Concept Mapping Myocardial Infarction Patient Case Study Assignment From the following case study, do a care plan and following the rubric 1 Concept Mappin

Concept Mapping Myocardial Infarction Patient Case Study Assignment From the following case study, do a care plan and following the rubric 1
Concept Mapping/Care Plan
The Concept Mapping assignment is worth 100 points and 10% of your NURS 411 grade.
Submit this grading tool with your Concept Map.
Criteria
Admissions Assessment
a. Included primary and secondary medical diagnoses
b. Included definitions for primary and secondary
Medical diagnoses
c. Included nursing assessment data: physiological,
spiritual psychological, developmental, and socio-cultural.
Pathophysiology, Lab & Diagnostic
a. Discussed the pathophysiology r/t medical
diagnosis
b. Identified significant lab and diagnostic data
and their interpretation as it relates to the client
Possible Grade Comments
Points
10 points
10 points _____
Nursing Diagnosis
20 points
a. Identified at least 3 problems based on assessment data
b. Prioritized Nursing diagnoses based on Maslow’s Hierarchy
of Needs, and ABC’s (airway, breathing, circulation)
c. All three parts of the nursing diagnoses are appropriate
Planning
a. Goals are appropriate (2)
b. Outcomes are measurable (6))
c. Outcomes are specific and relate to the nursing diagnoses
_____
20 points
_____
_____
Nursing Interventions
20 points _____
a. Therapeutic interventions reflect: (5)
1. cultural congruence
2. therapeutic communication
3. ethical consideration
4. legal standards
5. caring and concern
b. Nursing interventions are stated as dependent,
independent, or collaborative
c. Rationales are listed for nursing interventions.
(text & journal articles)
Evaluation
20 points _____
a. Describes clients response to nursing interventions
b. States the extent to which each outcome has been obtained
c. Determines the extent to which overall goals have been met
d. Reflects current data collected by the student.
2
3
Concept Map
Physiologic
Primary Medical Diagnosis:
Neurologic
Secondary Medical Diagnosis:
Cardiovascular
Respiratory
Gastrointestinal
Risk Factors:
Urinary
Musculoskeletal
Integumentary
Reproductive
Pathophysiology:
Psychological
(If needed complete on
following page)
Development (Erickson’S)
Diagnostic Findings &
Laboratory Values:
Sociocultural
Spiritual
4
Physiologic
If more space is required, please use this box; instead of the box on page one.
General:
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
5
Pathophysiology
Primary diagnosis
Secondary Diagnosis
Pathophysiology
Prescribed medications at home:
Generic & trade name
& classification of medication
Dose/route
Frequency
Purpose
Medications ordered this hospitalization:
Generic & trade name
& classification of medication
Dose/route
Frequency
Reason administered
to this client
Effects of medication
on this client
Diagnostic studies:
Test & definition
Initial admission test results &
date performed
Significance of results
to client’s condition
Most recent test results (if test
repeated) & date performed
Significance of repeated test
results to client’s condition
Based on your assessment data and the chart above, identify as many problems (listed as
problems not medical nor nursing diagnosis) as possible.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Based on the problems you have listed, identify the top three problems, and prioritize them.
1.
2.
3.
Using the problem with the highest priority, identify an appropriate nursing diagnosis based on
NANDA and develop a careplan for your client.
Concept Map Tool for Care Planning
Goals & Outcomes:
#1Nursing Diagnosis:
Client’s Primary
Medical Dx:
Secondary Medical
Dx:
Evaluation:
Nursing Interventions (With Rationale):
Goals & Outcomes:
#2 Nursing Diagnosis:
Client’s Primary
Medical Dx:
Secondary Medical
Dx:
Evaluation:
Nursing Interventions (With Rationale):
# 3 Nursing Diagnosis:
Goals & Outcomes:
Client’s Primary
Medical Dx:
Secondary Medical
Dx:
Evaluation:
Nursing Interventions (With Rationale):
Due 26th
1
m
Percutaneous Transluminal Coronary
Angioplasty and Thrombolytic
Therapy in Myocardial Infarction
Alice Lowe, RN, BSN
Sheila Drake Melander, RN, DSN, ACNP-C, FCCM
1
1st care plan
CASE PRESENTATION
Mr. Johnson, a 54-year-old, began having chest pain 1 hour after supper, while he was at
work. He described the pain as a “grabbing pressure” located midsternally. He rated the pain
at “about 2” on a scale of 1 to 5. He stated that the pain radiated down his left arm and
through to his back. He was transported to the emergency department (ED) by ambulance.
On admission Mr. Johnson was pale and diaphoretic and complained of shortness of breath
(SOB). He denied nausea or vomiting. In the ED, unstable angina was diagnosed and tests
to rule out myocardial infarction (MI) were initiated. He had experienced chest pain for
1 hour upon arrival in the ED at 8:13 PM.
The patient reports no previous episodes of chest pain or pressure. He has smoked
two packs of cigarettes daily for 25 years. His mother died of Alzheimer’s disease, and his
father died of cancer. He has no family history of heart disease.
On initial examination the patient did not exhibit jugular venous distention, the
carotid arteries were 2+/4 without bruits, and the point of maximum impulse was located
at the fifth intercostal space, midclavicular line. Normal S? and S2 sounds were auscultated
with an S3 present. No S4 sound or murmurs were heard. There were vesicular lung sounds
with scattered wheezes, but no crackles were heard. No edema was present, and bowel
sounds were normal.
Diagnostic data at admission were as follows:
BP
140/90 mm Hg
Sa02 95% with oxygen 4 L/min
HR
92 bpm and regular per nasal cannula
Respirations 32 breaths/min
Height 173 cm
Temperature
36.9° C (98.5° F)
Weight 104 kg
The 12-lead electrocardiogram (ECG) findings at 8:15 PM were as follows:
Normal sinus rhythm (NSR) with frequent premature ventricular contractions (PVCs) and three-
to four-beat runs of ventricular tachycardia (VT)
ST-segment elevation in leads I, aVu, and V2 through V. (3 to 4 mm)
2
Chapter 1
Percutaneous Transluminal Coronary Angioplasty and Thrombolytic Therapy in Myocardial Infarction
3
.
Swella $irritation
of ethn saclice
ST-segment depression in leads III and av,
Q waves in V, through Vi
The chest x-ray film revealed slight cardiomegaly with mild congestive heart
failure (CHF).
The echocardiogram findings were as follows:
Trileaflet aortic valve with normal openings
Normal mitral configuration with normal opening of mitral valve diastole and normal
coaptation in systole
Normal right atrium and right ventricle
Thin layer pericardial effusion (mostly posterior)
Left ventricular ejection fraction 25% to 30%
Mild mitral valve regurgitation
Cardiac enzyme measurements were as follows at admission and on day 1:
Admission 2013 Admission 2400 Day 1 0400
CK (U/L)
254
7357
5638
CK-MB (%)
10
>300
>300
Troponin I (ng/ml)
3.5
>50
membiare
Surrondt a ?
>50
In the ED, Mr. Johnson’s chest pain was unrelieved after three sublingual nitro-
glycerin (NTG) tablets. Morphine sulfate 5 mg intravenous push (IVP) was administered,
resulting in a small decrease in pain.
After evaluation of the initial laboratory results, presenting symptoms, and the ECG,
the diagnosis was an extensive anterolateral MI. Mr. Johnson was assessed for contraindi-
cations to thrombolytic therapy. The patient was considered a candidate for thrombolytic
therapy, and administration of tissue plasminogen activator (tPA) was started immediately.
An NTG drip (50 mg/250 ml in 5% dextrose in water [D5W]) was started at 20 ug/
min (6 ml/hr). A heparin bolus of 8000 U was given, and a drip was begun at 10 ml/hr
(1000 U/hr). Metoprolol titrate (Lopressor) 5 mg IVP was given every 5 minutes three times
(total 15 mg) and an enteric-coated aspirin was administered. After the NTG and heparin
drips were started, the patient’s pain was relieved. He was then transferred to the coronary
intensive care unit (CICU).
In the CICU Mr. Johnson’s chest pain returned. He rated it as 4 on a scale of 1 to
5. His blood pressure was 96/60 mm Hg, and he began having ST-segment elevations in the
anterior leads along with six- to eight-beat runs of VT. Three sublingual NTG tablets were
given, followed by 4 mg of morphine intravenously, but the pain did not decrease. Mr.
Johnson was sent to the catheterization laboratory for emergency angiography and possi-
ble angioplasty
The angiogram showed 90% blockage of the left anterior descending (LAD) artery.
An emergency rescue angioplasty (percutaneous transluminal coronary angioplasty (PTCA])
was performed, but the artery continued to reocclude, so a coronary stent was inserted.
While the PTCA was performed, 23,000 U of heparin and 500,000 U of urokinase were given
as an intracoronary injection. Mr. Johnson became hypotensive, tachycardic, pale, cool, and
diaphoretic. His arterial blood oxygen saturation (SaO2) dropped to 86%, and he was placed
on a mechanical ventilator with a 100% non-rebreather mask. He continued having runs
of VT; therefore a 100-mg bolus of lidocaine was given and a lidocaine drip (2 g/500 ml of
D5W) was started at 2 mg/min. A dopamine (Intropin) infusion was started at 2 ug/kg/min
and was gradually increased to 4 ug/kg/min. A dobutamine (Dobutrex) drip was started at
5 ug/kg/min. An abciximab (ReoPro) bolus of 0.25 mg/kg was administered followed by an
infusion at 21 ml/hr (which will continue for 12 hours). A pulmonary artery (Swan-Ganz)
catheter was placed to monitor for CHF and cardiogenic shock. An intraaortic balloon pump
(IABP) was inserted in the right groin to stabilize Mr. Johnson’s blood pressure (BP), decrease
the workload of the heart, and improve cardiac output. Upon return to the CICU,
Mr. Johnson was free of pain.
I cardiac
to
output
© 2004, 2001, 1996 Elsevier, Inc. All rights reserved.
UNITI
CARDIOVASCULAR ALTERATIONS
His vital signs and hemodynamic readings were as follows:
BP 133/59 mm Hg Map83
RAP
10 mm Hg
HR
90 bpm
PAS
42 mm Hg
SaO2
99% with 100% non-rebreather mask
PAD
22 mm Hg
ECG
NSR with occasional PVCs
MAP
31 mm Hg
PAWP
22 mm Hg
Findings from an ECG on the day of admission post-PTCA (11 PM) were as follows:
NSR, T wave inverted in aVR
ST segment elevated in leads I, a Vu, and V2 through Vo (1 to 2 mm)
Findings from an ECG on postadmission day 1 (6:50 AM) were as follows:
NSR, ST segment almost baseline
Q waves in V2 through Vo
Inverted T waves, leads V2 through Vo
aVRT waves now upright
Mr. Johnson’s lidocaine drip was discontinued the next day. The heparin drip was
discontinued and the arterial line, IABP, and pulmonary artery catheter were removed on
day 2. He was started on enoxaparin (Lovenox) 100 mg subcutaneously twice a day. On day
3 his dopamine, dobutamine, and NTG drip were tapered and discontinued. He was released
to the cardiac progressive step-down unit on day 4. On day 6 he was released to home. He
was instructed in outpatient cardiac rehabilitation, Smoking cessation, and a prudent heart
diet. He was sent home with prescriptions for diltiazem (Cardizem) 30 mg three times daily,
captopril (Capoten) 6.25 mg three times daily, ticlopidine (Ticlid) 250 mg twice daily, meto-
prolol (Lopressor) 25 mg twice daily, and NTG tablets as needed. Mr. Johnson was also
instructed to take an aspirin every day.
Chapter 1
Percutaneous Transluminal Coronary Angioplasty and Thrombolytic Therapy in Myocardial Infarction
Pecin
such as
cher getex Wocht lastest usually
monx
oronary
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY AND
THROMBOLYTIC THERAPY IN MYOCARDIAL INFARCTION
Angina pectoris is chest pour discomfort due to coronary
QUESTIONS
heart disease. occurs
Leat bloed as if needs, it
when the heart muscle doesn’t get
1. Describe angina pectoris and discuss the différence between chronic stable ah?iña, Instable Cischemia
angina, and Prinzmetal’s angina.
chronic stable Angina pecton’s is a
a forma chest pain that happens when your heart
is working hard and needs more & such as during exerce-pain goos wherg
you rest
Unstable
angina is ecther now chest pain ora change in
lemonaf releece rosto chest
& Prinzmetal’s angina occurs
person is at
Got midnight & eady ma
2. Define CAD and discuss associated risk factors.
CAD is the closing of the coro ertery
Risk factors) male sex, diabetes mellitus, & ripids locals, HTN,
Smoking, obesity, secondary lifestyle, high fat diet
3. Describe an acute myocardial infarction (AMI) and its effects on the heart and lifestyle.
Myocardia infat Angina (heart attack) occurs cohen the blood flow that
to
the heart musce is gecerely reduced or act off completely. This
bang
ad lead
to carrhythmia, bradycardia, tachycardia percarditis, Cardiogerie
Shock, centricular damage, threshbe enbolism
4. List the symptoms of an ami. Subjective data, anxiety feeling a imperdinig
doom, chest pain, nausea, dizziness.
Objective data pallor, and cool clannyskir tachycardia, heart palpitation,
diaphoresis, voniting
dekreas
consciousness
Ost
lecol
of co
5. What is the significance of the following heart sounds: S3, S4, and a murmur?
6. What do crackles auscultated during lung sound assessment signify?
atelectasis, pulmonar
disas, pulmon
nandy
edena
They sanchitis, ARAS, bronchiectasis inted, fibrosis,
hing
7. Discuss the use of cardiac enzymes and their normal values. What laboratory values would be
indicative of an AMI for Mr. Johnson?
water is
8. What is the significance of Mr. Johnson’s ST-segment changes? hos 7
inverted
© 2004, 2001, 1996 Elsevier, Inc. All rights reserved.
UNITI
CARDIOVASCULAR ALTERATIONS
9. Why was an echocardiogram done?
10. What are the desired pharmacologic effects of NTG?
dilates the heart, ak, relaxes
11. Why was Mr. Johnson given an aspirin in the ED? Explain the use of abciximab (ReoPro),
ticlopidine (Ticlid), and aspirin therapy for Mr. Johnson.
12. Discuss the pharmacologic actions of heparin and enoxaparin (Lovenox) and the indications
for use with a patient with an AMI.
13. Discuss the pharmacologic effects of morphine.
14. Describe what a B-blocker is and the rationale for Mr. Johnson receiving this medication.
15. Why was Mr. Johnson given lidocaine?
16. EPA is a thrombolytic agent. Discuss the effects of a thrombolytic agent and why it was used
for Mr. Johnson initially rather than angioplasty.
© 2004, 2001, 1996 Elsevier, Inc. All rights reserved.
Chapter 1
Percutaneous Transluminal Coronary Angioplasty and Thrombolytic Therapy in Myocardial Infarction
Pecin
such as
cher getex Wocht lastest usually
monx
oronary
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY AND
THROMBOLYTIC THERAPY IN MYOCARDIAL INFARCTION
Angina pectoris is chest pour discomfort due to coronary
QUESTIONS
heart disease. occurs
Leat bloed as if needs, it
when the heart muscle doesn’t get
1. Describe angina pectoris and discuss the différence between chronic stable ah?iña, Instable Cischemia
angina, and Prinzmetal’s angina.
chronic stable Angina pecton’s is a
a forma chest pain that happens when your heart
is working hard and needs more & such as during exerce-pain goos wherg
you rest
Unstable
angina is ecther now chest pain ora change in
lemonaf releece rosto chest
& Prinzmetal’s angina occurs
person is at
Got midnight & eady ma
2. Define CAD and discuss associated risk factors.
CAD is the closing of the coro ertery
Risk factors) male sex, diabetes mellitus, & ripids locals, HTN,
Smoking, obesity, secondary lifestyle, high fat diet
3. Describe an acute myocardial infarction (AMI) and its effects on the heart and lifestyle.
Myocardia infat Angina (heart attack) occurs cohen the blood flow that
to
the heart musce is gecerely reduced or act off completely. This
bang
ad lead
to carrhythmia, bradycardia, tachycardia percarditis, Cardiogerie
Shock, centricular damage, threshbe enbolism
4. List the symptoms of an ami. Subjective data, anxiety feeling a imperdinig
doom, chest pain, nausea, dizziness.
Objective data pallor, and cool clannyskir tachycardia, heart palpitation,
diaphoresis, voniting
dekreas
consciousness
Ost
lecol
of co
5. What is the significance of the following heart sounds: S3, S4, and a murmur?
6. What do crackles auscultated during lung sound assessment signify?
atelectasis, pulmonar
disas, pulmon
nandy
edena
They sanchitis, ARAS, bronchiectasis inted, fibrosis,
hing
7. Discuss the use of cardiac enzymes and their normal values. What laboratory values would be
indicative of an AMI for Mr. Johnson?
water is
8. What is the significance of Mr. Johnson’s ST-segment changes? hos 7
inverted
© 2004, 2001, 1996 Elsevier, Inc. All rights reserved.

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