Medical Case Study

Mr. D.M, 51 years old, was rushed to the emergency room complaining of chest pain, weakness, and fatigue. His chest pain was pleuritic in nature, worsening with movement and deep breathing. When he was motionless, the pain completely resolved. There was a family history of hypertension in both father and mother side. His sister had hypercholesterolemia. Mr. D.M is a known alcoholic for the past 25 years. He is a construction engineer and he usually works 12 hours a day. One month prior to admission he experienced shortness of breath, and palpitaitons but did not seek medical attention.

Patient’s status upon admission:
Tempearture : 37.8 C
Pulse rate: 112
Respiratory: 12 breaths per minute
BP: 158/115
Physician’s orders:
2gm sodium, low- cholesterol diet
Supplemental Oxygen at 2L/ min prn; pulse oximeter 90% or less
Saline lock IV and flush every shift
Mr. D.M was transferred to cardiology progressive care unit. Upon assessment patient complains of nausea and vomiting, and excessive sweating.

Medications:
1. Nitroglycerine 0.4mg SL q 5 min prn for chest pain. Not to exceed 3 doses in one hour; hold for systolic BP less than 90 mmHg.
2. ASA 81mg, 2tablets, to be chewed on admission. Then give enteric coated ASA 325mg PO daily. Hold ASA if patient is actively bleeding or allergic to ASA.
3. Metoprolol 12.5mg PO now then BID
4. Clopidogrel 75mg daily
5. Atorvastatin 10mg PO at bedtime
6. Ramipril 2.5mg PO daily
7. Metoclopramide hydrochloride 10mg IV q 6 hours prn for nausea
8. Acetaminophen 1g PO q 4 hours prn for pain or temperature greater than 101 F. Call physician for temperature greater than 101 F.
9. Milk of Magnesia 30ml PO q 12 hours prn for constipation
Laboratory orders:
1. Draw CPK and troponin I as follows: Run from admission blood if not done earlier, then q 8hrs x 2 for a total of 3 sets of CPK’s/ Tropnin I
2. CBC, Basic Metabolic Panel, PT, PTT
3. U/A
4. CXR (upright portable)
5. EKG
6. Stat EKG prn for chest pain
7. Fasting Lipid Profile

Additional physician orders:
Monitor Vital Signs every 4 hours
Monitor Intake and ouptut
Bed rest
Bleeding precaution

Mr. D.M EKG result. 12 Lead ECG EKG showing ST Elevation (STEMI), Tachycardia, Anterior Fascicular Block, Anterior Infarct, Heart Attack. Color Key: ST Elevation in anterior leads=Orange, ST Depression in inferior leads=Blue

Care Plan:
Maintain IV as ordered
Continuous cardiac monitoring
Provide smoking cessation counseling
Assess pain and give an analgesic as ordered.
Record the severity of pain, location, type, and duration of pain.
Check the patient’s blood pressure before and after giving nitroglycerin, especially the first dose.
Frequently monitor ECG rhythm strips to detect rate changes and arrhythmias. if any new arrhythmias are documented, if chest pain occurs, or at least every shift change or according to facility protocol
Watch for crackles, cough, tachypnea, and edema, which may indicate impending left-sided heart failure.
Monitor daily weight, intake and output, respiratory rate, serum enzyme levels, ECG readings, and blood pressure.
Organize patient care and activities to maximize periods of uninterrupted rest.
Provide a clear liquid diet dietary until nausea subsides. A low-cholesterol, low-sodium diet, without caffeine-containing beverages, may be ordered.
Provide a stool softener to prevent straining during defecation, which causes vagal stimulation and may slow heart rate.
Allow the patient to use a bedside commode, and provide as much privacy as possible.
Assist with ROM exercises.
Provide quiet environment, calm activities
Provide comfort measures (e.g Back rub, change of position)
Reference:
Nurse’s Pocket Guide 10th Edition, Marilynn E. Doenges, Mary Frances Moorhouse,
Alice C. Murr
Nursing Care Plans for Myocardial Infarction (MI) by lifenurses.com

Ethical principles used:
1.moral code and moral justification to guide the physician in his actions.
2. nurse/doctor-patient relationship. Essential to this relationship is the element of trust. The patient trusts the physician to counsel him to make the right decision regarding his care, to ensure his privacy, and to be a patient advocate.
3. patient autonomy. Individual self-determination is highly valued in our American tradition, and rightly so. Patients should have the right to accept or refuse treatment, or allow the natural course of events to take place. It is important to remember that one must respect autonomy as long as we live in harmony with the first principle of our moral law and the sanctity of life.
4. beneficence, or the act of helping others. Beneficence refers to the traditional role of the nurse as the Good Samaritan.
5. nonmalificence. Nonmaleficence is the warning, “Never do harm to anyone.” The nurse must evaluate whether any particular treatment or procedure is clinically indicated, and whether the procedure will provide benefit or undue burden to the patient.