Acute problem #1 Decreased CO r/t left sided Acute problem #2: Impaired Gas Exchange r/t

HF due to left ventricle damage and MI
Interventions: Check care plan for assessments and
evaluation
• Assess HR and BP
• Monitor RR and lung sounds
• Monitor and examine lab test
• Monitor pulse oximetry and administer oxygen
needed
• Monitor I/O
• Check mental status changes and LOC
• Administer medications as prescribed
anaphylactic shock due to contrast dye allergy
Interventions with assessments: Check care plan for
assessments and evaluation
• Monitor RR, depth and note any changes
• Auscultate breath sounds. Assess for narrowed
airway
• Observe for changes in color of the skin, tongue,
and mucosa. Assess the presence of angioedema.
• Monitor oxygen saturation and administer
oxygen
• Administer medications as prescribed.

Lab Values:
 CMP: normal – except potassium
(3.2 mEq/L)
 CBC: normal
 Cardiac Enzymes: Trop T ↑ (0.2
ng/mL); Trop I ↑ (0.06 ng/mL)
 Coagulation panel – normal
 Urinalysis – specific gravity ↑
1.030
Dx Procedures:
 ECG – showed ST elevation; showed
heart attack due to coronary artery
blockage - STEMI
 Cardiac catherization with contrast
 Percutaneous Transluminal
Coronary Angioplasty with stent –
(left anterior descending coronary
artery). Reopen blocked artery
 Chest Xray- to rule out chest pain
from dissecting aorta
 Chest MRI
54 y/o, Male
 Dx: Myocardial Infarction, STEMI
 ED chief complaint: chest pain
 Hx: blocked arteries, HTN, CAD with
angina, asthma, quit smoking (1
month ago), occasionally chews
tobacco
 Allergies: penicillin, shellfish,
peanuts, sulfa, contrast dye
 Telemetry: RSR with PVC’s
Medications:
• Albuterol – PRN bronchodilator; helps increase airflow
to lungs; ↓heart workload and anxiety; for asthma
• Aspirin – anticoagulant/salicylates; prevent clotting,
vasoconstriction, and thrombus formation; ↓ blood
viscosity; coagulation test normal
• Lisinopril- antihypertensive ACE-I; given for HTN
• Clopidogrel – antiplatelet; given to reduce formation
of clot
• Naloxone – PRN morphine antidote if RR <10/min
• Morphine - PRN opioid analgesic; for pain relief,
sedation, ↓ oxygen demand
• Diphenhydramine – antihistamine, antiallergy; given
for itching and restlessness
• Epinephrine IV – adrenergic agonist; bronchodilator,
vasoconstrictor, maintain BP and HR; given for
anaphylaxis
• Dobutamine drip – ↑ CO; helps heart pump blood
• Norepinephrine – vasopressor, vasoconstrictor, ↑ BP,
↑ CO, ↑ blood flow to kidneys and brain
• Potassium chloride – K+ supplement. given due to
K+=3.2.
CARE PLAN
Patient Problem #1: Decreased CO r/t left sided HF due to left ventricle damage and MI
Nursing Intervention
Monitor I/O.
Check mental status and LOC
Assess HR and BP.
Monitor RR. Note rhythm, and
breath sounds.
Monitor and examine lab test
Administer medications as
prescribed. Monitor effects.
Monitor pulse oximetry and
administer oxygen needed as per
MD orders.
Rationale Patient Evaluation
I/O levels evaluate fluid volume status. ↓ CO results in ↓UO 48 ml/hr.; shows inadequate perfusion or
reduced kidney perfusion resulting in low urine output. dehydration during cardiogenic shock episode
Hypoxia and ↓cerebral perfusion can manifest as irritability, A&O most shift but pt. was showed s/s of cardiogenic
difficulty in concentrating, or restlessness. shock during shift (restlessness and agitation)
Most pts. compensatory response to ↓CO is tachycardia and PR:74-78; SBP: 110-112; DBP: 72-74; ABP 88/54 during
very low blood pressure. cardiogenic shock; MAP 54 mm Hg
↓CO can manifest in shallow, rapid respirations. Fluid RR:12-14
buildup from impaired LV emptying can cause crackles.
Lab test can provide discernment into etiology of heart CMP: normal – except potassium (3.2 mEq/L); given
disease and the extent of decreased function. potassium supplements
Electrolyte imbalance can affect cardiac rhythm and CBC: normal
contractility. Cardiac Enzymes: Trop T ↑ (0.2 ng/mL); Trop I ↑ (0.06
Serum creatinine levels can increase in severe HF due to ↓ ng/mL); elevation caused by MI
kidney perfusion. ACE inhibitors can also increase Coagulation panel – normal
creatinine. Urinalysis – specific gravity ↑ 1.030; possible due to
dehydration
Older adults have difficulty with metabolism and excretion No indications of toxicity seen on pt. after medication
of medications because of ↓ function of the liver and administration.
kidneys; therefore, toxic side effects are common. Given dobutamine drip IV during signs of cardiogenic
shock
Supplemental oxygen increases oxygen availability to the O2 Sat: 99-100% 3L/min via NC
myocardium and can relieve symptoms of hypoxemia.
Resting hypoxia or oxygen desaturation may indicate fluid
overload or concurrent pulmonary disease.

Patient Problem #2: Impaired Gas Exchange r/t anaphylactic shock due to contrast dye allergy

Nursing Intervention Rationale Patient Evaluation

Monitor RR, depth and Histamine is the primary mediator of
note any changes anaphylactic shock. It causes smooth muscle
contraction in the bronchi. It also caused
respiratory distress due to swelling in the
upper airways.
Auscultate breath sounds. Wheezing can be heard over chest during
Assess for narrowed auscultation.
airway. Systemic antigen-antibody immune response
can result in severe bronchial airway
narrowing, edema, and obstruction.
Pt. had systemic allergic reaction to
contrast dye during catherization.
Pt. was coughing, had nasal congestion,
SOB, dyspnea.
Pt. was anxious and distressed.
Pt. experienced wheezes, and intermittent
stridor during anaphylactic shock.
Pt. also had nasal congestion and increasing
respiratory distress
Observe for changes in Anaphylactic shock can cause bluish
color of the skin, tongue,discoloration of body parts. This is
and mucosa. Assess the considered a medical emergency
presence of angioedema. Angioedema is described as swelling of skin,
lips, tongue, hands, eyelids, and feet.
Monitor oxygen saturation As shock progresses, aerobic metabolism
and administer oxygen stops, and lactic acidosis occurs. This results
in the ↑ Co2 and ↓pH.
Oxygen saturation that is less than 90%
results to tissue hypoxia, acidosis,
dysrhythmias, and changes in the LOC.
Administer medications as Medications can reduce bronchospasm, open
prescribed airways, and relax pulmonary vessels.
Pt. tongue was swollen, skin color was
dusky, and nail beds ashen
Pt. experienced oxygen desaturation at
87%. Given oxygen therapy via
nonrebreather mask at 15L/min.
Called MD and rapid response.
Given diphenhydramine and epinephrine
IV for anaphylaxis