CASE STUDY 10 1.

Intravenous therapy may be used to correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for example, dehydration. 2. Classically, aspirin is known to possess analgesic, antiinflammatory, antiplatelet, and antipyretic properties. The American College of Cardiology, and the American Heart Association all recommend that 160-325 mg non-entericcoated aspirin be chewed and swallowed as soon as possible after the diagnosis of acute MI is made and repeated once daily indefinitely, regardless if thrombolytic therapy will be given. Some clinicians have recommended patients at high risk of myocardial infarction take a single oral or rectal dose of aspirin at the first sign of chest pain. More recently, it has been proposed that the beneficial effect of aspirin in MI prophylaxis might be related to its ability to reduce circulating levels of C-reactive protein. In very high and toxic doses, aspirin also exerts a direct inhibitory effect on vitamin K-dependent hemostasis. Prothrombin synthesis is impaired, resulting in hypoprothrombinemia. Enteric-coated or extended-release tablets: May help to reduce gastric irritation and/or symptomatic GI disturbances associated with uncoated tablets. Contraindications: anemia asthma bone marrow depression breast-feeding children coagulopathy G6PD deficiency hepatic disease hypoprothrombinemia influenza intramuscular injections nasal polyps peptic ulcer disease pregnancy renal failure surgery tartrazine dye hypersensitivity thrombocytopenia urticaria varicella viral infection vitamin K deficiency

3. Components of the Adult Health History Chief Complaint: Initial History of Present Illness: Past Medical and Surgical History: Social History: Family History: Medications: Review of Systems: Allergies: Full systems assessment:

4. Cardiac Biomarkers Laboratory Tests Current cardiac biomarker tests used to help diagnose, evaluate, and monitor individuals suspected of having acute coronary syndrome (ACS) include: Troponin I or T are structural components of cardiac muscle. They are released into the bloodstream with myocardial injury. They are highly specific for myocardial injury--more so than CK-MB--and help to exclude elevations of CK with skeletal muscle trauma. Troponins will begin to increase following MI within 3 to 12 hours, about the same time frame as CK-MB. However, the rate of rise for early infarction may not be as dramatic as for CK-MB CK CK-MB

Other biomarker tests that may be used: Myoglobin BNP (or NT-proBNP) although usually used to recognize heart failure, an increased level in people with ACS indicates an increased risk of recurrent events B-type natriuretic peptide (BNP) is released from ventricular myocardium. BNP release can be stimulated by systolic and diastolic left ventricular dysfunction, acute coronary syndromes, stable coronary heart disease, valvular heart disease, acute and chronic right ventricular failure, and left and right ventricular hypertrophy secondary to arterial or pulmonary hypertension. BNP is a marker for heart failure. hs-CRP C-reactive protein (CRP) is an acute phase protein elevated when inflammation is present. Since inflammation is part of atheroma formation, then CRP may reflect the extent of atheromatous plaque formation and predict risk for acute coronary events. However, CRP lacks specificity for vascular events.

Phased out biomarkersthe tests below are not specific for damage to the heart and are no longer recommended for evaluating people with suspected ACS: AST LDH

More general tests frequently ordered along with cardiac biomarkers include: Blood gases CMP BMP Electrolytes CBC

Diagnostic Tests These tests allow doctors to look at the size, shape, and function of the heart as it is beating. They can be used to detect changes to the rhythm of the heart as well as to detect and evaluate damaged tissues and blocked arteries. EKG (ECG, electrocardiogram) This test records the electrical activity of your heart through electrodes attached to your skin. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show that a heart attack has occurred or is in progress.Nuclear scan Coronary angiography (or arteriography) Echocardiogram (Cardiac echo, transthoracic echocardiography (TTE)) Stress testing

Chest X-ray

5. Heart problems that can cause chest pain: Angina or a heart attack is pain that occurs because your heart is not getting enough blood and oxygen. The most common symptom is chest pain that may feel like tightness, heavy pressure, squeezing, or crushing pain. The pain may spread to the arm, shoulder, jaw, or back. A tear in the wall of the aorta, the large blood vessel that takes blood from the heart to the rest of the body (aortic dissection) causes sudden, severe pain in the chest and upper back. Swelling (inflammation) in the sac that surrounds the heart (pericarditis) causes pain in the center part of the chest.

Lung problems that can cause chest pain: A blood clot in the lung (pulmonary embolism) Collapse of the lung (pneumothorax) Inflammation of the lining around the lung (pleurisy) can cause chest pain that usually feels sharp, and often gets worse when you take a deep breath or cough. Pneumonia causes a sharp chest pain that often gets worse when you take a deep breath or cough.

Other causes of chest pain: Panic attack, which often occurs with fast breathing Inflammation where the ribs join the breast bone or sternum (costochondritis) Shingles, which causes sharp, tingling pain on one side that stretches from the chest to the back, and may cause a rash Strain or inflammation of the muscles and tendons between the ribs

Chest pain can also be due to the following digestive system problems: Spasms or narrowing of the esophagus (the tube that carries food from the mouth to the stomach) Gallstones cause pain that gets worse after a meal (most often a fatty meal) Heartburn or gastroesophageal reflux (GERD) Stomach ulcer or gastritis (burning pain occurs if your stomach is empty and feels better when you eat food)

6. Differential diagnosis is a thought process that healthcare providers use to consider and then eliminate potential causes for an illness. Differential diagnosis is the determination of which of two or more diseases with similar symptoms is the one from which the patient is suffering, by a systematic comparison and contrasting of the clinical findings. 7. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved. As well, the patient's response to therapy can expand or narrow the differential diagnosis list. In patients with chest pain, many potential diagnoses may exist, and the healthcare provider will want to first consider those that are life-threatening. Tests to rule out heart attack, pulmonary embolus, or aortic dissection may not be necessary; when clinical skill and judgment may be all that is needed to consider or discard a diagnosis. 8. Chest pain is a common complaint among adult patients. Chest pain may be a signal of an impending lifethreatening event. The accurate assessment of chest pain is difficult. The responsibility of identifying a potentially life-threatening condition accompanied by chest pain presents the nurse with an incredible challenge. Chest pain may be caused by a variety of cardiac, respiratory, gastrointestinal and musculoskeletal illnesses. A complete,

thorough history that includes family history and risk factors is the most important part of the assessment. The history is followed by the physical assessment. This phase of the assessment process may include important tests such as a chest X-ray, 12-lead electrocardiograph and cardiac isoenzymes. A perceptive and observant nurse with astute assessment skills will set the tone for optimal patient treatment leading to a more positive outcome for the patient. 9. ECG If the left ventricle increases its activity or bulk then there is said to be "left axis deviation" as the axis swings round to the left beyond -30, alternatively in conditions where the right ventricle is strained or hypertrophied then the axis swings round beyond +90 and "right axis deviation" is said to exist. The most common causes of left axis deviation are left anterior fascicular block and Q-waves from inferior MI. Serial ck tests: MB usually becomes abnormal three to four hours after an MI, peaks in 1024 hours, and returns to normal within 72 hours. Normal ranges Creatine Kinase (CK or CPK) for a Female are 96 - 140 units/L 10. Coronary artery disease can lead to: Chest pain (angina). When your coronary arteries narrow, your heart may not receive enough blood when demand is greatest particularly during physical activity. This can cause chest pain (angina) or shortness of breath. Heart attack. If a cholesterol plaque ruptures and a blood clot forms, complete blockage of your heart artery may trigger a heart attack. The lack of blood flow to your heart may damage to your heart muscle. The amount of damage depends in part on how quickly you receive treatment. Heart failure. If some areas of your heart are chronically deprived of oxygen and nutrients because of reduced blood flow, or if your heart has been damaged by a heart attack, your heart may become too weak to pump enough blood to meet your body's needs. This condition is known as heart failure.

11. Check pts vital signs, Breathing exercises, repositioning, guided imagery and relaxation techniques, o2 administration 12. Does he have a support system? Does he live with anyone else besides his wife?