1) Mr Kent, a 67-year old male, presents to the Emergency Department (ED) with chest pain. He reports that the pain started about an hour after dinner, while he was working on his car. He describes the pain as a "crushing pressure" located midsternal and radiating down his left arm and to his back. He rates the pain a 4/10. On assessment, Mr. Salazar is diaphoretic and pale and complains of shortness of breath (SOB).  

- What nursing assessments needs to be performed for Mr. Kent?

- What intervention should you as the nurse perform right away? Why?

- What medication should be the first one administered to this patient? Why? How often? create 1 med template.

- What tests do you anticipate will be ordered?

 

• For the patient history, ask whether he previously took a medication when his chest pain started and if was there relief. ask if the patient has other comorbids such as hypertension and diabetes. Also ask if patient had history of previous myocardial infarctions. Elicit any family history of cardiac and cardiovascular events. Also monitor the patient's vital signs especially his pulse and heart rate. Assess also the patient's breath sounds and heart sounds. Monitor if there were changes in the mental status.

• Establish and IV line to administer analgesics and hook this patient to Oxygen via nasal cannula at 2LPM. As soon as the patient comes in, after proper assessment, you would want to give symptomatic relief since this patient complains of pain and difficulty of breathing.

• Morphine is usually administered every 3-4 hours. Again, this is to give symptomatic relief. Also to prevent further ischemia.

Generic name: Morphine

Classification: Opioids

Action: Inhibits ascending pain pathways and alters perception of and response to pain by binding to opioid receptors in the CNS.

Dose: Oral: 10 mg every 4 hours, up to 30mg every 4 hours; Initially: 1-4 mg every 1 to 4 hours PRN

Route: Oral or IV

Side effects: more frequent: drowsiness, urinary retention, constipation; less frequent: peripheral edema, chest pain, depression, paresthesia to name a few

Contraindications: hypersensitivity and significant respiratory depression

• The following tests may be ordered: 12-Leas ECG, cardiac enzymes such as CK-MB and troponin, LDH, CBC with differentials, arterial blood gas, electrolytes, chest x-ray

Step-by-step explanation

For number 1:

Making a diagnosis for any condition mainly relies on the presenting symptom. In this case, it is more likely a case of a myocardial infarction. Thus, the nursing assessment to be done would be:

• Obtain a good patient history by asking the characteristics of the pain noting for the radiation and associated signs and symptoms.
• Assess whether this patient has other known comorbidities such as hypertension and diabetes that increase his risk of developing a cardiac event. Ask if patient is a known smoker to consider probable COPD exacerbations or a known asthmatic presenting with an exacerbation.
• Ask whether this patient had prior MI events.
• Assess also whether this patient has a family history of heart diseases, DM, and even stroke.
• Upon PE, monitor the patient's vital signs with focus on the blood pressure and the pulse. Note that the patient is diaphoretic and pale which may also be signs of shock.
• Assess for any vein distensions, and assess the patient's heart sounds noting for any murmurs, as well as assess his breath sounds and note for wheezing, rales, and crackles.
• Assess the abdomen for ascites and check the peripheries as well and check whether there is peripheral edema, as to rule out any signs of congestive heart failure.

For numbers 2 and 3:

For nurses, a useful guide in the immediate management of patients with MI is MONA; this stands for:

Morphine

Oxygen

Nitroglycerin

Aspirin

So in this case, the next best step would be to establish an IV line for your morphine administration, and then giving this patient supplemental oxygen usually started at 2 lpm. Morphine is given to reduce the pain and the patient's anxiety as well as it is known to have contributory effects on decreasing the workload of the heart by reducing the preload and the afterload due to its vasodilatory effects. Morphine is usually given every 1 to 4 hours intravenously. Oxygen is given since this patient presented with shortness of breath and adequate oxygenation provides relief to the ischemic myocardial tissue. A sample drug template for morphine is:

• Generic name: Morphine
• Classification: Opioids
• Action: Inhibits ascending pain pathways and alters perception of and response to pain by binding to opioid receptors in the CNS.
• Dose: Oral: 10 mg every 4 hours, up to 30mg every 4 hours; Initially: 1-4 mg every 1 to 4 hours PRN
• Route: It may be given orally or via IV
• Side effects: more frequent are drowsiness, urinary retention, constipation, vomiting and nausea; less frequent are peripheral edema, chest pain, depression, paresthesia, hypotension, tachycardia, abdominal pain and leukopenia

Contraindications: hypersensitivity and significant respiratory depression

Precautions: CNS depression and respiratory depression, hypotension

For number 4

The following tests are usually requested and should be expected:

• 12L ECG - would show ST segment elevations, T wave inversions, and some pathologic Q waves. Such findings signify ischemia of the cardiac muscles.
• Cardiac enzymes such as CK MB or troponin I, LDH - these are released by the damaged myocardium and are usually elevated
• Electrolytes - an electrolyte imbalance especially that of potassium and sodium may affect the heart's contractility
• CBC with differentials - would show sometimes decreased hemoglobin as well as elevated white blood cell counts signifying an ongoing inflammation
• serum chemistry such as lipid panel, fasting blood glucose, serum creatinine and BUN, ALT/AST - all may be requested to check for renal function, hepatic function, as well as to check risk of hypercholesterolemia and hyperlipidemia which may contribute to atherosclerosis which predisposes patients to MI
• Chest radiographs - would also show an enlarged heart that may suggest left ventricular hypertrophies and increased risk of heart failure