Cardiac Case Study

Haley Fortier, Erika Flynn, Sarah Mayers,

Jessica Costa

Chief complaint
Patient: C.P.
52-year-old
Male
Experiencing chest pain
Radiating to his left arm and jaw

Uninsured

background
Full-time construction worker
Four children
Past episodes of chest tightness with exertion
the past six months
first visit to the ED

Smoked one pack of cigarettes daily for more

than 35 years
Drinks 3-4 beers a day after work.

Past Medical History

Atrial Fibrillation
Elevated CHO
GERD
NIDDM
NKDA

Surgical history:
total cholecystectomy 10 years ago

Emergency department
12 lead ECG
hyper acute ST elevation
anterior, lateral and inferior leads

C.P. is continuing to experience substernal

chest pressure
becoming more anxious

Lab work on Admission

Normal Lab Values

Abnormal Lab Values

Na

135 mmol/L

3.0 mmol/L

Co2

28

Cl

101 mEq/L

BUN

12 mg/dL

Glucose

165

Ca

10.1

Creatinine

2.8 mg/dL

CPK

12.4 ng/ml

HCO3

18 mmol/L

ABG

PaO2 86
PaCO2 35
Bicarb 24

WBC

14.5

Hgb

8.5 g/dL

Hct

35.3%

INR

3.9

Hgb A1C

7.0

pH

7.30

Do you recognize any

lab values that would
be of importance in
this patients
situation?

What is the priority action?

Priority action
Put on cardiac monitor immediately
Support ABCs
Notify the MD
Have the code cart ready
Be prepared for CPR and/ or defibrillation
Know that rapid reperfusion is the priority
when a client is experiencing a STEMI we
would start to prep the client for the cath lab.

additional actions

Put on 2L O
Give 325 mg aspirin
Insert 2 large bore IVs (20 or better)
Give Nitro
Systolic should be greater than 100 before
administering Nitro

Evaluate VS Q 15 min
Portable chest X-Ray within 30 minutes

Immediate concerns
Reperfusion
Maintaining BP (ABCs)

additional lab values

Need to obtain:
Troponin
Magnesium

update
During interview C.P. reports:
Worsening chest discomfort

The cardiac monitor shows ST segment

elevation
Physician orders the following:

Administer morphine sulfate 2 mg IV push

Obtain an ECG,
Draw blood for coagulation studies
Administer ranitidine (Zantac) 75 mg orally
every 12 hours.

Which of these orders will take priority at this

time?

1. Administer morphine sulfate 2 mg IV push

2. Obtain an ECG
3. Draw blood for coagulation studies
4. Administer ranitidine (Zantac) 75 mg orally
every 12 hours

Morphine sulfate
Nursing considerations:
Solution is colorless; do not administer
discolored solution.
Dilute with at least 5 mL of sterile water 0.9%
NaCl for injection
Concentration: 0.5-5 mg/mL
Rate: Administer over 5 min. Rapid
administration may lead to increased
respiratory depression, hypotension, and
circulatory collapse.

Nursing interventions
Morphine Sulfate
Assess type, location, and intensity of pain prior
to and 20 min after IV
High Alert!! Assess level of consciousness, BP,
pulse, and respirations before and periodically
during administration. If RR is <10/min, assess
level of sedation. Physical stimulation may be
sufficient to prevent significant hypoventilation.
Advise patient to change position slowly to
minimize orthostatic hypotension.

update

C.P.s lab work that was sent from your ED

and you notice that the laboratory value
Troponin T level of more than 0.20 ng/mL was
documented.
What is the significance of this finding?

Troponin interpretation
Elevated serum enzyme levels are the result
of the necrosis from the MI
Troponin T > or = to 0.01 are at increased risk
for cardiac events.
His was at .20
Puts him at greater risk for cardiac events.

Admitting diagnosis

Positive anterior lateral MI with

inferior involvement

st elevations on ECG

ST elevation in lead 2, 3, AVF, AVL, and lead 1

in AVL.

Ecg description to
patient
ST elevation
indicates lack
of oxygen to
the muscle
tissue of your
heart.

Myocardium areas
Anterior lead= left anterior descending coronary
artery (LAD)

Lateral lead= right coronary artery

Inferior lead= circumflex artery

Administer TPA?
NO!
C.P. INR value= 3.9 seconds (too high)
Puts patient at risk for bleeding
Administration contraindicated INR>1.7
seconds

TPA indications

ST elevations
Timeframe

Tpa contraindications
Absolute
Hemorrhagic stroke
Ischemic stroke within 6
mos.
Recent trauma to the
head
Aortic dissection
Major GI bleed
Known bleeding
disorder

Relative
Hypertension systolic
>180
Oral anticoagulation
therapy
Traumatic resuscitation
Non compressible
puncture sites
Active peptic ulcer

Dosage
Total 100mg IV
60 mg over 1st hr
20 mg over the 2nd hr
20 mg over the 3rd
Usually accompanied by heparin therapy

Nursing interventions
Monitor VS including temperature
Continuous or Q4 hours
Do not use lower extremities to monitor BP
Notify HCP:
systolic >180 mmHg or diastolic >110mmHg
Hypotension occurs
Result from drug, hemorrhage, or cardiogenic
shock

 Assess patient carefully for bleeding

Q 15 min 1st hour of therapy
Q 15-30 min next 8 hours
Q 4 hrs for remaining duration

 Assess patient for hypersensitivity reaction

Rash
Dyspnea
Fever
Changes in facial color
Swelling around the eyes
Wheezing

Inform HCP promptly

Epinephrine, an antihistamine and resuscitation
Anaphylactic reaction

 Assess neurological status

Intracranial bleeding
Altered sensorium
Neurological changes

Risks
Hypersensitivity reaction
Frank bleeding may occur
Invasive procedure sites
Body orifices

Internal bleeding
Decreased neurological status
Abdominal pain
Coffee-ground emesis or black tarry stools

Hematuria
Joint pain

Stroke

Concerns
Long term:
Extending the MI
Chance of the patient coding

Short term:
Contraindicated with anticoagulants
When did the symptoms onset

Clinical symptoms
TPA

Epistaxis
Bronchospasm
Hemoptysis
Reperfusion arrhythmias
Hypotension
N/V
Flushing
Phlebitis at injection site
Fever

UPDATE
C.P taken to cardiac catheterization lab for
further evaluation and intervention.
Part of tx intractable chest pain

Pre-procedure
responsibilities
Prior to cardiac catheterization lab

Informed consent
Reinforce teaching
Shave/prep the groin
Establish two peripheral venous access sites.
Specimens for lab tests
Chest x-ray
EKG/ECG, baseline vascular observations

 Additional info obtained

Allergies (contrast agent)
Hx of asthma (increased reaction)

Withhold or decrease medications

Insulin, antihypertensive, diuretics

Assess/mark pulses on the extremity

What arteries are used
what the test consists of

Pre-op responsibility
Monitor
PTT
INR
CBC with differential

What does PTCA stand

for?

What occurs during a

ptca?

PTCA

Nurses explanation
Patient:
Panicked
Urgent situation

Nurse:

Advocate for the patient

Calm, soothing, reassuring
Patients experience
Patients concerns

UPDate
C.P
Pain free
Brief V.fib
Defibrillated two
times

Currently NSR
PTCA
3 non medicated
stents

Cardiac cath- right

femoral artery

Update cont.
Strong pulses bilaterally
AAOx3
O2 sat 96% RA

Return to telemetry unit

update
IV fluids
0.9% NS at 75 mL/hr
Heparin 25000U/500mL D5W at 1000U/hr
Patent and running

Vital signs stable

BP 90/58
HR 60
RR 18
Pulse ox 92%

Additional assessment
Neurological status
Signs of bleeding
Frank/internal

Femoral/ pedal pulses

Capillary refill
Feelings and current state of mind

Additional assessment
cont.
Inspect insertion site
Color, warmth, sensation, movement
Distal pulse
Place mark on sites

Vascular observations
Q 15min first 2 hours
Hourly remaining 6 hours

Post-Op complications
Chest pain
Ischemic chest pain similar to prior pain
Pericarditic chest pain
Inflammation of pericardium

Mainstay treatment
Analgesia- NSAIDs

Possible Post-Op
complications
Renal impairment
Contrast induced nephropathy
Particularly pre-existing renal failure, diabetic
neuropathy and older patients

Minimize contrast load

Adequate hydration
Stop metformin, NSAIDs before procedure
Oral intake fluids

Post-op complications
Bleeding
Aggressive anti-platelet and anti-thrombotic
therapies
Contact HCP:
Swelling
Blood loss
Tenderness around access site

Post-op complications
Pseudoaneurism
Considered in any patient with a hematoma
Artery fails to close
Pulsatile swelling
Pain on palpitation
Analgesia and atropine

Post cath ECG

Goal: baseline rhythm (NSR)
Resolution of ST elevation

update
Unequal pulses in LE
Weak pedal pulses right side
Large hematoma right groin

Nursing action to follow

2L O2
Notify HCP
Fluids
Dopamine

Post PTCA
Nursing interventions:
Bed-rest 4-6 hours
Prevent bleeding at insertion site

Asses
Vital signs
Delayed allergic reactions
Rash, tachycardia, hypertension, palpitations, N/V

Extremities
signs of ischemia, no distal pulse

Insertion site
Bleeding, inflammation, hematoma

Post PTCA
Nursing interventions:
Education
Resume usual diet, fluids, medications, activity
Observe insertion site
Cold compresses to puncture site
Bed rest 4-6 hours afterwards

Report to provider
Pleuritic pain, persistent right shoulder pain,
abdominal pain

Post PTCA
Positioning
Legs in abduction/ parallel
Lay flat HOB no higher 30
Affected extremity kept straight
4-6 hours

Compression applied to avoid bleeding

complications

What labs should continue to be monitored

since the patient is receiving Heparin post
PTCA procedure?

Additional labs
Monitor PTT
Monitor platelet count Potassium (may cause
hyperkalemia)
AST and ALT levels (may increase)

UAP delegation
Vital signs q15 min(4), every 30min(2), and
every 60 min(2): Report Systolic BP under 90
Check stool to monitor signs of bleeding
Assist patient with ADLs and positioning: he
must lay flat to prevent bleeding from incision
site
If Nursing Assistant is skilled, have her attach
patient to ECG machine

Which Pharmaceutical
treatments would you
give C.p. ?
Nitroglycerin
Lidocaine
Dopamine
Metroprolol
Aspirin
And heparin

Medications to
administer
Dopamine: vasopressor/adrenergic, increases cardiac output,
increases BP,
contraindicated in: tachyarrhytmias, pheochromocytoma, and
hypersensitivity
Use cautiously in: hypovolemia, myocardial infarction, occlusive
vascular diseases

Lidocaine: antiarrhythmic, control of ventricular arrhythmias

Contraindicated in: hypersensitivity, third degree heart block
Use cautiously in: HF, respiratory depression, shock, and heart block

Heparin: antithrombotic, prevention of thrombus formation,

prevention of extension of existing thrombi
Contraindicated in: hypersensitivity, uncontrolled bleeding
Use cautiously in: untreated hypertension, history of bleeding
disorder, history of thrombocytopenia

Concerning labs if not

corrected
* Troponin

*Glucose: 80-110 is the goal

*Electrolytes: specifically Magnesium and
Potassium
- Potassium 3.0mmol/ml: LOW
Hgb 8.5g/dl and Hct of 35.3%: LOW
Creatinine of 2.8mg/dl: HIGH
INR

Interdisciplinary care
Potassium supplementation
Echocardiogram post cath
Dietary
Diabetes education
Weight loss/ nutrition counseling
Occupational Therapy
Smoking cessation- alcohol awareness r/t CAD
Case worker: health insurance

CAD risk factors

Cholesterol: LDL, HDL
Glucose
Hgb & Hct: Not enough O in the blood
Increased BUN and Creatinine- indicates renal
impairment
Hx of high cholesterol, diabetes, smoking,
hypertension
Increased age and weight also has an effect on
CAD

Update
During his PTCA procedure, a circumflex
coronary artery lesion was found
The PTCA failed in that artery and a stent was
inserted
He remains on lidocaine and dopamine drips
VS are now stable and PCWP is 20mmHg, and
CO is 7.3L/min

Lidocaine
Lab results for Patients licocaine level is 2.5 m/ml
Lidocaine therapeutic levels are between 1.5-5.0
mcq/ml
Toxicity:
Confusion, excitation, blurred vision,
nausea/vomiting, tinnitus, tremors, twitching,
seizures, dyspnea, dizziness, fainting, decreases
heart rate
If occurs, stop infusion, notify the provider and
monitor the patient

Update
C.P. is becoming increasingly anxious
Stent was successful and he is stable and
present at the time
While continuing to monitor
- C.P. suddenly becomes faint, immediately
loses consciousness and becomes pulseless
and apneic
- No BP, and heart sounds are absent

What will be your first

action?

 Initiate CPR and call code blue!!!!

Additional steps
Nurses need to communicate to one another and
determine who is leading the code, obtaining
emergency code medications and administering
Be prepared to switch roles for CPR
Have the code cart available
Be prepared to give code meds
Be prepared for intubation
Room needs to be free of clutter, and patient
needs to be easily accessible

Why initiate CPR?

C.P. is unresponsive, pulselessness, and
apneic
C.P. has no blood pressure and absent heart
sounds

Update
The patient is in full cardiac arrest and CPR is
in progress.
The ECG monitor shows PEA.
What is the priority nursing intervention for
this patient?

 Continue CPR for 2 minutes

IV/IO access
Administer Epinephrine every 3-5 minutes
Consider advanced airway

Place electrodes on the client in case a

shockable rhythm develops.

 To the right of the

sternum just below
the clavicle
To the left of the
anterior axillary
line, 5th-6th ICS

Treat Reversible Causes

5 Hs
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypothermia

5 Ts
Tension
pneumothorax
Tamponade, cardiac
Toxins
Thrombosis,
pulmonary
Thrombosis, coronary

Update
The family is asking to be present in the room
during CPR.
Should this request be honored?

Role of the Nurse

Help with resuscitation

Provide the family with comfort and support
Keep the family informed

Will we be performing
defibrillation on this
patient?

Defibrillator Charge
Biphasic

Monophasic

Initial dose of
120-200 J
Second and
subsequent
doses should be
equivalent or
higher .

360 J

What drugs should the

nurse prepare to
administer during the
resuscitation?

Epinephrine
(Adrenalin)
Indication: Part of ACLS
guidelines for the
management of cardiac
arrest
Action:
Affects both beta
(cardiac)-adrenergic
receptors and beta
(pulmonary)-adrenergic
receptor sites
Alpha-adrenergic agonist
properties, which result
in vasoconstriction
Produces bronchodilation

Vasopressin
(Pitressin)
Indication: Management
of PEA
Action:
Alters the
permeability of the
renal collection ducts,
allowing reabsorption
of water
Directly stimulates
musculature of the GI
tract
In high doses acts as
a nonadrenergic
peripheral
vasoconstrictor

Route, Administration &

Dosage
Epinephrine
(Adrenalin)

Vasopressin
(Pitressin)

IV push
1 mg q 3-5
minutes

IV push
40 units as a single
dose
Can replace first or
second dose of
epinephrine

family support
Offer comfort and
support.

Is there anything you

need to have clarified?

Would you like us to

notify your priest or
spiritual advisor?

Ensure social work has

been contacted if they
are not already there.

Is there anything I can

get for you (hospitality
cart)?

Ensure the family that

everything possible is
being done to save
their loved one.

Update
The CODE BLUE was ended after 30 minutes of
ACLS interventions.

The team was unable to restore C.P.s pulse

nurse's responsibility
Clear all medical equipment and supplies out of the
room, cover the patient from the neck down, and make
the environment comfortable for the family to mourn
Listen, answer questions, and provide support for the
family
Ensure they understand everything that was done to
try and save their loved one
Provide referrals
Post mortem care