STAGE 1 Ben Carlos is a 64-year-old Caucasian male who presents to… STAGE 1 Ben Carlos is a 64-year-old Caucasian male who presents to the emergency room with a two-day history of intermittent substernal chest pressure associated with shortness of breath and diaphoresis. The pain had originally awoken Mr. Thomas from sleep 2 nights ago and has been intermittently relieved with some sublingual nitroglycerin tablets that he had received from his physician 3 years ago. The pain increases with exertion, but now is constant. He rates the pain a “7” on a scale of 1 to 10. Past Medical History: HTN, Type 2 DM Home Medications: Lopressor (metoprolol) 50 mg PO daily Lasix 40 mg PO daily ASA 325 mg PO daily Glucophage 50 mg PO BID Vital Signs: T-98.9 (O) P= 110 R=28 BP= 90/60 SpO2=88% on RA Physical Exam: Neuro: Anxious, but alert and oriented x3 Pulm: Bilateral rales, labored CV: RRR; S1, S2, S3; tachycardic; PMI displaced laterally ABD: Active bowel sounds; soft/non-tender; liver enlarged EXT: 2+ lower extremity edema; 1+ peripheral pulses INTEG: Poor capillary refill; nail beds cyanotic; skin is diaphoretic Lab Results_Na= 133; K=5.0; C1=100; CO2=22; BUN=29; Cr=1.8; Glucose=183 Hgb=9.2; Hct=27.6; WBC=11.2; Plt=203 CPK=2900; CKMB=432%; LDH=972; Troponin=6 Diagnostic Tests: 12 lead ECG; Sinus tachycardia with left ventricular hypertrophy and ST elevation in leads V1, V2, V3, & V4 CXR: Increased vascular markings in both lungs Critical thinking exercises 1. List your primary medical and nursing diagnoses for this patient. 2. What area of the left ventricle is affected by this MI? 3. What is your rationale for EACH of the abnormal physical assessment parameters, the abnormal laboratory results, and the abnormal diagnostic tests? 4. What are your anticipated nursing interventions for this patient? STAGE 2 Mr. Thomas is admitted to the CCU with a diagnosis of Acute MI with congestive heart failure. The following orders are obtained: Vital Signs q1h Continuous ECG monitor Bedrest Foley catheter Nitroglycerin IV infusion @ 10 mcg/min Heparin IV infusion @ 1000 units/hr PTT q6h and call results if <60 or > 90 CK isoenzymes q8h x3 Troponin level q12h x2 O2 at 2 1iters/min per NCtitrate for SpO2>91% Lopressor 25 mg PO BID Ambien 5 mg PO qHS PRN sleep CRITICAL THINKING EXERCISE 1. What is your rationale for each of the admitting orders? STAGE 3 Mr. Thomas’ urine output decreases to 10 ml/hr and is unresponsive to a dose of IV Lasix. He complains of increased SOB and physical exam reveals increasing rales bilaterally. A pulmonary artery catheter is inserted with the following parameters obtained: CVP= 10 PCWP=22 PA pressure=38/20 CO= 4.1 CI=1.9 SVR=1872 CRITICAL THINKING EXERCISE 1. What is the reason for each of the above parameters and what medication do you anticipate starting? STAGE 4 You had provided Mr. Thomas with some IV morphine sulfate for pain. You check on him 30 minutes later and find that he is unresponsive with slow, shallow respirations. He is diaphoretic. An ABG on 2L/NC reveals: pH=7.22 pCO2=50 pO2=82 HCO3=26 SaO2=83% CRITICAL THINKING EXERCISES 1. What does the ABG reveal? 2. What is the probable cause? 3. What are the anticipated medical and nursing interventions? STAGE 5 Mr. Thomas is intubated and CXR reveals proper tube placement. His ventilator settings are as follows: Assist Control, rate=10 TV=600 FiO2=100% PEEP=5 An ABG is drawn 1 hour later and reveals the following: pH=7.13 pCO2=80 pO2=347 HCO3=29 SaO2=100% CRITICAL THINKING EXERCISES 1. What does the ABG reveal? 2. What changes do you anticipate to the ventilator settings and what is the rationale for each change? STAGE 6 You are in Mr. Thomas’ room and notice that he is unresponsive and does not have a pulse.This rhythm is on his bedside monitor: The rhythm quickly changes to this one: CRITICAL THINKING EXERCISES 1. What are both of the rhythms? 2. What could have caused each of the rhythms? 3. What is the treatment for each rhythm? CRITICAL THINKING EXERCISE 1. What patient/family teaching is important for each of the previous stages discussed (Stage 1 through Stage 6). Health Science Science NursingRNSG 1441
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