Critical Care Nurs Theo for the Expd Nurse

NUR440 Case Study 3 Case # 3 (Acute MI) Mr. Jones is a 52-year-old obese man with a medical history of gastric reflux and degenerative arthritis. He arrives at the emergency department with his wife. They had been to dinner and a movie. During the movie Mr. Jones began experiencing excruciating chest pain that radiated to his jaw and left arm. He appears short of breath and diaphoretic. He reaches the registration window when he suddenly collapses. The nurses place him on a stretcher. He has no pulse and the defibrillator paddles reveal ventricular tachycardia. He was successfully converted to a sinus tachycardia after two shocks, one at 200j and one at 300j. Mr. Jones regains consciousness after his rhythm converts. He has a blood pressure of 130/92, a heart rate of 112, and a respiratory rate of 24. O2 is immediately started at 3 liters/minute. Three 18 g IV’s are started, lab work is drawn (CPK-MB, Troponin, CBC, PT,PTT, type and screen& Chem 21) and a 12-lead EKG is preformed. He still complains of chest pain (8/10) and nausea. Sublingual NTG 1/150 gr is given. Amiodarone 150 mg IV over 10 minutes is ordered and is to be followed by 360 mg over the next 6 hours (maintenance will be 0.5mg/min). The 12-lead EKG reveals 2-3 mm ST-segment elevation in leads II, III, and aVf with a PR interval of 0 .24. Retavase therapy is ordered. The dosage is 10 U IV over 2 minutes, repeated in 30 minutes. After being admitted to the CCU Mr. Jones complains of chest pain continuing at 8/10. Mr. Jones is started on IV morphine 3mg IV and a NTG gtt . This drip was started 5 mcg/min and titrated up every 3-5 minutes until the pain was relieved at 25 mcg/min. His blood pressure had dropped to 84/40. He is pale and diaphoretic. With a weak and thready pulse. A dobutamine infusion was started at 5 mcg/kg/minute. Case Study Questions 1. What classic signs and symptoms did Mr. Jones experience which would indicate myocardial infarction (MI)? What are the specific pathophysiological reasons for each of these signs and symptoms? Classic signs and symptoms of chest pain Mr. Jones experienced were: chest pain that radiated to his jaw and left arm, shortness of breath and diaphoresis. The chest pain is caused from the lack of oxygen to the myocardial cells. When lipids accumulate in the intima of the artery, they evolve into a fibrous-fatty lesion. Sometimes the lesions contain a fibrous cap and this cap ruptures, allowing the lipid center into the bloodstream. This stimulates clot formation, known as thrombogenesis and blocks the vessel, preventing oxygenated blood from passing through, ultimately depriving myocardial cells from their nutrients. Electrolyte disturbances are also triggered by oxygen deprivation, especially loss of potassium, calcium and magnesium from the cells. Myocardial cells deprived of their nutrients tend to lose their contractility, this all resulting in pain, often radiating to the jaw, neck, back and arms. Shortness of breath is due to the decreased contractility of the heart. With decreased contractility, blood from the heart backs up into the lungs causing a decrease in respiration, resulting in shortness of breath. Shortness of breath is also related to the patient’s anxiety. Mr. Jones diaphoresis is caused by the stimulation of the sympathetic nervous system-- when catecholamines are released, diaphoresis occurs as well as peripheral vasoconstriction, resulting in cool and clammy skin.

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