CPC306 Complex Care
Question:
Presenting history
Michael presented to the ED in a personal car, after waking today at 0630 (it is now 0740) with central “crushing” chest pain, which was unresolved with coughing. States also experienced sweating and nausea. Over the last week had episodes of shortness of breath at rest. In A&E.
12 lead ECG shows elevated ST segments in leads II, III and AVF, V5 and V6 suggesting a ST elevated (inferior) myocardial infarction Aspirin 300mg orally STAT
Observations:
T 37.2oC
P 88 bpm
R 20 bpm
BP 145/90mmHg
Blood samples:
Urea and Electrolytes – WNL
Full Blood Count -WNL
Troponin I 3.98 µg/L (normal <0.03 µg/L)
Management
Seen by the cardiac care team who diagnosed an Acute STEMI – Inferior
Based on ECG and elevated troponin and > 2.5 hours since onset of chest pain, commence
antiplatelet therapy (copy of document provided in Appendix 1), beta blockers and statins.
Coronary angiogram
Echocardiogram
O2 therapy to keep SpO2 >93%
Admission to Coronary Care Unit.
Serial ECGs
Serial troponin’s (National Heart Foundation of Australia, 2016). Normal diet and fluids as tolerated.
Fluid balance chart – monitor input and output.
Toilet privileges
Medications
Oral Aspirin 150mg daily
Oral Clopidogrel 300mg
Oral Ramipril 5mg Daily
Oral Simvastatin 40mg
Oral Metoprolol 50mg Daily
SL GTN spray for episodes of chest pain
IV Morphine 1 – 2mg if pain persists
Acute Coronary Syndrome Clinical Pathway commenced (copy provided in Appendix 2).
O/A to coronary care ward – Nursing assessment:
Airway patent
Breathing – normal, RR 20 bpm
Circulation – HR 88 BP 130/75mmHg, Peripheral circulation CAP< 2 secs, hands and feet warm and pink. Connected to cardiac monitor. In Sinus Rhythm, intermittent ectopic beats.
Neurological – Conscious and cooperative. Pain 1/10 and dull ache in centre of chest. No radiation, constant pain.
Respiratory – RR as above. Auscultation bilateral AE, Equal. Symmetrical chest expansion, nil changes on percussion or palpation. GIT – Remains nauseous, bowels opened 1/7 ago.
Abdomen soft. Normal BS.
GIT – Normal urine flow, last voided down in A&E. Abdomen soft, bladder not distended.
Requires a UA.
Skin – warm, dry and intact.
Vision – wears glasses for reading only.
Hearing – no difficulties.
Observations – T. 37.2 0C, HR 80 bpm, RR 18 bpm, BP 140/70 mmHg. SaO2 – 92% of RA
Social – Carer for elderly father, other family members are away. Work related
responsibilities – exam preparation for undergraduate courses. Has not informed children or ex-wife of admission to hospital. Limited other social supports. Lives at home alone with two cats. Car in hospital car park.
Psychological – anxious about impact a heart attack will have on his career and future and ability to earn money to support the family.
Spiritual – Active member of the local Greek orthodox church.
