CASE SCENARIO:

You are assigned to a 75kg patient who suffered from anterolateral wall ST elevation MI who
was placed in the ICU manifesting with difficulty of breathing which necessitated intubation
with mechanical vent setting of SMIV mode, TV 450, BUR I:E1:2, PIP/PEEP 18/0. His GCS is
E2VTM4. He had expiratory wheeze, rales over bilateral bases of the lungs, his heart sound was
irregular at 62/min, pansystolic murmur over the erbs point and 4th ICS Left parasternal border.
There is S3 and PMI is at 6th ICS left lateral mid-clavicular line. There is pulsus alternans
appreciated in the peripheral pulses. There are grade 2 edema on bilateral upper and lower
extremity. His BP ranged between 80/50-100/50 as per the past 4 hours. Current cardiac monitor
showed sinus rhythm with episodes of sinus bradycardia with occasional PAC’s. His general
color is pale and latest CBC is 110mg/dl. He was placed on D5NR 1L q 8hrs and D5W250+1
amp Dopa (at 200mg/amp) at 25cc/hr.

Question:
1. What is your ND in this case and give 4 supporting cues?

 Decreased cardiac output as evidenced by difficulty of breathing, irregular heart

sound at 62/min, S3 sound, changes in BP ranged between 80/50-100/50 as per
the past 4 hours, PMI is at 6th ICS left lateral mid-clavicular line, pulsus alternans
appreciated in the peripheral pulses, pansystolic murmur over the erbs point and
4th ICS Left parasternal border and rales.

2. Give 5 priority interventions for your ND ?

a. Auscultate apical pulse, assess heart rate and sounds, and monitor blood pressure
(BP) regularly.
b. Maintained a high fowler’s position with the head of the bed elevated.
c. Check for diminished pedal pulses, swelling, or pallor of extremity.
d. Provide a restful environment and encourage periods of rest and sleep.
e. Administer oxygen as indicated by the patient’s symptoms, oxygen saturation,
and ABGs.
f. Administer prescribed medications as ordered.

3. What is the purpose of Dopamine at this point? Show your computation to support your
answer for the dose of Dopamine.
a. Dopamine, a vasopressor, since the client has low blood pressure (hypotension)
and pump failure, it increases myocardial contractility and causes
vasoconstriction, thus, improving blood pressure and cardiac output.

b. 200mg/250ml = 0.8mg/ml
0.8mg x 1000 = 800 mcg
 X (ordered amount of drug) x patient weight x (minutes/hr)
Drug concentration
X (by cross multiplication) = 25 cc/hr x 800mcg = 20,000 = 4.4
mcg/kg/min
75kg x 60 minutes/hr 4,500

Scenario: following day, you determined that there was a large amount of residual feed from the
NGT amounting to 200cc. you discharged this and referred it and the doctors ordered to defer
current feed and to resume on next due feeding. After an hour the mech vent started to alarm
because of apnea with periods of desaturation and bradycardia below 50/min. you referred the
patient and doctor ordered atropine and shifter the mech vent mode to AC and BUR at 20/min at
the same time ordered a stat ABG. Latest CBG was at 90mg/dl and Dopamine was increased at
30cc/hr.

Questions:
1. What did your patient suffer from apneic periods?

 Based on the situation, this is due to a large amount of residual feed from the
NGT amounting to 200cc because the excess residual volume may indicate an
obstruction or some other problem that must be corrected before tube feeding can
be continued. Also, during an apneic episode, the diaphragm and chest muscles
work harder as the pressure increases to open the airway resulting in desaturation
and bradycardia.

2. What is the purpose of the mechanical vent setting changes?

 Mechanical ventilation is indicated when alveolar ventilation is inadequate to

maintain blood oxygen and carbon dioxide level. Specific indications for apnea or
acute ventilator failure, increased work of breathing with progressive client
fatigue and hypoxemia unresponsive to oxygen therapy alone. Almost all
ventilators have the capability of being set to four basic modes: AC, synchronized
intermittent mandatory ventilation (SIMV), airway pressure release ventilation
(APRV), and pressure support (PS).

3. At this point from what condition did your patient suffer which led to the cascade of
symptoms?

 Based on the symptoms above the patient is suffering from Heart failure/attacks
that may lead to STEMI (ST- Elevation Myocardial Infarction).