Question

a. Mrs. Ho is a 55 year old female with a five year history of type 2 diabetes and hypertension. She has been brought into the ER via an ambulance. While at home watching TV on her sofa, she developed crushing sub-sternal chest pain (9/10) which radiates to her back and left arm. She took a S.L. nitroglycerin and five minutes later took another when the pain did not subside. She called 911. She is very frightened because her chest pain had always resolved with nitroglycerin in the past and only when she was exerting herself. Mrs. Ho is crying; her heart rate is 128/min; BP 150/76; respiratory rate 24/min; and O2 Sat 96%. Her chest pain remains 9/10. 2. Research the case study and the nursing diagnosis. 3. As a group, submit the answers to the following questions: a. What medications should be considered and why? b. What lab work and procedures should be done and why? c. Her initial EKG does not demonstrate any abnormalities. After receiving several meds, her chest pain subsides to 5/10. Her husband arrives at the ER to be with her. She begins crying. Her chest pain increases to 8/10. What nursing actions should be performed at this point and why? d. A second EKG reveals an elevated ST segment. A diagnosis of myocardial infarction is made. The doctor orders tPA to be given? Why is this drug useful in this situation? Describe its implications and potential side effects? What should be known prior to giving this medication and why? e. After the fibrinolytic medication has been infused, the ST segment returned to baseline and the patient verbalized that she no longer had pain. Heparin is then started on this patient. What does heparin do and why would it be necessary in this patient f. What is the difference between her previous chest pain episodes and the present episode?

Subject : nursing pharmacology

can you please cite me the reference when you solved this case studies ?

Thanks

Answer 1

The patient have unstable angina because the chest pain occurs during rest and chest pain does not relieved with nitroglycerin. The unstable angina is a sign of heart attack.

Unstable angina results from occlusion of the coronary arteries by intraluminal plaque formation, thrombosis ,vasospasm and high blood pressure. This occlusion will lead to decreased perfusion to myocardium. It is a warning sign of acute myocardial infarction.

b) Diagnostic findings of this patient include

:examination of cardiac enzymes like troponin I and troponin T,creatinine phosphokinase ,and myoglobin. It may be elevated in anginal attack.

:ECG__ECG help to identify the incidence of MI as early as possible and find any abnormalities in heart.

:stress test:it help to know the function of heart.

:Echocardiogram_find abnormalities in structure of heart.

:immediate coronary angiography to know the place of occlusion.

Medication for this patient

:antianginal drug:the prefered drug is nitroglycerin, in this case patient not respond to nitroglycerin there for we can administer morphine with close monitoring or T. Ranolazine

:antiplatelet drug_this help to prevent thrombus formation drugs include clopidogrel, aspirin.

:anticoagulants _this prevent clot formation drugs include low molecular weight heparin or bivalirudine.

:antilipedemic drug such as atorvastatin it help to decrease cholesterol levels .

:beta blockers_it help to decrease cardiac work load and lower the BP. Drugs include atenolol, propranolol etc,

:calcium channel blockers _vasodialation and lower the cardiac work load.

Nursing diagnosis for this patient include

:decreased cardiac output related to disease condition as evidenced by verbalization of chest pain,heart rate 128b/mt,BP 150/76

:acute pain related to decreased myocardial perfusion as evidenced by radiating chest pain score is 9/10,BP 150/76,Heart rate 128b/min

:anxiety related to disease condition as evidenced by verbalization and crying.

C) patient chest pain during meeting her husband is due to severe stress or anxiety. At this situation as a nurse we give reassurance and use mind diversion technique or relaxation techniques.

d) use of tPA(tissue plasminogen activator) is a drug of choice for thrombolytic therapy. This medication help to break of dissolve the blood clot that include the blood vessels. In this condition the patient have unstable angina and ST segment elevation in ECG. It indicates the occurance of MI. This condition is happened due to occlusion of coronary artery by a thrombus. This tPA help to dissolve the clot.

Side effects of tPA

:bleeding from nose, gum etc,

Nausea and vomiting

:skin rash

:bruising

:fever

:hives

What should be known prior to thrombolytic therapy

:age of the patient (older age have greater complications)

:medical history including history of previous heart attack, hypertension ,bleeding disorder, diabetes mellitus etc,

:history of recent head injury

:history of bleeding ulcers

:history of trauma and recent surgeries

:taking blood thinning medications such as warfarin.

These all condition leads to occurance of complications.

e) Heparin treatment for MI patient

Heparin is given as an adjunct for thrombolytic therapy. Because it help to prevent clot formation during the recovery period. This patient is underwent thrombolytic therapy and symptoms are subsided so we have to prevent further formation of thrombus. The heparin help to prevent further clot formation.

f) she is relieved from chest pain because she get adequate perfusion to myocardium and relive congestion due to thrombolytic therapy.