MI Case Study: Cardiac Knowledge
Question
MI Case Study Assignment
Purpose: The student completing the MI case study will utilize new cardiac knowledge and draw on previously learned content to determine a plan of care for the patient experiencing a myocardial infarction. This assignment aligns with the following course learning outcomes and essential employability skills as noted in the Cardiac Course Outline.
1. Interpret pathophysiology and pharmacology to ensure safe and effective care of the critically ill patient with cardiac challenges.
2. Assess hemodynamic profiles to create a prioritized plan for a patient experiencing critical cardiac challenges
3. Implement a collaborative plan of care to achieve optimal outcomes for a patient experiencing critical cardiac challenges
4.Evaluate patient responses to the cardiac plan of care and reassess or adapt to ensure optimal outcomes.
5. Implement best practices and evidenced based research to create a prioritized patient/family centered plan of care for a cardiac patient.
Directions
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1. This case study covers the content in sessions 1, 2 and 3. 2. This is a short answer assignment and not require that you use APA format; however, you must include your references with each question and a reference page at the end of the assignment. 3. To complete your assignment, copy the questions into a word document, do use this template to submit your answers. For reach question respond with appropriate detail. For example, a question worth a total of 20 marks requires a high level of detail. 4. All assignments submitted to DC connect are automatically submitted to Turnitin to support academic integrity. |
Grading Rubric
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Criteria |
Level 4 |
Level 3 |
Level |
Level 1 |
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Question 1 What are the risk factors for a MI? What risk factors are specific to Mr. Campbell? (4 marks) |
Demonstrates a comprehensive understanding of the risk factors for an MI and those specific for Mr. Campbell (4 marks). |
Demonstrates a thorough understanding of the risk factors for an MI and those specific for Mr. Campbell (3 marks). |
Demonstrates a basic understanding of the risk factors for an MI Does not address those specific for Mr. Campbell (2 marks). |
Demonstrates a lack understanding of the risk factors for an MI and Does not address those specific for Mr. Campbell (0 marks). |
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Question 2 Nursing priorities and intervention: patient assessment and symptoms; medications; lab tests; interventions; patient Teaching; post MI care (20 marks). |
Demonstrates a comprehensive understanding of nursing priorities and interventions for a patient diagnosed with a STEMI (20 marks). |
Demonstrates a thorough understanding of nursing priorities and interventions for a patient diagnosed with a STEMI (15 marks). |
Demonstrates a basic understanding of nursing priorities and interventions for a patient diagnosed with a STEMI (10 marks). |
Demonstrates a lack understanding of nursing priorities and interventions for a patient diagnosed with a STEMI (5 marks). |
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Question 3 Interpret the cardiac rhythm using the 8 step systematic approach (8 marks). |
One mark for each of the eight steps in (correct order) for the systematic approach to cardiac rhythm interpretation (8 marks). |
One mark of each of the eight steps |
One mark of each of the eight steps |
One mark of each of the eight steps |
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Question 4 Interpret the ECG using the 8 step systematic approach (8 marks). |
One mark for each of the eight steps in (correct order) for the systematic approach to ECG interpretation (8 marks) |
One mark of each of the eight steps |
One mark of each of the eight steps |
One mark of each of the eight steps |
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Question 5 PCI and reperfusion drugs. Including eligibility criteria for reperfusion drugs (4 marks)
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Demonstrates a comprehensive understanding of PCI & repreferusion drugs including the criteria for reperfusion (4 marks) |
Demonstrates a thorough understanding of PCI & reperfusion drugs including the criteria for reperfusion (3 marks) |
Demonstrates a basic understanding of PCI & reperfusion drugs. Dose not include the criteria for reperfusion (2 marks). |
Demonstrates a lack of understanding of PCI & reperfusion drugs. Does not include the criteria for reperfusion (0 marks). |
Case Presentation
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On Arrival to the Emergency Department Mr. Denzel Campbell is a 48-year-old, (260 lb) male that began having chest discomfort at home approximately one hour ago. The chest discomfort was unrelieved by sublingual nitro sprays. Hi wife immediately drove him to the Emergency Department where he presented with `pressure` midsternally that radiated down his left arm and through to his back. On admission Mr. Campbell was pale, diaphoretic and SOB. He denied nausea or vomiting. Further questions revealed that over the last few weeks, he has been having frequent episodes of chest discomfort upon exertion that was relieved by rest. Past Medical History Mr. Campbell has a history of diabetes mellitus that is controlled by diet. He reports smoking two packs of cigarettes daily for 30 years. His father died of lung cancer two years ago. His mother, who has hypertension, lives with him, and his wife and their two teenage sons. On assessment, Mr. Campbell has normal S1 and S2. Lungs are clear. No edema is present and bowel sounds are normal. No jugular venous distension is noted. Vital Signs T: 36.9 HR: 94 bpm/regular RR: 30 breaths/minute BP: 140/98 Sa02: 92 % with 2L 02 via nasal cannula Blood work was drawn and an ECG done. Mr. Campbell was diagnosed with an ST segment elevation MI (STEMI). Labs ▪ Hg 149 g/L ▪ WBC 8 x109/L ▪ Glucose 9.5 mmol/L ▪ K+ 3.7 mmol/L ▪ Troponin I 5.8 mcg/L |
MI Case Study
Case Study Questions
1. What are the risk factors for myocardial infarction? What risk factors are specific to Mr. Campbell (discuss both modifiable and non modifiable risk factors)? (4 marks)
2. What are the nursing priorities and interventions for a patient diagnosed with STEMI? Please ensure that you relate the priorities to Mr. Campbell`s situation. Include the following in your discussion and the rationale for each priority/intervention. Please use the following table for criteria below. You may use bullet points (20 marks).
a. Patient assessment (head-to-toe)
b. Medications
c. Laboratory and Diagnostic Tests
d. Medical and Nursing Interventions
e. Patient Teaching
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Criteria |
Priorities |
Rationale |
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a. Patient Assessment |
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b. Medications |
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c. Lab and Diagnostic Tests |
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|
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d. Medical and Nursing Interventions |
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|
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e. Patient Teaching |
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3. Interpret the following cardiac rhythm using the 8 step systematic approach for cardiac rhythm interpretation (8 marks).
4. Interpret the following ECG using the 8 step systematic approach for ECGs interpretation (rhythm, axis, R wave progression/transition, voltage, BBB, hypertrophy, location and stage) (8 marks).
5. Discuss percutaneous coronary intervention and reperfusion drugs, including the eligibility/exclusion criteria for fibrinolytic therapy. Explore the appropriateness of each for Mr. Campbell. (4 marks)
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Solution
MI Case Study: Cardiac Knowledge
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On Arrival to the Emergency Department Mr. Denzel Campbell is a 48-year-old, (260 lb) male that began having chest discomfort at home approximately one hour ago. The chest discomfort was unrelieved by sublingual nitro sprays. Hi wife immediately drove him to the Emergency Department where he presented with `pressure` midsternally that radiated down his left arm and through to his back. On admission Mr. Campbell was pale, diaphoretic and SOB. He denied nausea or vomiting. Further questions revealed that over the last few weeks, he has been having frequent episodes of chest discomfort upon exertion that was relieved by rest. Past Medical History Mr. Campbell has a history of diabetes mellitus that is controlled by diet. He reports smoking two packs of cigarettes daily for 30 years. His father died of lung cancer two years ago. His mother, who has hypertension, lives with him, and his wife and their two teenage sons. On assessment, Mr. Campbell has normal S1 and S2. Lungs are clear. No edema is present and bowel sounds are normal. No jugular venous distension is noted. Vital Signs T: 36.9 HR: 94 bpm/regular RR: 30 breaths/minute BP: 140/98 Sa02: 92 % with 2L 02 via nasal cannula Blood work was drawn and an ECG done. Mr. Campbell was diagnosed with an ST segment elevation MI (STEMI). Labs ▪ Hg 149 g/L ▪ WBC 8 x109/L ▪ Glucose 9.5 mmol/L ▪ K+ 3.7 mmol/L ▪ Troponin I 5.8 mcg/L |
MI Case Study
Case Study Questions
1. What are the risk factors for myocardial infarction? What risk factors are specific to Mr. Campbell (discuss both modifiable and non modifiable risk factors)? (4 marks)
Risk factors for myocardial infarction
These are factors that accelerate the unwanted buildup of atherosclerosis, narrowing the blood throughout Mr. Campbell’s body.
The risk factors specific to Mr. Campbell case include are:
i. Age: older adults especially age 45 years and 55 years for men and women respectively, have increased possibility of contracting MI than younger men and women (non-modifiable factor).
ii. Diabetes mellitus which results to insufficient production of insulin causing the blood sugar levels to increase (modifiable factor).
iii. Active cigarette smoking has increased risk of inferior wall acute MI (modifiable factor).
iv. Overweight which is associated with elevated cholesterol, triglyceride, and blood levels (modifiable factor).
Other general risk factors to MI patients include:
1. High blood pressure which damages arteries circulating blood to the heart.
2. High triglyceride levels
3. Metabolic syndrome
4. Family history of MI
5. Insufficient physical activity accelerates increased blood cholesterol levels and obesity, thus increasing the risk of MI
6. Autoimmune condition such as rheumatoid arthritis or lupus.
2. What are the nursing priorities and interventions for a patient diagnosed with STEMI? Please ensure that you relate the priorities to Mr. Campbell`s situation. Include the following in your discussion and the rationale for each priority/intervention. Please use the following table for criteria below. You may use bullet points (20 marks).
a. Patient assessment (head-to-toe)
b. Medications
c. Laboratory and Diagnostic Tests
d. Medical and Nursing Interventions
e. Patient Teaching
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Criteria |
Priorities |
Rationale |
|
a. Patient Assessment
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Pain assessment, vital signs, and 12-lead ECG performance |
Focuses on capturing characteristics of Mr. Campbell’s pain using PQRST mnemonic whereby the patient is asked what provokes the pain, the quality of pain (dull, sharp, stabbing), pain radiation, pain severity, and the time and triggering pain factors. These elements together with clear communication will assist RRT to deliver quick care and advocate for Mr. Campbell’s need for cardiac catheterization and PCI for STEMI. Obtained in within the first 10 minutes on arrival at ER, the 12-lead ECG will help determine the if Mr. Campbell has a history of syncope or palpitations, monitor an effect of a medication, evidence of MI, and determine ICD functioning |
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b. Medications |
· Anticoagulation agents such as unfractionated heparin, bivalirudin, decreased molecular heparin (enoxaparin) · Antiplatelet agents such as empiric loading dose of aspirin prior to perfusion (160-325 mg dose). Afterwards, a continuous dosage of 75 to 81 mg daily should be described to Mr. Campbell after STEMI. · Sublingual nitroglycerin at a recommendable dose of 0.4 mg until pain subsides · Low molecular weight heparin such as enoxaparin sodium at a recommendable dosage of 1 mg/kg SC q12 hours (Medscape, 2021). |
· Anticoagulant agents are significant adjunctive therapy for reperfusion therapy regardless of whether it is primary percutaneous intervention or fibrinolysis therapy (Medscape, 2021) · Antiplatelet agents will advantageously reduce the adverse ischemic incidents enhancing the effects of platelet activation and aggregation (Medscape, 2021). · Sublingual nitroglycerin will help relief pain and coronary artery dilation · To reduce the complications of STEMI |
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c. Lab and Diagnostic Tests |
· Cardiac Troponin I · Serial testing |
· The necessity of troponin is based n establishing MI diagnosis n a clinical setting with ischemia (RCPA manual, n.d.). · To confirm or exclude an increase of decrease of troponin concentration. |
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d. Medical and Nursing Interventions |
· Begin and I.V and place Mr. Campbell on a heart monitor and pulse oximeter · Supplying oxygen to maintain saturation levels ab above 90% · Encouraging bedrest with elevated back rest · Encouraging change of positions frequently · Frequent checking of skin temperature and peripheral pulses. · Close monitoring of patients for changes in heart rate and rhythm, heart sounds, blood pressure and lab values. |
· Assist symptoms’ relief · Bed rest assist in decreasing chest discomfort and dyspnea. · Change of positions help in keeping fluid from pooling in the lungs’ bases. Monitoring tissue perfusion |
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e. Patient Teaching |
· Simplicity and conciseness of initial information that focuses on what to expect. · Educate Mr. Campbell and his family about the thrombolytic agents “clot-buster” and PCI. · Emotional support and relieve anxiety · Verbal and written instructions about smoking cessations, medications, exercise and day-to-day activities, and dietary alteration. |
· The nurses must explain that thrombolytic agents “thin the blood” and may cause hemorrhage complications. · Relieving patient anxiety will help in explaining what happened. Instructions help in assessing whether the patient has necessary resources to get medications or if he may be given a social worker to be able to assist him. |
3. Interpret the following cardiac rhythm using the 8 step systematic approach for cardiac rhythm interpretation (8 marks).
(Image)
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Rhythm |
regular rhythm |
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Heart Rate |
300/4=75bpm |
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P wave evaluation |
sinus |
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PR interval duration |
0.12-0.20 sec |
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QRS complex |
Narrow |
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P-QRS |
Av association |
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QT interval duration |
400ms |
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Axis |
normal |
4. Interpret the following ECG using the 8 step systematic approach for ECGs interpretation (rhythm, axis, R wave progression/transition, voltage, BBB, hypertrophy, location and stage) (8 marks).
(Image)
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Rhythm |
Irregular |
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axis |
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R wave progression |
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voltage |
1mV |
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BBB |
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Hypertrophy |
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Location |
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Stage |
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5. Discuss percutaneous coronary intervention and reperfusion drugs, including the eligibility/exclusion criteria for fibrinolytic therapy. Explore the appropriateness of each for Mr. Campbell. (4 marks)
Percutaneous coronary intervention (PCI) involves a minimally invasive procedures’ family utilized in opening clogged coronary arteries without fibrinolytic treatment, resorting blood flow hence improving the blocked arteries’ symptoms such as chest pain, while reperfusion drugs are thrombolytics and fibrinolytics responsible for thrombolysis process.
PCI is the preferred reperfusion approach in STEMI patients, and achieves greater reperfusion results and is linked with decreased complication, death and STEMI’s long-term complications in comparison to fibrinolytic therapy. The recommended guidelines advices performing primary PCI in patients that presents with symptoms of less than a duration of 12-hours. Pharmacologic reperfusion should be performed to Mr. Campbell due to his STEMI’s clinical presentation occurred within 12 hours of system onset and his ST-segment elevation is persistent (Medscape, 2021).
In order to reach for a decision of fibrinolytic therapy administration, the patient must be rapidly assessed for the time for symptoms’ onset, complications risk related to STEMI, bleeding risks with fibrinolysis therapy, severe heart failure, and time needed for transfer to PCI-capable hospital. As such, based on these elements, fibrinolytic therapy cannot be administered to Mr. Campbell (Medscape, 2021).
References
Medscape. (2021, October 17). Myocardial infarction treatment & management: Approach considerations, prehospital care and initial management, emergency department care and in-hospital management. Diseases & Conditions - Medscape Reference. Retrieved April 7, 2022, from https://emedicine.medscape.com/article/155919-treatment#d25
RCPA manual. (n.d.). Myocardial infarction. RCPA. Retrieved April 7, 2022, from https://www.rcpa.edu.au/Manuals/RCPA-Manual/Clinical-Problems/M/Myocardial-infarction
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