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Mr. Bob Carlson is a 59 year old male who came to Ventura County Medical Center (VCMC) with nausea, upper back pain he rated 7/10, and diaphoretic. His vital signs were BP 156/92, HR 90, RR 22 SpO2 90%, and temperature 99.5. Physical examination revealed clear lung sounds, mild tachypnea, S1 S2 present, and several ulcerations to the right foot. Ordes were given to obtain a 12-lead ECG and labs (CBC, CMP, Coagulations, Cardiac Enzymes, and Lipid Profile). In addition orders were given to start Mr. Carlson on 2L oxygen via nasal cannula and obtain venous access. A 20 gauge IV was started in his left AC.
Mr. Carlson’s medical history revealed that he is a type II diabetic, has hypertension, hyperlipidemia, and smokes 1/2 pack of cigarettes a day for the past 40 years. His diabetes is poorly managed and Mr.Carlson had a left below the knee amputation 2 years ago due to diabetic ulcers that were gangrenous. In addition, Mr. Carlson has a history of IV drug use but now receives a daily dose (90 mg) of Methadone at a local clinic. He is divorced, no children and is currently living with his 85 year old mother.
Mr. Carlson’s ECG results showed ST-segment elevation in leads II, III, and aVf and in V4, V5 and V6 with ST-segment depression V1, V2, and V3. The provider identified this to be an MI occurring in the inferior portion of the heart, likely affecting his right coronary artery (RCA). Lab results confirmed a ST-segment elevation MI (Troponin-I 12.9, CK 520, and CKMB 25.2). A code STEMI was called and Mr. Carlson was immediately prepared for a Percutaneous coronary intervention (PCI). While waiting for transfer to the Catheterization Lab at Community Memorial Hospital (CMH) Mr. Carlson was given 325 mg of Aspirin, 2 mg Morphine, and was started on a 5000 unit bolus of Heparin. Nitroglycerin was not given due to the profound hypotension associated with nitroglycerin and patients experiencing an inferior myocardial infarction.
Mr. Carlson was transferred to the CMH catheterization lab. His vitals were stable and he was able to give informed consent. The cardiac angiography showed a 95% occlusion to the RCA. A stent was placed, the patient tolerated the procedure well. The patient’s right femoral artery was closed successfully with manual pressure.
Mr. Carlson returned to the cardiac care unit where upon assessment his groin was found to be soft and without hepatoma and with minimal drainage from incision site. His peripheral pulses were present, and distal to the incision his skin was warm with capillary refill less than 2 seconds. Mr. Carlson was transferred back to VCMC the following day were he recovered without further incident.
Before discharge Mr. Carlson’s was educated on his new prescriptions and was educated on the importance of taking his daily aspirin. He met with the diabetes educator, dietician, and social worker before discharge. Mr. Carlson was informed of smoking cessation programs in the area but declined to enroll. Case Management found placement in a skilled nursing facility for 20 days, the amount of days 100% covered by Medi-Cal, where he could start a cardiac rehabilitation program. A home health organization was organized to help provide care for Mr. Carlson when he returned to his home.
Questions
- What medications do you anticipate Mr. Carlson being prescribed upon discharge? Aspirin, ACE-I or ARB, beta blocker, and a statin
- What nursing interventions are critical prior to the patient being taken to the cath lab? -Assess the client’s and family’s knowledge and understanding of the procedure. –Provide routine preoperative care as ordered. Signed consent is required and maintain patient NPO. -Assess for hypersensitivity to iodine, radiologic contrast media, or seafood. An iodine-based radiologic contrast dye is typically used for angiogram. Iodine or seafood allergy increases the risk for anaphylaxis and requires an alternative dye or special precautions. -Record baseline assessment data, including vital signs, height, and weight. Mark the locations of peripheral pulses; document their equality and amplitude.
- Which risk factors may have contributed to Mr. Carlson’s myocardial infarction? Hyperlipidemia, uncontrolled diabetes, smoking, inactivity, drug use, and diet.
