Mr. Sanborn is a 55 year old male who experienced substernal chest pain and was

Question

Mr. Sanborn is a 55 year old male who experienced substernal chest pain and was brought to the hospital by ambulance. A STEMI alert was called and the goal is that the patient will be brought to the cath lab with a door to balloon time of 45 minutes.

1. What information did you receive from the hand-off communication and your observation?   

2. What are the initial nursing interventions that need to be performed when Mr. Sanborn arrives in the emergency room? Why?

3. What are the apparent risk factors that Mr. Sanborn has for cardiac disease?

4. The physician orders a Nitro drip and the IV bag has 25mg in 250ml. What rate and dose will you start the Nitroglycerine at?

5. What complications can result before you get Mr. Sanborn to the cath lab?

6. What type of EKG changes do you anticipate? Rhythms?

7. Upon transfer to the cardiac cath lab, the nurse explains that he may have a balloon or stent inserted in the coronary artery. What is a cardiac catheterization, PCTA, stent, rotoblator or intravascular ultrasound?

8. What is the difference between a bare metal stent and a drug eluting stent? What drug will be required after the stent is employed? The cardiac catheterization reveals significant disease with 75% occlusion in the distal portion of the left anterior descending (LAD), 80% in the circumflex, and the left main is 95% occluded. A drug eluting stent was inserted in the left anterior descending and the circumflex artery. The left main requires surgery and the patient was transferred to the telemetry floor and is scheduled for surgery in the morning.

9. What type of assessment does the patient require post cardiac cath and what type of complications may result?

10. When would you call the rapid response team (RRT)? What type of drugs would you anticipate if the patient codes?

The patient continued to have refractory chest pain, an intraaortic balloon pump was inserted into the right groin, and the patient was transferred to OR for immediate CABG surgery.

11. What is the purpose of an intraaortic balloon pump? Describe the nursing care that is essential for this patient.

12. What is the purpose of the cardiopulmonary bypass machine and cardioplegia solution?

13. What are the advantages and disadvantages of using an IMA rather than the SVG?

14. What is the purpose of the arterial line and what nursing interventions are essential? Mr. Sanborn has just been transferred to the ICU after successful CABG with a LIMA graft to the left anterior descending and saphenous vein grafts to the right coronary artery, circumflex and obtuse marginal artery. The total pump time was 200 minutes and was under general anesthesia for 4 ½ hours. Currently he is intubated, not responding to verbal or painful stimuli, has two chest tubes on 20cm wall suction, pacer wires, right arterial line, pulmonary artery catheter, two peripheral IV’s, and a foley catheter. History and physical includes a strong family history of cardiac disease, hypertension, high cholesterol, an unfavorable HDL/LDL ratio. Review the attached physican order sheet.

15. Why does this patient have chest tubes? Describe the nursing care that is required while caring for a patient with chest tubes. Should the chest tubes be stripped/milked postoperatively?

16. What is the purpose of pacer wires in a post-op CABG pt?

17. Discuss the nursing care of a mechanically ventilated patient. Explain TV, FIO2, PEEP, respiratory rate and required oral care (refer to physician orders).

18. What is the purpose of a pulmonary artery catheter? What nursing care is essential in caring for a patient with a pulmonary artery catheter? What are the normal values of the PAP, PAWP, and CVP?

19. Why is it necessary to maintain normotension ? How about laboratory values? (refer to physician orders)

20. Mr. Sanborn is not maintaining an adequate blood pressure. The monitor reveals: B/P 78/46 CVP 6 CT drainage 30 – 50ml/hr HR 130 PaO2 90 Urine output – 15ml/hr PAWP 25 SaO2-98% CO – 3.2 Hgb 9.0 grams Calculate the MAP and the Stroke Volume. Interpret all the data.

21. What medications would you consider beneficial?

22. What are the signs and symptoms of cardiac tamponade?

23. What should be included in Mr. Sanborn’s discharge teaching? Health Promotion?

24. Prioritize and list pertinent nursing diagnoses.

25. Document your care on the flow sheet and also narrative format.

Explanation / Answer

Ans No. 1: Following information is gathered by the information:

(a) the person is suffering from substernal pain (i.e. pain just below the sternum) which is suggestive of either of the following:

1. Aortic Stenosis,

2. Myocardial Infarction

3. Angina Pectoris

4. Pulmonary Embolism,etc

(b) A STEMI ( ST- Elevation Myocardial Infarction) alert suggests that an artery supplying blood to the heart is completely blocked.

Ans. No. 2: Following nursing interventions are done as soon as Mr. Sanborn arrives in the emergency room:

Step 1 : Connect the patient to a cardiac monitor and observe an ECG (Electrocardiogram). This is done because the patient complains of substernal chest pain and an ECG gives information regarding cardiac rhythm and any abnormalities in it.

Step 2: Apply a pulse oximeter to the patient to calculate his SpO2 to calculate the amount of oxygen in his blood.

Step 3: Measure Blood Pressure to monitor haemodynamic status.

Step 4: Insert an IV line (Intravenous), since the condition of the patient is critical and can require emergency medicine and fluids.

Step 5: Take a finger stick to measure blood glucose to monitor the patient's blood glucose.

Step 6: Insert a Catherter,if needed.

Ans. No. 3: Following are the risk factors for cardiac diseases:

1. Age

2. Gender

3. Family History

4. High Blood Pressure

5. Diabetes

6. Smoking

7. Obesity

8. Excessive alcohol

9. Excessive stress

10. Sedentary lifestyle

Ans No. 4: The initial Nitroglycerine drip must be at 5mcg/min and is increased every 3-5 minutes until the patient responds. If no response is seen at 20mcg/min, the dosage is increased at 10mcg/min until a blood pressure response is noted. Maximum dosage is of 400mcg/min.

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