, S4, and a murmur? 6. What do crackles auscultated during lung sound assessment signify? 7. Discuss the use of cardiac enzymes and their normal values. What laboratory values would be indicative of an AMI for Mr. Rubin? 8. What is the significance of Mr. Rubins ST-segment changes? 9. What are the desired pharmacologic effects of NTG? 10. Why was Mr. Rubin given an aspirin in the ER?and explain its use. 11. Discuss the pharmacologic actions of heparin and enoxaparin and the indications for use with a patient with an AMI. 12. Discuss the pharmacologic effects of morphine. 13. Describe what a -blocker is and the rationale for Mr. Rubin receiving this medication. 14. Why was Mr. Rubin given lidocaine? 15. Discuss the effect of a thrombolytic agent and why it was used for Mr. Rubin initially rather than angioplasty? 16. What are the contraindications for tPA? 17. What is a PTCA? 18. What made Mr. Rubin a candidate for PTCA? What are the potential complications for a patient undergoing PTCA? 19. What is a stent and why it was used on Mr. Rubin? 20. What do the readings from the pulmonary artery catheter tell the nurse about Mr. Rubin? 21. What is cardiogenic shock?what symptoms did Mr. Rubin exhibit? 22. What are the therapeutic effects of dopamine at low, moderate, and high dosages? 23. What are the therapeutic effects of dobutamine? 24. What advantages does an IABP offer Mr. Rubin? 25. What significance does the IABP have in relation to the tPA and urokinase previously? 26. Mr. Rubin was sent home with prescription for diltiazem. Why would a patient with heart disease be given a calci block? 27. Why was Mr. Smith sent home with a prescription for captopril?