Rapid Reasoning Acute Coronary Syndrome Your patient: Mrs. M

Rapid Reasoning Acute Coronary Syndrome Your patient: Mrs. MN is a… Rapid Reasoning Acute Coronary Syndrome  Your patient:Mrs. MN is a 58-year-old female who has ben more fatigued the past week.  She has had intermittent epigastric burning that lasts 30-60 minutes that comes at rest as well as with moderate physical activity.  The burning has not been relieved by antacids.  This epigastric pain is different and more debilitating and now has pain in her upper back that she rates at a 6/10, persistent for the past two hours.  An EKG was done immediately upon arrival in the ED and revealed 2 mm ST depression across leads II, III, AVF (inferior leads).  She received NTG 0.4mg sublingual with a decrease in upper back pain down to a 2/10.  The repeat EKG done 30 minutes later showed ST segment depression has resolved and no longer present. Past History:*Smoking 1ppd x 40 years8Obesity (BMI = 34)*GERD Your initial assessments:VS:  T=98.8,  P=90,   R=20,   BP=148/82,  O2 saturation 92% on RAResp: Breath sounds are clear with good rise of the chest cavity, non-laboredCardiac: pink, warm & dry skin, S1S2, no signs of edema, pulses 3+ in all extremitiesNeuro: alert & oriented x4, appears anxious over not feeling wellGI / GU: active BS in all quadrants, soft, no tenderness, voiding without difficulty DiagnosticsCXR: normal heart side, not infiltratesEKG: 2mm ST depression in leads II,III, AVF that has resolved following NTGTroponin: 0.01CK: 50      CKMB: 2 Physician Orders:*NTG 0.4mg SL every 5min x3, follow with NTG gtt.  Titrate to pain relief and maintain SBP>90*ASA 325mg PO daily*Plavix 600mg now x1, then 75mg daily PO*metoprolol 25mg PO daily*Heparin gtt per hospital protocol*Admit to cardiac telemetry*NPO except for meds with water Use this information to answer this   1. What VS & assessment data is RELEVANT that must be recognized as clinically significant        to the nurse?   Relevant: VS/assessment data     Relationship to primary medical problem     2. What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?  Relevant: diagnostic results   Relationship to primary medical problem   3. What is the medical problem that your patient is most likely presenting with?       4. What is the underlying cause/pathophysiology of this concern?      5. Based on the data you collected, what is your primary concern right now?     6. What interventions will you initiate based on this primary concern? (start with A-B-C      priorities)     7. What body system will you mostly thoroughly assess based on the patient’s chief complain        and primary/priority concern>   8. What is the worst possible complication to anticipate?    9. What nursing assessments will you need to initiate to identify and respond to quickly if this      complication develops?  10. What is the relationship between the following physician orders/medication orders and your patient’s primary medical problem?    Physician order   How it will help resolve primary problems     Health Science Science Nursing PN 3

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