Rule Out Myocardial Infarction
Scenario:
The time is 1900 hours. You are working in a small, rural hospital. It has been snowing heavily
all day, and the medical helicopters at the large regional medical center, 4 hours away by car (in
good weather), have been grounded by the weather until morning. The roads are barely passable.
W.R., a 48-year-old construction worker with a 36-pack-year smoking history, is admitted to
your floor with a diagnosis of rule out myocardial infarction (R/O MI). He has significant malepattern obesity (“beer belly,” large waist circumference) and a barrel chest, and he reports a
dietary history of high-fat food. His wife brought him to the emergency department (ED) after he
complained of (C/O) unrelieved “indigestion.” His admission vital signs (VS) were 202/124, 96,
18, and 98.2° F. W.R. was put on oxygen (O2) by nasal cannula (NC) titrated to maintain SaO2
(arterial oxygen saturation) over 90% and an IV of nitroglycerin (NTG) was started in the ED.
He was also given aspirin 325 mg and was admitted to Dr. A.’s service. There are plans to
transfer him by helicopter to the regional medical center for a cardiac catheterization in the
morning when the weather clears. Meanwhile you have to deal with limited laboratory and
pharmacy resources. The minute W.R. comes through the door of your unit, he announces he’s
just fine in a loud and angry voice and demands a cigarette.
1. From the perspective of basic human needs, what is the
first priority in his care? (Kara)
Maslow’s hierarchy of needs indicates that physiological
needs are priority. For W.R., this would include his oxygen
saturation, blood pressure and his unrelieved “indigestion”
pain. (Potter 43)
2. Are these VS reasonable for a man his age? If not, which one(s) concern(s) you? Explain
why or why not? (Jill)
Some of the vital signs are not normal for a man his age. The ones I am especially concerned
with are the blood pressure (202/124) and needing oxygen to obtain a saturation over 90%. The
pulse is on the higher end (96 bpm), but it may be because he is agitated or anxious. Respirations
and temperature are within normal limits. The blood pressure is concerning because a normal
blood pressure is 120/80. Blood pressure changes in the event of the cardiac cycle, and a high
blood pressure (smoking and eating unhealthily) while having chest pain would leave me to
believe it is a possible MI. I am also concerned about the 90% because if he is at home and on
the job, smoking, etc. he is not getting the correct amount of oxygen his body needs circulating
throughout his blood. (Jarvis 121)
3. Identify five priority problems associated with the care of a patient like W.R. (Hoda)
Lifestyle: 36 pack year smoking history (O2 sat/blood pressure), high fat diet, high stress work
environment, barrell chest (copd), and obesity.
4. Which of the following laboratory tests might be ordered to investigate W.R.’s
condition? If the order is appropriate, place an “A” in the space provided. If inappropriate,
mark with an “I,” and provide rationales for your decisions. (Hoda)/(Jenna)
1. CBC - A
2. EEG in the morning - I
An EEG is a test that tracts brain wave patterns. This type of test
would not reveal any information about a possible MI.
3. Chem 7 (electrolytes) - A
4. PT/PTT - A
5. Bilirubin every morning - I
Bilirubin testing reflects the health of the liver. While studies
do show that liver congestion due to an increase of central venous pressure may possibly cause
elevations of serum bilirubin, recurrent testing every morning would not confirm a MI.
(Alvarez & Mukherjee, 2011).
6. Urinalysis (UA) - I
While there is a list of things you can tell from testing a person’s urine,
especially the health of the kidneys and bladder, a myocardial infarction in not something on that
list.
7. STAT 12-lead ECG - A
8. Type and crossmatch (T&C) for 4 units packed RBCs (PRBCs) - A
5. What significant lab tests are missing from the previous list? (Hoda)
● Cardiac biomarkers/enzymes
● Troponin levels
● Creatine kinase (CK) levels: CK-MB levels increase within 3-12 hours of the onset of
chest pain, reach peak values within 24 hours, and return to baseline after 48-72 hours
● Myoglobin levels: Myoglobin is released more rapidly from infarcted myocardium than
is troponin; urine myoglobin levels rise within 1-4 hours from the onset of chest pain
● Lipid profile
● C-reactive protein (CRP) and other inflammation markers
6. How are you going to respond to W.R.’s angry demands for a cigarette? He also
demands something for his “heartburn.” How will you respond? (Jenna)
I would explain to W.R. that while I understand he is frustrated and would like a cigarette, the
hospital is a smoke-free facility. Also, with his O2 stats being where they are, smoking would
furthermore decrease the much needed oxygen in his body. Not to mention, smoking near
oxygen is very dangerous. I would also offer to speak to Dr. A about getting a nicotine patch to
help with his cravings. I do not believe that now would be an appropriate time to talk about
smoking cessation since he is angry and it probably wouldn’t do any good.
As far as his “heartburn” goes, I would calmly and in layman’s terms explain the severity of the
situation. I would explain that even though it feels like indigestion, a tums will not fix it. I will
tell D.W. that I will contact Dr. A. right away to see about a getting an order for an analgesic for
the pain.
CASE STUDY PROGRESSES: You phone Dr. A.’s partner, who is “on call.” She prescribes
morphine sulfate 4 to 10 mg IV push (IVP) q1h prn for pain (burning, pressure, angina).
7. Explain two reasons for this order. (Hoda)
Pain from MI is often intense and requires prompt and adequate analgesia. The agent of choice is
morphine sulfate. Reduction in myocardial ischemia also serves to reduce pain, so oxygen
therapy, nitrates, and beta blockers remain the mainstay of therapy. It is important to consider
that morphine can mask ongoing ischemic symptoms, it should be reserved for patients being
sent for coronary angiography.
8. What special precautions should you follow when administering morphine sulfate IVP?
(Kara)
● Push med slow and monitor patient for respiratory depression.
● Administer 1 mg/minute
● Assess BP, Pulse, RR, LOC during administration.
(Lilley 83)
9. Angina is not always experienced as “pain” (as many people understand pain). How
would you describe symptoms you want him to warn you about? Why is this important?
(Jill)
I would tell W.R. to let me know if he has chest discomfort that radiates down his left arm, pain
or discomfort in his jaw, shoulder, abdomen, or back, palpitations, shortness of breath, anxiety,
dizziness, etc. This is extremely important because it could mean that he is going to have an MI.
(Chard 696)
10. What safety measures or instructions would you give W.R. before you leave his room?
(Kara)
Safety measures to include for W.R. would include keeping his side rails up, bed should be in the
lowest position, having his call light within reach. Instructing him to change positions slowly to
prevent orthostatic hypotension. Instruct W.R. to call if he needs to use the washroom and to not
get up without assistance. Instruct W.R. to call if he is having any of the symptoms listed above
in #9.
11. One of the housekeeping staff asks you, “If the poor guy can’t smoke, why can’t you
give him one of those nicotine patches?” How will you respond? (Kara)
Unfortunately, due to HIPPA laws, I can’t discuss his plan of care with you.
12. If the patch were to be used later to help him quit smoking, how would it be dosed for
him? (Kara)
If W.R. were to use a nicotine patch, such as Nicoderm CQ, he would use a schedule that
tapers the dose of nicotine. This ultimately weans him off of the drug. If W.R. smokes greater
than 10 cigarettes per day, he would begin by applying one 21 mg patch transdermally daily for
weeks 1-6, then one 14 mg patch daily for weeks 7-8, and then one 7 mg patch daily for weeks 910.
If W.R. smokes less than 10 cigarettes per day, he would begin by applying one 14 mg
patch transdermally daily for 6 weeks, then one 7 mg patch daily for 2 weeks. (Micromedex)
13. Before leaving for the night, Mrs. R. approaches you and asks, “Did my husband have a
heart attack? I’m really scared. His father died of one when he was 51.” How are you going
to respond to her question? (Jenna)
I would acknowledge Mrs. R.’s fears and concerns, and explain to her that we are running
various tests to verify if W.R. has in fact had a heart attack or not. At this time we cannot
confirm a heart attack diagnosis but we will know more once the test results come back.
14. When you come into W.R.’s room at 2200 hours to answer his call light, you see he is
holding his left arm and complains of aching in his left shoulder and arm. What
information are you going to gather? What questions will you ask him? (Jenna)
I will gather vitals, primarily blood pressure, heart rate, and O2 stat. If possible, I would also
place W.R. on a cardiac monitor and obtain an EKG (look for ST elevation). Also, have
someone bring an AED close by.
I would ask W.R.:
● to fully describe the pain, including the location, intensity (1-10 scale), duration, and
characteristics (dull, pressure, crushing, burning).
● if he is having any difficulty breathing?
● if he is feeling lightheaded?
● if he is feeling nauseous?
15. Based on your assessment findings, you decide to call the physician. What information
are you going to report to the physician, and why? Use SBAR. (Jenna)
Hello Dr. A., this is Jenna, the nurse here in room 10 with Mr. W.R. W. is a 48-year-old who
was admitted at 1900 this evening to rule out a MI after coming into the ER with complaints of
unrelieved indigestion. Upon admission, BP was 202/124. Heart rate, temp, and respirations
were WNL. O2 by nasal cannula was started to maintain SaO2 over 90%. Nitroglycerin IV was
started in the ED as well as aspirin 325mg. He was last given __mg of morphine IV push at
___time. W. began feeling pain in his left arm and shoulder about 10 minutes ago. I assessed
him personally and his current vitals are___. He is on __L of O2. Most recent EKG shows___.
W. is alert & oriented but is visibly anxious. We are still waiting on the lab results from earlier.
He appears that W. is experiencing a MI. How do you recommend we proceed until we are able
to transfer him to the regional medical center for a cardiac catheterization in the morning?
CASE STUDY PROGRESSES: In the morning W.R. is transferred by chopper to the medical
center, and a cardiac catheterization is performed. It is determined that W.R. has coronary artery
disease (CAD). The cardiologist suggests it would be best to treat him medically for now, with
follow-up (F/U) counseling on risk factor modification, especially smoking cessation. He is
discharged with a referral for an F/U visit to his local internist in 1 week.
16. What does it mean to treat him “medically” (conservatively)? What other approaches
may be used to treat CAD? (Jill)
The doctor means treat his symptoms he is having now and stabilize him when he says
“medically.” We are worried about the patient’s physical condition right now. Later on, when his
chest pain and vital signs are stabilized, we can move into patient teaching and lifestyle
modifications. By lifestyle modifications, I mean such as quitting smoking, eating healthier,
losing weight, etc. (Dechant 832)
17. What personality characteristic do you observe in W.R. that places him at high risk for
CAD? (Jill)
A personality characteristic that I observe in W.R. that places him at high risk for CAD is his
unhealthy lifestyle choices. He has a 36 pack year smoking history, eats poorly, and is obese.
Even upon entering the unit the client stated angrily that he needed a cigarette. This gives me the
idea that he is in denial of his poor health and will continue to pursue unhealthy lifestyle choices
that may eventually lead to coronary artery disease. (Dechant 832)
18. What follow up care is needed for him post discharge? (Kara)
Follow up care that would be indicated for W.R would include:
●
Cardiac Rehab- this can help with:
○ Exercise planning
○ Reducing risk factors
○ Dealing with stress, anxiety and depression
● Dietitian: to help with healthy food choices.
● Home health nurse- build a therapeutic relationship to educate the patient and
● Family counseling: to help everyone understand his risks and to discuss enabling
behaviors. By cooking poor food choices, the family is enabling.
● Regular Doctor appointments to ensure W.R. is taking his prescribed medications
(Ignatavicius 840)
References
Alvarez, A., & Mukherjee, D. (2011). Liver abnormalities in cardiac diseases and heart failure.
International Journal of Angiology, 20(3). http://dx.doi.org/10.1055/s-0031-1284434
Ignatavicius, D. D., Workman, L. M., & Dechant, L. M. (2013). Medical-surgical nursing:
Patient-centered collaborative care (7th ed.). St. Louis: Elsevier Saunders.
Jarvis, C. (2012). Physical Examination & Health Assessment (6th ed.). St. Louis, Mo.:
Elsevier/Saunders.
Lilley, Linda L., Shelly Collins, Julie Snyder. (2013). Pharmacology and the Nursing Process.
(7th ed). St. Louis: Elsevier Saunders.
Nicoderm CQ. Truven Health Analytics. (2016). Retrieved September 3, 2016, from
http://www.micromedexsolutions.com.
Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. (2013). Fundamentals of Nursing (8th
ed) .St. Louis: Elsevier Saunders.
2330 Rubric for Online Group Assignment
Criteria
1
Collaboration
Consistently adheres to group
timeline in posting input.
Information given is supported by
valid evidence and cites source
Critical
Member provides consistent, and
evaluation of
substantial critical input as the
project as it
project evolves
develops.
Organization
The end product is organized and
0
and
flows well
presentation
Engagment
Use of at least 2 online tools
(Pinterest, Facebook, YouTube) to
engage whole group in assignment
Grammar and
Assignment is free of grammatical
citing sources
errors and has a professional
of information
presentation
ENGAGEMENT: I found a few things on pinterest.