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 The time is 1900. You are working in a small, rural hospital. It has been snowing heavily all day, and the medical helicopters at the large regional medical center, 4 hours away by car (in good weather), have been grounded by the weather until morning. The roads are barely passable. W.R., a 48-year-old plumber with a 36-pack-year smoking history, is admitted to your floor with a diagnosis of rule out myocardial infarction (R/O MI). He has significant male-pattern obesity (“beer belly,” large waist circumference) and a barrel chest, and he reports a dietary history of high-fat food. His wife brought him to the emergency department after he complained of unrelieved “indigestion.” His admission vital signs (VS) were 202/124, 106, 18, and 98.2° F (36.8° C). W.R. was put on oxygen (O2 ) by nasal cannula (NC) titrated to maintain SaO2

(arterial oxygen saturation) over 90% and started on an IV of nitroglycerin (NTG). He was given aspirin 325 mg to chew and swallow and was admitted to Dr. A.’s service. There are plans to transfer him by helicopter to the regional medical center for a cardiac catheterization in the morning when the weather clears. Meanwhile, you have to deal with limited laboratory and pharmacy resources. The minute W.R. comes through the door of your unit, he announces he’s just fine in a loud and angry voice and demands a cigarette. He also says he has no time to fool around with hospitals.

 

1. From the perspective of basic human needs, what is the first priority in his care?

2. Are these VS reasonable for a man of his age? If not, which one(s) concern(s) you? Explain why or why not.

 

3. Identify five priority problems associated with the care of a patient like W.R.

4. Which laboratory tests might be ordered to investigate W.R.’s condition? If the order is appropriate, place an “A” in the space provided. If inappropriate, mark with an “I,” and provide rationales for your decisions.

1. _______CBC

2. _______EEG in the morning

3. _______Chem 7 (electrolytes)

4. _______PT/PTT

5. _______Bilirubin

6. _______Urinalysis (UA)

7. _______STAT 12-lead ECG

8. _______Type and crossmatch for 2 units of packed RBCs (PRBCs)

5. What significant lab tests are missing from the previous list?

6. How are you going to respond to W.R.’s angry demands for a cigarette? He also demands

something for his “heartburn.” How will you respond?

You phone Dr. A.’s partner, who is on call. She prescribes morphine sulfate 4 to 10 mg IV push (IVP) q1h PRN for pain (burning, pressure, angina).

 

7. Explain three reasons for this order.

8. What special precautions should you follow when administering morphine sulfate IVP?

9. The pharmacy supplies morphine for injection in vials of 5 mg/mL only. For the first dose,

you will be giving 4 mg of morphine. How many milliliters will you give for this dose? Mark

the syringe with your answer.

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10. What will you do with the rest of the morphine in the vial?

a. Discard it.

b. Save it for the next dose.

c. Return it to the pharmacy.

d. Discard it with a second witness.

11. Angina is not always experienced as “pain” as many people understand pain. How would you

describe symptoms you want him to warn you about? Why is this important?

 

12. What safety measures or instructions would you give W.R. before you leave his room?

 

13. Mrs. R. asks you, “If he can’t smoke, why can’t you give him one of those nicotine patches?”

How will you respond?

 

14. Are there any alternatives to help him with his nicotine cravings? Would they be helpful now?

15. Before leaving for the night, Mrs. R. approaches you and asks, “Did my husband have a

heart attack? I’m really scared. His father died of one when he was 51.” How are you going to

respond to her question?

16. When you come into W.R.’s room at 2200 hours to answer his call light, you see he is holding his left arm and complaining about aching in his left shoulder and arm. What information will you gather? What questions will you ask him?

17. You give him one sublingual NTG tablet, per protocol, but his pain is not relieved. Based

on your assessment findings, you decide to call the HCP. Using SBAR ( Situation,

Background, Assessment, Recommendation), what information would you provide to the

HCP when you call?

S.

 

B.

 

A.

 

R.

 

 

In the morning, W.R. is transferred by helicopter to the medical center, and a cardiac catheterization is performed. It is determined that W.R. has coronary artery disease (CAD). The cardiologist suggests it would be best to treat him medically for now, with follow-up counseling on risk factor modification, especially smoking cessation. He is discharged with a referral for a follow-up visit to his local internist in 1 week.

 

18. What does it mean to treat him “medically” (conservatively)? What other approaches might

be used to treat CAD?

SCIENCE
HEALTH SCIENCE
NURSING
NURSING NUR2222

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