Cardiac Case StudyHaley 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 AdmissionNormal Lab Values

Na 135 mmol/L

Co2 28

BUN 12 mg/dL

Ca 10.1

CPK 12.4 ng/ml

ABG PaO2 86PaCO2 35Bicarb 24

Abnormal Lab Values

K 3.0 mmol/L

Cl 101 mEq/L

Glucose 165

Creatinine 2.8 mg/dL

HCO3 18 mmol/L

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 ABC’s

• 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 O₂

• Give 325 mg aspirin

• Insert 2 large bore IV’s (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 (ABC’s)

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 push2. Obtain an ECG3. Draw blood for coagulation studies4. 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

Nurse’s explanation

• Patient:• Panicked• Urgent situation

• Nurse:• Advocate for the patient • Calm, soothing, reassuring • Patient’s experience • Patient’s 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 ADL’s 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

LidocaineDopamineMetroprolol

AspirinAnd 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 O₂ 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

• Hypovolemia

• Hypoxia

• Hydrogen ion (acidosis)

• Hypo/hyperkalemia

• Hypothermia

• 5 H’s • 5 T’s

• 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

• Initial dose of 120-200 J

• Second and subsequent doses should be equivalent or higher .

Monophasic

• 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 beta₁

(cardiac)-adrenergic receptors and beta₂ (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)

• IV push

• 1 mg q 3-5 minutes

Vasopressin (Pitressin)

• IV push

• 40 units as a single dose

• Can replace first or second dose of epinephrine

family support

• Offer comfort and support.

• Would you like us to notify your priest or spiritual advisor?

• Is there anything I can get for you (hospitality cart)?

• Is there anything you need to have clarified?

• Ensure social work has been contacted if they are not already there.

• 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