John Thomas is a 64-year-old Caucasian male who presents to the emergency room with a two-day history of intermittent substernal chest pressure associated with shortness of breath and diaphoresis.

Table of Contents

Description

STAGE 1

John Thomas is a 64-year-old Caucasian male who 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. Thomas
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 1 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
50 mg PO BID

Vital Signs: T-98.9 (O) P=
110 R=28 BP= 90/60 SpO2=88% on RA

Physical Exam:

Neuro: Anxious, but alert and oriented x3

Pulm: Bilateral rales, labored

CV: RRR; S1, S2,
S3; tachycardic; PMI displaced laterally

ABD: Active bowel sounds;
soft/non-tender; liver enlarged

EXT: 2+ lower extremity edema; 1+
peripheral pulses

INTEG: Poor capillary refill; nail beds
cyanotic; skin is diaphoretic

Lab Results:

Na= 133;         K=5.0;             C1=100;
         CO2=22;          BUN=29;        Cr=1.8; Glucose=183            Hgb=9.2;
        Hct=27.6;        WBC=11.2;     Plt=203

CPK=2900; CKMB=432%; LDH=972;
Troponin=6

Diagnostic Tests:

12 lead
ECG; Sinus tachycardia with left ventricular hypertrophy and

ST elevation in leads V1,
V2, V3, & V4

CXR: Increased vascular markings in both lungs

Critical
thinking exercises

1. List your primary medical and nursing
diagnoses for this patient.

2. What area 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?

4. What are your anticipated nursing interventions
for this patient?

STAGE 2

Mr. Thomas is admitted to the CCU with a diagnosis of Acute
MI with congestive heart failure. The
following orders are obtained:

Vital Signs
q1h

Continuous
ECG monitor

Bedrest

Foley
catheter

Nitroglycerin
IV infusion @ 10 mcg/min

Heparin IV
infusion @ 1000 units/hr

PTT q6h and
call results if <60 or > 90

CK
isoenzymes q8h x3

Troponin
level q12h x2

O2
at 2 1iters/min per NC—titrate for SpO2>91%

Lopressor
25 mg PO BID

Ambien 5 mg
PO qHS PRN sleep

CRITICAL THINKING EXERCISE

1. What is your rationale for each of the
admitting orders?

STAGE 3

Mr. Thomas’ urine output decreases to 10 ml/hr and is
unresponsive to a dose of IV Lasix. 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= 4.1 CI=1.9 SVR=1872

CRITICAL THINKING EXERCISE

1. What
is the reason for each of the above parameters and what medication do you
anticipate starting?

STAGE 4

You had provided Mr. Thomas 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=26 SaO2=83%

CRITICAL THINKING EXERCISES

1. What does the ABG reveal?

2. What is the probable cause?

3. What are the anticipated medical and
nursing interventions?