Question

Mr. and Mrs. T. are naturalized Americans. They were born and raised in Japan and moved to the United States 20 years ago. Mrs. T. is 45 and teaches kindergarten. Mr. T. is 54 and runs an import store. Their son, Ritchie, 16 years old, was born in the United States. He is a sophomore in high school, where he plays baseball.

Mr. T. started having some chest pains 2 years ago and was diagnosed at the clinic with mild angina. He takes nitroglycerin (NTG) 0.3 mg SL when he feels any discomfort. His chest pain is usually exertion related. Lately, he has had to take the NTG more often. He has an appointment with the cardiologist next week.

The paramedics put an oxygen cannula on Mr. T. and start an IV in his left arm. They give him a baby aspirin to chew, contact the local hospital, and prepare Mr. T. for transport. Upon arrival in the ED, Mr. T.’s heart rate is 110 beats/min, and he is diaphoretic.

Mr. T. was quickly triaged in the ED with a preliminary diagnosis of acute inferior wall MI. The hospital is in a rural area, and the weather is severe. Ground transport to the nearest hospital able to do PCI is 2 hours. Therefore, a decision is made to administer thrombolytics. Within 1 hour, Mr. T. was started on reteplase.

One day after the thrombolytic therapy, Mr. T.’s cardiac rhythm suddenly dropped to 40 beats/min, and he became very dizzy and breathless.

One month after Mr. T.’s revascularization, he develops chest pain and visits the cardiologist. He is having T-wave changes in the anterior leads. He is referred to as the tertiary care center for additional testing. He undergoes cardiac catheterization and angiography, and a lesion of the left main coronary artery is found. He is scheduled for a CABG.

Mr. T. had the CABG. It was difficult to get Mr. T. weaned from the cardiopulmonary bypass machine. A decision was made to insert an Intra aortic balloon pump (IABP).

Mr. T. required the IABP for 24 hours, at which time it was weaned and removed. The remainder of his postoperative course was uneventful, and he was discharged home 6 days after surgery.

Answer the following questions:

Who has observed resuscitation efforts?

What observations were made?

What perceptions of care were noted?

Related to the case study in the cardiovascular lecture:

What nursing care was done prior to starting reteplase?

What is the nursing care associated with a patient receiving reteplase?

What complications must be assessed during and after the administration of the medication?

Answer 1

The Major observations based on the case study:H/o chest pain and angina 2 years back,nitroglycerin (NTG) 0.3 mg Sublingually, SOS after that, chest pain on exertion, and takes NTG more often now and a scheduled appointment with cardiologist coming wek. Chest pain on exertion indicates stable angina which develops due to poor blood flow throgh the blood vasels in the heart.Increased need for NTG indicates more comnpromised cardiac functioning.

Perception of care:  Nitroglycerin as prescribed as it helps widen the blood vessels and improve blood supply to the myocardium.NTG is the treatment of choice for stable angina.

observation:Heart rate on admission to ED is 110 beats/min, and diaphoresis and the client is diagnosed with acute Inferior Wall Myocardial Infarction. The patient needed a PCI and it was perceived to take 2hrs for transporting to an advanced care centre that the client maynot withstand in the current situation. So thrombolytic therapy with reteplase was started immediately.

Perception of care: mid sternal chest pain that radiates to shoulders associated with nausea and diaphoresis are major indications of an MI. Within 10 minutes in ED the care needed are checking SPO2,starting with oxygen administration if SPO2 is less than 94%. So in this case the SPO2 may be less which made the paramedic to start O2 on admission.Two IV lines needs to be placed for patients with ACS to ensure that adequate access is available for administering emergency medications. In this case an IV line is secured on the left forearm. The goal of management for a patients with Myocardial Infarction is to achieve thrombolysis within 30 minutes that is called door-to-needle time  and to perform PCI within 90 minutes that is called as door-to-balloon time . In this case as PCI in 90 minutes was not possible.

Observation: After one month of revasculirization (PCI), client again develops chest pain and showed T-wave changes in the anterior leads that is suggestive of a severe stenosis of the proximal left anterior descending coronary artery. The client underwent cardiac catheterization and angiography, and a lesion of the left main coronary artery was found and was scheduled for a CABG. After CABG an IABP was inserted for 24hrs after which it was removed. Client got discharged after 6 post operative days.

Perception of care: Coronary angiography and revascularization are reserved for those who fail to settle with medical treatment. In this case study the initial pharmacological management to PCI was a failure neccesitating the need for CABG.In this the blocked arteries are bypassed using a graft from patients own arterial or venous vessels or synthetic grafts.This procedure restores the normal blood flow,relieves the symptoms of chest pain and breathlessness and improved patient's quality of life. In the early postoperative phase,IABP offers temporary mechanical support to the circulatory function of heart after cardiac surgeries from patients with low cardiac output. The discharge after 6 days indicates a successful surgery.

What nursing care was done prior to starting reteplase?

The necessary nursing interventions before thrombolytic therapy are :complete health related history collection including allergies, history of drug intakes and drug interactions, lab values including the cardiac markers/bed side trop test, APTT, PT, Hgb, Hct, platelet count, vital signs and neurological status (in case of stroke),menstrual history in women, history of recent surgery or injuries, history of any bleeding disorders needs to be assessed as the thrombolytic drugs may precipitate bleeding in such conditions, strictly maintain intake and output,do not administer heparin or other antiplatelet agents for atleast 24 hrs of thrombolytic infusion and maintain adequate oxygenation.

Nursing care associated with a patient receiving reteplase

Patient should be closely monitoring in ICU for next 24 hrs after treatment, monitoring of vital signs, protecting client from external injuries, monitoring for cardiac rhythm (reperfusion may lead to dysrhythmias). IV and arterial lines as well as foleys catheterization needs to be performed before procedure as it minimises risk for bleeding(if conducted after thrombolytics this may cause prolonged bleeding), Monitoring CBC to monitor evidence of internal bleeding before and after therapy (the client after thrombolysis will be at risk for bleeding 2 to 4 days post thrombolysis).

Complications during and after the administration of the medication

Most common complication of thrombolysis is bleeding.

Hypotension may also develop

Intra cerebral hemorrhage:  close monitoring for neurological statutus may help to rule out this

Internal bleeding: signs include pallor, restlessness,tachycardia, hypotension, complaints of low back pain, muscle weakness, or numbness in lower extremities

External bleeding from invasive lines or wounds: check the IV lines,urine(hematuria) or gums for evidence of bleeding

GI bleeding: aseess the GI secretions and faeces for occult blood