Complex Health Concepts
Crittenden, Booher, Brendley, & Teal
January 23, 2014
Case Study: Cardiac Catheterization
Client Profile: Robert Wilson is a 55 year old male with a history of angina, hypertension, Type 2 diabetes, COPD, and sleep apnea. He comes to the physician’s office complaining of worsening shortness of breath. His skin tone is grey, and his angina is worsening. Previously stable, he now does not get relief from rest or nitroglycerin. The physician called 911 and had Mr. Wilson directly admitted to the hospital.
What are the treatment priorities of the registered nurse upon admission?
Priority treatments for Mr. Wilson would start with the administration of Oxygen 2L/nasal cannula. This will help to perfuse oxygen to the body in the occurrence of shortness of breath. It is stated that Mr. Wilson’s angina is not resolved with nitroglycerin or rest, so we can assume that it is now unstable. In cases of unstable angina the supply of oxygen to the body is decreased, which decreases the overall arterial oxygen content. This lack of oxygen is caused from the buildup of plaque which increases resistance through the arteries, making it harder for blood and oxygen to perfuse through the body (“Crittenden, 2011,”).
The RN would assess Mr. Wilson’s vital signs especially in regards to oxygen saturation and blood pressure. With the administration of oxygen the saturation would need to be >90%. Next, the RN would administer nitroglycerin. This is standard protocol for chest pain even though Mr. Wilson’s has previously not been getting resolution of his pain from nitroglycerin. Mr. Wilson still can benefit from the nitroglycerin because nitroglycerin is a vasodilator, meaning that it expands the diameter of the vessels to decrease the oxygen demands of the body. The blood carrying the oxygen to the body meets less resistance when the arteries are at a greater diameter. Since Mr. Wilson is in distress with shortness of breath, his oxygen demand being decreased will help him with comfort as well as perfusion. The standard order for nitroglycerin in instance with chest pain is 0.4mg sublingual times three, every five minutes as necessary (DeVon & Ryan, 2009, para. 2).
The nurse would then administer aspirin in a 325mg chewable tablet. Aspirin in this dose given in the first 10 minutes of arrival at the hospital has been proven through evidence based practice to decrease mortality from myocardial infarction. Aspirin interferes with platelet activation, adhesion, and cohesion, preventing further damage when MI is expected or any other acute coronary syndrome (McNab & Burdess, 2009). These are the priority nursing interventions for Mr. Wilson upon admission.
The nurse will then want to administer pain medication to Mr. Wilson if and only if he has either been ruled out for cardiac catheterization or his informed consent for the procedure has already been signed. Once pain medication is administered informed consent is no longer valid if singed after the admin of the pain medication. The pain medication used most often in chest pain cases is Morphine. If Mr. Wilson has severe chest pain that is not being resolved with the above nitroglycerin that is dilating his vessels; the morphine will decrease pain, as well as myocardial oxygen demand due to decreasing preload and afterload (“F.A. Davis Company, 2009”). What orders would the RN expect to be included on the standing orders?
Standing orders for chest pain patients may vary from hospital with exact procedures. However, there are some universal standing orders used for cardiac patients. The nurse would expect to get an ECG within 10-15 minutes of arrival to the ED. The Echocardiogram is going to give the best picture of how severe the cardiac event is or was, is it happening currently or has it already happened. An ECG showing an elevated ST segment MI, or a STEMI is the most serious acute cardiac event and