ASSESSMENT 2 CASE STUDY /A 12 lead ECG was taken at her home and data transmitted to a doctor in the Emergency Department.Mrs. Grace Kelly, a 69 year old recently retired bank chief executive officer is admitted via ambulance at 13.00 hours to the Emergency Department, accompanied by her husband. She experienced severe chest pain that radiated to her neck, jaw, and left arm, which started about 12.15 hours. The pain was accompanied by shortness of breath and sweating.
On arrival to the Emergency Department Mrs. Kelly is alert and tells you that she had experienced pain after returning home from her retirement dinner the previous evening. She has held senior management positions in the bank for 35 years. She described that pain as more of a burning, aching discomfort in her epigastrium, shoulders and back and thought it was indigestion and so took antacids. This pain continued all night and she felt it was a consequence of the evening’s celebration. However, when it became more intense and she became anxious and restless, her husband called the ambulance.
Report from paramedics
Patient had severe sub sternal chest pain that radiated to neck, jaw and left arm. She was pale and anxious.
Initial vital signs:
Temperature: 37.2° C
Pulse: 118 beats/minute BP: 120/70
Oxygen saturation: 93%
A 12 lead ECG was taken at her home and data transmitted to a doctor in the Emergency Department.
IV cannula was inserted into the left antecubital vein. Medications administered (MONA Acronym):
• Morphine 2.5mg IV / Maxolon 10mg IV
• Oxygen (Face Mask 6L)
• Nitrates: (glyceryl trinitrate 600micrograms sublingual) • Aspirin 100mg
Emergency Department management
Her pain was assessed using the SOCRATES acronym:
Site
Onset Character
Radiating
Associated symptoms
Time/Duration
Exacerbating Severity
The following assessments are immediately performed:
PRIMARY SURVEY
AIRWAY: No signs of obstruction or noisy breathing, talks in full sentences.
BREATHING: RR 28 breaths/min, labored; oxygen saturation: 92% (on 6L/min 02 via a Hudson mask). Bilateral basal crackles and crepitation.
CIRCULATION: HR 120 bpm BP 90/50mmHg; JVP elevated 4cm; peripheral pulses –rapid and faint; capillary refill 4 secs; extremities cool, clammy and mottled; bilateral ankle oedema; 3rd heart sound present; Temp 37.5°C.
DISABILITY: Anxious and restless, oriented in person, time, place; GCS 15/15; pain 5/10.
EXPOSURE: No bruising.
FLUIDS: I.V. inserted; no IV fluids in progress.
GLUCOSE: BGL 4.0 mmol/L
• A 12 lead ECG is performed with the following trace:
• An extra peripheral venous line and peripheral arterial line are inserted in the ED.
• She was connected to a cardiac monitor
Diagnosis
Acute anterior ST elevation myocardial infarction (STEMI) with onset of cardiogenic shock.
Tests and investigations
Immediately on completion of the primary survey
• Blood was taken for full blood count, EUC, coagulation studies, cardiac enzymes.
• Arterial blood gas analysis performed.
• Urgent chest X-ray performed.
• Transthoracic echocarcardiogram (TTE)
Results of investigations
Chest X- Ray: Heart normal size. Pulmonary vascular congestion and pulmonary oedema.
Transthoracic echocardiogram: showed a hypokinetic left ventricular and septal wall.
Blood results
Result (Day: 13.15 hours) Reference Range
Red blood cells 4.8×1012/L 4.5-5.5×1012/L
Haemoglobin 140g/L 130-170g/L
White cell count 14.5×109/L 4.0-10.0 x109/L
Neutrophils 11.4×109/L 2.0-7.0×109/L
Eosinophils 0.04×109/L 0.02-0.5×109/L
Basophils 0.06×109/L 0.05-0.1×109
Monocytes 1.3×109/L 0.2-1.0×109/L
Lymphocytes 1.5×109/L 1.0-3.0×109/L
Platelets 155×109/L 150-400×109/L
Electrolyte, urea and creatinine:
Result (Day: 13.15 hours) Reference Range
Sodium 137 mmol/L 135-147 mmol/L
Potassium 3.9 mmol/L 3.5-5.2 mmol/L
Chloride 105 mmol/L 95-107 mmol/L
Urea nitrogen (BUN) 5.0 mmol/L 3.0-8.0 mmol/L
Creatinine 85 µmol/L 64 -104 µmol/L
Coagulation profile:
Result (Day 1: 13.15 hours) Reference range
Partial thromboplastin time (PTT) 35 sec 30-45 sec
Prothrombin time (PT) 12 sec 10-12 sec
Cardiac enzymes:
Result (Day 1: 13.15 hours) Reference range
High sensitivity Troponin T 88 ng/L 0-14 ng/L
Arterial blood gas analysis
Result (Day 1: 13.15 hours) Reference Range
pH 7.26 7.35-7.45
PaO2 75 mmHg 80-100 mmHg
PaCO2 37 mmHg 35-45 mmHg
HCO3- 19 mmol/L 22-26 mmol/L
BE -9 mmol/L -2 – +2mmol/L
Lactate 4mmol/L 0.5-1.6mmol/L
Management
• Central line inserted and dobutamine 10 micrograms/kg/min commenced.
• Fentanyl 25micrograms IV given.
• Booked for urgent angiogram and percutaneous intervention (PCI).
Medical history
• No known allergies
• Medications: enalapril 20mm/day, simvastatin 10mg/day
• Past medical history: hypertension for 5 years. No other significant illnesses. Has had intermittent indigestion for several months.
• Social history: Smokes two packets of cigarettes /day; 2-3 glasses of alcohol/day, sometimes more.
• Family history: her father died of a heart attack at age 50. Her twin sister has Type 2 diabetes mellitus.
1330 hours Mrs. Kelly transferred to the cardiac catheter lab for an urgent percutaneous coronary intervention of the left anterior descending (LAD) coronary artery – which was unsuccessful. Mrs. Kelly’s blood pressure continued to remain low (80/40) and Sp02 of 85%, even with the dobutamine infusion.
Mrs. Kelly was electively sedated and intubated, an intra-aortic balloon catheter was inserted via the right femoral artery and connected to an intra- aortic balloon pump (IABP – set at 1:1) and was admitted to the ICU.
Mrs. Kelly was reviewed by the cardiothoracic team and was scheduled for coronary artery bypass grafting if and when the cardiogenic shock had resolved.
Assessment 2: Short Answer Questions
Aim of assessment
The purpose of the assessment is to enable students to demonstrate knowledge by analyzing accurately information in a case study of a critically ill or deteriorating patient. It will include knowledge and concepts in relation to:
1. Prioritisation and justification of care based on the primary survey including an explanation and understanding of the development of the abnormal physiology
2. Critical analysis of diagnostic results relating to the underlying pathogenesis
3. Pharmacological concepts relating to the underlying pathogenesis
Details
Short Answer Questions
The assessment is based on three areas of one case study that will be related to those studied Using the information in the case study:
Question 1 15 marks
Critically analyse and explain the findings of each component of the primary survey with reference to the pathogenesis of the patient’s condition or deterioration.
For each component of the survey select one appropriate nursing strategy, including the rationale. State whether this strategy is a high, medium or low priority in context of the total survey.
Approximately 600 words.
Question 2 10 marks
Critically analyse TWO (2) diagnostic results, and relate to the underlying pathogenesis. Approximately 300 Words
Question 3 10 marks
Discuss:
a) the mode (mechanism) of action of ONE drug, relating to the underlying pathogenesis
b) how you would evaluate the therapeutic effect of the drug and
c) Explain how you would monitor for and respond to adverse effects of the drug. Approximately 300 words
