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Jimmy Kearns
Age: 68 Weight: 85 kg Base: Stan D. Ardman
Overview
Synopsis
This simulated clinical experience focuses on the emergent treatment of a patient who experiences an acute ST-segment elevation myocardial infarction (STEMI). The patient is within a two-to-four hour window from the time chest pain began and his arrival to the Emergency Department (ED) for treatment. While in the ED the patient experiences a recurrence of his chest pain as his condition rapidly progresses to cardiogenic shock. The patient is transported to the Cardiac Catheterization Laboratory for Percutaneous Coronary Interventions (PCI) and subsequently admitted to the Coronary Care Unit (CCU ) for post PCI observation and management. The SCE has four states that are transitioned manually at the facilitators discretion with the exception of State 2 Onset of Cardiogenic Shock that automatically transitions to State 3 Ventriculater Tachycardia after 90 seconds for a run of Ventricular Tachycardia. State 3 Ventriculater Tachycardia transitions back to State 2 Onset of Cardiogenic Shock after 10 seconds. With manual transitions, instructors should advance to the applicable state when appropriate interventions are performed. During State 1 Initial Assessment, the patient demonstrates a HR in the 100s, BP in the 90s/50s, RR in the low 20s and SpO2 in the high 90s on 2 LPM of oxygen via nasal cannula. Breath sounds are clear in all lobes. Heart sounds reveal S4 with the cardiac rhythm showing sinus rhythm with ST segment elevation that is characteristic of a STEMI. Bowel sounds are normoactive. His temperature is 37.5C with a capillary refill less than 3 seconds with normal skin color and warmth. If the learner requests blood results they are told White Blood Cells (WBC) 11.8, Red Blood Cells (RBC) 5.2, Hemaglobin (Hgb ) 15.4, Hematocrit (Hct) 47%, Platelets 350. Sodium (Na) 138, Potassium (K) 4.2, Chloride (Cl) 102, Carbon Dioxide Content (CO2 ) 30, Glucose 88, Blood Urea Nitrogen (BUN) 18, Creatinine (CK) 0.9. Cardiac Enzymes: Creatinine Kinase (CK) 457, Creatinine Kinase Specific for Myocardium (CK-MB ) 24.1, Troponin I 1.1. Urinalysis (UA) on dipstick within normal limits (WNL) with no results back yet for culture and sensitivity (C&S). Prothrombin Time (PT) 14, International Normalized Ratio (INR) 1.2 and Partial Thromboplastin Time (PTT) 33. He denies any chest pain. The learner is expected to perform an initial physical assessment interpreting and recording all vital signs and reporting abnormalities to the healthcare provider. The learner should undertake and implement all the healthcare providers orders and document as appropriate. All specimens (e.g., urinalysis and venepuncture) should be carried out in a safe manner, and when the results are returned, they should be passed to the healthcare provider. Oxygen and any medications should be calculated and administered according to the Six Rights. The patient should be prepared according to local protocol to undergo a Percutaneous Transluminal Coronary Angioplasty (PTCA). Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
Author
Original Author: Isaac Smith, Prairie View A & M University, Houston, Texas and Cheri Hernandez, California State University - Long Beach, Long Beach, California. Reviewer: Isaac Smith, Prairie VIew A & M University, Houston, Texas and Christie Pawley, METI. Sarasota, Florida 2008 and Amanda Wilford, METI Sarasota, Florida, 2009
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
Background
Patient History
Past Medical History: Unknown Allergies: No known drug allergies Medications: No medications Code Status: Full Code Social/Family History: He is a retired postal worker who is accompanied by his wife.
Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment findings where appropriate and necessary. The report should follow the SBAR format and include: Situation: The patient is a 68-year-old male who was admitted to the ED reluctantly by the paramedics from his home. At the scene, the paramedics administered sublingual (SL) nitroglycerin three times. While being transferred in the ambulance and following an ECG that showed an ST segment elevation of 2 mm, the paramedics commenced 2 LPM of oxygen via nasal cannula, asked the patient to chew 160 mg of aspirin and inserted an IV saline lock in the right forearm. The patient has been seen by the healthcare provider and orders have been written including to prepare him for a cardiac catheterization Background: 68-year-old man chest pain at home that on ECG indicates an acute myocardial infarction (AMI). He has been having crushing chest pain that radiates to his neck and jaw during the afternoon whilst cleaning out his garage. His wife reports that he appeared to be a horrible blue-grey color and the pain was not relieved until the paramedics arrived. The patient did not want to come to the hospital, and the paramedics needed to convince him. The time frame from initial onset to now is within the four-hour window. Assessment by the paramedics: HR 115, BP -106/68, RR 24, SpO2 95% on air, maintained now on oxygen at 2 LPM. General Appearance: Seems anxious. Cardiovascular: Cardiac Rhythm sows 2 mm ST-segment elevation Respiratory: Lungs clear GI: Bowel sounds normal GU: Not formally assessed Extremities: Not formally assessed Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
Orders
Initial Orders Continuous cardiac monitor 12-lead ECG STAT and with complaints of chest pain MI Panel: CK, CK-MB, and Troponin I STAT and every 6 hours x3 CBC, Electrolytes, BUN, Creatinine, Glucose, PT/INR, PTT, UA C&S STAT Chest x-ray STAT NPO Saline lockpotential for thrombolytic therapy O2 at 2-6L PM by nasal cannulatitrate to maintain SpO2 greater than 92% Aspirin 325 mg chewed and swallowed STAT if not given by paramedics Nitroglycerin 50 mg/ 250 mL mixed with 5% Dextrose (D5W) IV at 5 mcg/minute, titrate for chest pain with SBP greater than 90 mmHg Morphine 2-10 mg Intravenous Push (IVP) as required if chest pain not relieved by nitroglycerin Metoprolol 5 mg slow IVP every 5 minutes for a total of 3 doses. Hold for HR less than 60 or SBP less than 90 mmHg Heparin 5000 units IVP and start continuous infusion at 1000 units/hr Vital signs every 15 minutes while titrating nitroglycerin, then every hour Foley catheter Weight on admission Intake and output Prepare for cardiac catheterization Obtain permit for cardiac catheterization and possible percutaneous transluminal coronary angiography (PTCA) with stent placement Notify healthcare provider of SBP less than 90 mmHg, HR less than 60, or PVCs greater than 6 per minute
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
Preparation
Learning Objectives
Integrates theoretical knowledge from the sciences, humanities and nursing into Uses critical-thinking and the nursing process as a framework for clinical decision-making Designs an individualized plan of care for the nursing management of a patient with an
acute coronary syndrome (APPLICATION). (ANALYSIS). professional nursing practice (SYNTHESIS).
State 2 Following Healthcare Providers Orders: Repeats assessment, evaluates data and documents ndings Reassesses cardiac rhythm Medicates patient, demonstrating the Six Rights Correctly administers medication amiodarone and dopamine Administers (drug-route) using the correct technique Documents on medication administration record (MAR) Anticipates and monitors for side effects of medication Prepares for STAT the transfer to Cardiac Catheter Laboratory when stable hemodynamically State 4 CCU Post PTCA: Performs a physical assessment Identies and prioritizes teaching needs Evaluates pain and documents appropriately Reassesses cardiac rhythm Monitors the pulse oximetry Assesses the level of social support Assesses the readiness to learn and provides appropriate education Communicates effectively with patient and family members Monitors IV infusion and site Converts IV to saline lock when taking oral fluids Instructs the patient to post-PTCA care Offers uids orally Evaluates assessment ndings. Documents ndings and intervenes appropriately Administers medications using the Six Rights Begins discharge teaching appropriate for patient with acute myocardial infarction (AMI)
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
Acute Coronary Syndrome and Acute Myocardial Infarction PNCI Preparation Questions
What is Acute Coronary Syndrome (ACS)? Describe the etiology and pathophysiology of ACS. What are the differences between a transmural (e.g., full thickness) myocardial infarction How are these differences depicted on the ECG? What are the areas of infarction? Correlate the location and area involved with the part of the coronary circulation involved: Right coronary artery Left anterior descending artery Left circumex artery Why does the younger person who has a severe MI usually have more serious impairment
(MI) and a subendocardial (e.g., partial thickness) MI?
than an older person? Why is it common for the temperature to rise in the rst 24 hours following an AMI? What is the most common complication following an AMI? Why? Correlate the area of infarction and the side effects/complications most commonly seen: Inferior wall damage Lateral wall damage Anterior wall damage Posterior wall damage What are the serum cardiac markers used in diagnosing an AMI? When do their levels peak? When do their levels return to normal? Thrombolytic therapy should be instituted within how many hours of the onset of pain to be of most benet? What are the nursing implications and management of the patient receiving thrombolytic therapy? What are the major drug classications the nurse would anticipate a patient with ACS receiving? For each of the classications, identify the action and key nursing implications. Outline the components of a teaching plan for a patient with ACS and successful revascularization via PCI. What is the half-life of amiodarone? Why is this important to know?
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Acute Coronary Syndrome and Acute Myocardial Infarction PNCI Equipment and Supplies
IV Supplies Transparent dressing (2) IV pumps (4) IV pump tubing (4) Distilled water 250 mL (labeled Nitroglycerin 50 mg in 250 mL 5% Dextrose, Heparin 25,000 units in 250 mL 0.9% Sodium Chloride, Dopamine 200 mg in 250 ml 5 % Dextrose) (3) Distilled water 100 mL (labeled 5 % Dextrose) (2) Distilled water 500 mL (labeled 5 % Dextrose) IV Piggy Back (PB) tubing (3) Saline lock 20ga IV catheter (2) Supplies Simulated pills (labeled Aspirin 325 mg, clopidogrel 300 mg, metoprolol 50 mg, quinapril 2.5 mg, captopril 12.5 mg, isosorbide 10 mg, diltiazem 30 mg, simvastatin 10 mg, acetaminophen 325 mg x2, docusate 100 mg, promethazine 12.5 mg, temazepam 15 mg, alprazolam 0.25 mg, alprazolam 0.5 mg) Distilled water 10 ml vial (labeled Metroprolol 10 mg/10 mL) Empty nitroglycerin bottle with baby aspirin (labeled NTG 0.4 mg) Distilled water 1 mL vial (labeled Morphine Sulfate 5 mg / mL, promethazine 25 mg/ mL, heparin 10,000 units/ mL) Distilled water 10 mL vial (labeled Amiodorone 50 mg/ mL x2) 60 mL bottle (labeled antacid, labeled Laxative) 3 mL syringe Plastic medication cup Prelled 1 mL syringe lled with 1 ml distilled water (labeled Exonaparin 100 mg /mL) Oxygen, Airway and Ventilation Supplies Oxygen owmeter Oxygen source Nasal cannula Non-rebreather mask Oxygen connection tubing Water to humidify oxygen (if needed) Genitourinary Supplies 14 Fr urinary catheter with drainage bag Urimeter Distilled water 1000 mL with 2 mL of yellow food coloring for urine source
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Notes
Facilitator Notes
This SCE was created with the patient Jimmy Kearns, and only this patient can be used. The physiological values documented indicate appropriate and timely interventions. Differences will be encountered when care is not appropriate or timely. If using the Muse platform, dont hit Run until you are ready to start the scenario. If using the HPS6 platform, open the patient and scenario directory. Do not open the scenario until you are ready to start the simulated clinical experience. Learners should perform an appropriate physical exam, and the facilitator or patient should verbalize physical findings the learner is seeking but not enabled by the simulator (such as pain on palpation). The facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to respond to learner questions if present on your simulator. Where appropriate, do not provide information unless specifically asked by learner. In addition, ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them. If the patient becomes unconscious in the SCE, remember the patient stops speaking. It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinical experience. For this patient, dress the simulator in casual clothing. At the end of State 2, place a pressure dressing and sandbag over the left groin. When the learner initiates cardiac monitoring, the tracing and heart rate appear on a real ECG monitor for those simulators with this feature. For simulators without ECG monitoring, have the learner apply ECG electrodes to the mannequin and attach leads. Once all 3 or 5 leads are in place, reval the TouchPro or Waveform display ECG tracing. Prime the Genitourinary system per simulator feature. Leave the indwelling catheter in place to the drainage bag if the patient already has a urinary catheter in place. Remove the catheter if the learner is to insert a urinary catheter. Add one drop of yellow food coloring to 1000 mL of distilled water, and pre-fill a urinary catheter bag to simulate that the patient has already drained an additional 50 mL of urine. Place a code cart either outside the room or away from the patient area in the room to allow the secondary nurse to retrieve it and bring it to the bedside, if needed. Have a code cart and either an automated external defibrillator or a defibrillator with the code cart. Simulation center personnel should play the following roles: Healthcare provider Laboratory technician Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Debriefing Points
The facilitator should begin by introducing the process of debriefing: Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safediscussion environment Personal Reactions: Allow students to recognize and release emotions, explore student reactions Discussion of Events: Analyze what happened during the SCE, using video playback if available Summary: Review what went well and what did not, identify areas for improvement and evaluate the experience
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Teaching Q&A
State 1 Initial Assessment: Is this patient a candidate for thrombolytic therapy? Yes, must be symptomatic for less than six hours, have pain for 20 minutes unrelieved by nitroglycerin and have a ST segment elevation greater than or equal to 1 mm in two or more continuous leads and no contraindications for thrombolytic therapy Contraindications include: previous hemorrhagic stroke at any time, other strokes or CVA within past one year, known intracranial neoplasms, active bleeding or suspected aortic dissection Should this patient develop chest pain, what is the rationale behind each of the modalities ordered? ECG: To be interpreted by healthcare provider for extension of current MI or development of right ventricular infarctions Nitroglycerin SL: Immediate relief of ischemic pain of AMI; increases coronary perfusion (vasodilation); caution should be used in administering nitroglycerin to patients with inferior or right ventricular infarctions Nitroglycerin drip: Initiated after SL nitroglycerin for titration to relief of ischemic pain Morphine IV: When symptoms are not immediately relieved with nitroglycerin or when acute pulmonary congestion is present; induces modest arterial and venous dilation resulting in reduced myocardial oxygen demands from its effect on afterload and preload Call healthcare provider if chest pain is not relieved by nitroglycerin: Warrants intervention What is the rationale for oxygen administration? Assists myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarctions; assists in maintaining oxygenation
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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State 2 Onset of Cardiogenic Shock What is the appropriate sequence of interventions for a patient having chest pain? STAT ECG to assess for ischemic changes or nding consistent with pericarditis Immediate set of vital signs Assess for new murmurs or friction rubs Increase FiO2 Give nitroglycerin SL or morphine sulfate for chest pain unrelieved by nitroglycerin Notify healthcare provider for chest pain unrelieved by nitroglycerin What response(s) would cause the nurse to alter this sequence? If systolic BP falls below 90 and unable to give nitroglycerin or morphine sulfate If rapid decline of condition Immediately call healthcare provider and start ACLS protocol Is uid resuscitation appropriate in this patient? Why or why not? No, the problem is not volume Heart has lost its pumping ability to adequately eject blood (volume) secondary to damage from AMI What has caused this dramatic change in condition? Cardiogenic shock What is this patient most at risk for now? Increasing infarction size Circulatory collapse Possible right ventricular infarct What is the treatment indicated to prevent the progression of the shock state? Aggressive approach to treat underlying cause Enhance effectiveness of the pump Improve tissue perfusion Inotropic agents to increase cardiac output and maintain adequate BP and peripheral perfusion Diuretics for preload reduction Once BP has been stabilized, vasodilating agents are used for preload and afterload reduction Antidysrhythmic agents are used to suppress dysrhythmias that can affect cardiac output Intubation and mechanical ventilation may be necessary to support oxygenation Possible intraortic balloon pump to augment coronary artery perfusion and decrease myocardial oxygen demand by reducing afterload Strict glucose control (80-110) Revascularization Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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References
Fenton, D. (2004). Acute coronary syndrome. Postgraduate Medicine 1, 1-33. Fonarow, G.C., Wright, R.S., Spencer, F. A., Fredrick, P. D., Dong, W., Every, N. et al. (2005). Effect of statin use within the rst 24 hours of admission for acute myocardial infarction on early morbidity and mortality. The American Journal of Cardiology 86(5), 611-615. Hani, J., (2003). Aspirin and clopidogrel in acute coronary syndromes. Arch Intern Med 163, 1143-1151. Kee, J.L. (2009). Prentice hall handbook of laboratory and diagnostic tests with nursing implications. (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Keeley, E.C. and Grines, C.L. (2004). Primary coronary intervention for acute myocardial infarction. JAMA 291, 6, 736-739 Kowalak, J.P., Hughes, A.S. & Mills, J.E. (2003). Best practices: A guide to excellence in nursing care. Philadelphia: Lippincott Williams & Wilkins. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., OBrien, P.G. & Nucher, L. (2007). Medical- surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Mosby. Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence Based Healthcare 2(6), 207-230. Mahaffey, K.W., Cohen, M., Garg, J., Antman, E., Kleiman, N.S., Goodman, S.G., et al (2005). High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin. JAMA 294, 20. McGee, S. (2007). Evidence-based physical diagnosis (2nd ed.). Philadelphia: Saunders.
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL
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