Management of Acute Coronary Syndrome, Case Study Example

The patient selected for the assessment is Mr. Bates, who presented to the emergency department with complaints of ‘chest pain.’ Australian emergency departments use triage categories to identify patients who need urgent medical care and those who need intervention to save their lives (Dittmar et al., 2018). The triage score for the patient was determined to be the immediate category. A focused cardiovascular assessment is essential for the patient since it allows the physicians to focus on the factors contributing to the cardiovascular event (Zaunseder et al., 2018). Such factors include high blood cholesterol and diabetes, to mention a few (Katsiki et al., 2019). Nurse practitioners need to be skilled in identifying the regular and abnormal cardiovascular events to provide quality care. The following is a focused assessment of Mr. Bates to identify the coronary artery that might be affected, the rationale for medical intervention, and the appropriate education approach and support for the patient.

Consent Script

Me: How are you to Mr. Bates? I am deeply concerned about your condition. I need to get your permission to do a further assessment of your situation. The hospital has a strict policy on ensuring the autonomy of its patients is observed.

Me: A proper assessment must be done as soon as possible to detect any abnormalities earlier. Do I have your consent to proceed?

Mr. Bates provided verbal consent for the assessment to take place.

Presentation and Health History

HPI: Mr. Bates is a 48-year-old man admitted to the emergency department after an attack of severe chest pain. The pain had a rapid onset, and the patient rated it to be 9/10. The pain was termed as ‘central and crushing.’ It was not relieved by the use of antacids

Medical history: He has diabetes mellitus that is controlled by following a strict diet. The patient has not experienced any cardiac problems in the past.

Family history: He has a strong genetic predisposition to cardiovascular disease because his mother and father died from acute myocardial infarction in their fifties.

Allergies: The patient did not suffer from any known allergic reactions.

Social history: Mr. Bates is employed as a truck driver. He is married with three children that are currently in their teenage period. The patient denies smoking. He engages in moderate amounts of alcohol over the weekends.

Clinical observation: The patient’s vitals were measured and found to be within these ranges. The heart rate was recorded as 60-70 beats per minute, which was weak for the patient. The patient had an elevated blood pressure of 140/90 mmHg that indicated a possible hypertensive crisis. His oxygen partial pressure was 92%. The patient’s temperature was 36.3 degrees Celsius. The jugular venous pressure was not heightened.

ECG Analysis

Due to the cardiovascular problems experienced by Mr. Bates and the positive confirmation of the patient’s past family history, an ECG was done. The rhythm of the patient’s ECG was irregular due to the differing elevation in the QRS peak levels (Ç?nar & Tuncer, 2021). The aVL was very depressed for the patient, while his V5 spiked beyond the normal range. This aspect indicated that the patient had an irregular ECG reading. Further, the P wave on a VL was not well defined, indicating an abnormality in that region of the heart.  The vessel that is likely to be affected in the patient is the left coronary artery.

The findings are relevant to guiding the planning and prioritising the care of Mr. Bates. Localisation of the ECG abnormality to the artery allows specific treatment to be provided to the patient. The narrowing of the left coronary artery leads to the reduced blood supply to particular muscles of the heart supplied by that vessel. The left coronary artery supplies the muscles of the left atrium and the left ventricle. These muscles undergo ischemia due to the reduced blood supply, resulting in a lactic acid buildup that leads to pain over the chest. Further, the findings can assist in determining the severity of coronary syndrome. The left ventricle pumps blood to the periphery. As such, ischemia in that area is significant as it affects the body’s ability to transport nutrients and oxygen to peripheral tissues. The course of the disease is often acute and needs to be addressed by the medical team promptly.

Rationale for Therapy

Medical Therapy

The therapy chosen for the patient involves the use of glyceryl trinitrate. The drug is used to manage hypertension, especially in emergency cases where rapid relief is desired (Sridharan & Sequeira, 2018). The drug can be given in various formulations that include sublingual, transdermal, and oral, depending on the desired rapidity of onset (Ralph et al., 2018). The drug leads to the release of nitric oxide. Nitric oxide is helpful as a vasodilator agent and widens the patency of the associated vessels. Morphine 5 mg IV bolus is also included in the initial treatment plan for Mr. Bates. It is utilised to reduce the patient’s pain. Morphine is a potent analgesic drug with potency to u receptors critical in regulating pain (Serafini & Zachariou, 2019). Aspirin 300mg orally is also administered to the patient. It acts to reduce the clotting of blood. Aspirin is a potent anticoagulant that is useful for the patient (Jenny et al., 2018). It lowers blood thickness and the formation of blood clots that can occlude narrow vessels like the coronary arteries.

Adjunct Therapy

An adjunct therapy that will be useful for the patient involves using diuretic drugs, such as hydrochlorothiazide. Induction of the drug will reduce the patient’s blood pressure, adding to the efficacy of the above drug regimen (Cirri et al., 2018). Before using the drug, the apical pulse must be monitored. Analysing the patient for hyperkalemia is also appropriate.

Surgical intervention is necessary for the patient to ensure that the symptoms are abated. There are a variety of surgical procedures that can be applied to the patient with successful outcomes. An angioplasty, also known as a percutaneous coronary intervention, is necessary (Trerotola et al., 2018). It involves widening the affected blood vessels to re-establish blood flow. The intervention is crucial in checking the damage to the heart muscles of the patient. The angioplasty results in continued blood flow to the patient’s musculature (Feng et al., 2018). As such, the symptoms of the patient are controlled, and disease progression is limited.

Nursing Management

Appropriate nursing management is a prerequisite to ensure the patient has optimum care. The nurse in charge should continuously monitor the patient’s vital to ensure that the blood pressure is maintained at the required levels (Downey et al., 2018). Any spikes in the blood pressure readings should be reported immediately. The nurse practitioner should also advise the patient on stress management to ensure that the patient gets better. Further, the patient’s diet should be strictly controlled while in the hospital to recover quickly. Fatty foods should not be given to the patient. These activities by the nurse will ensure that disease management is tailored for a speedy recovery.

Patient Education

By relaying the appropriate information to patients and family members, nurses can take control of disease management. Further, the patient will be more inclined to adhere to the recommended medications and therapies through such health improvement efforts. Mr. Bates should be educated on strategies to reduce his body weight and cholesterol levels (Amegah, 2018). Further, patient education should inform Mr. Bates of the severity of the condition he is suffering from. Making Mr. Bates aware of the seriousness of his illness will assist in ensuring that he adheres to the prescribed intervention strategies.

The family also needs to be involved in the education process for maximum results for Mr. Bates. The family members need to recognise the warning signs of an imminent cardiovascular attack on Mr. Bates. Empowering the family members to recognise such signs will allow them to rapidly institute intervention measures, such as drug administration or visiting the emergency department early (Arkansas State University, 2018). Such action will be lifesaving to the patient; it will also reduce the increase in severity for Mr. Bates. The family also needs to be included in the education process as they are crucial in ensuring that the patient follows up with the medication (Kokorelias et al., 2019). Making the family aware of the drug dosages prescribed to the patient will improve Mr. Bates’ compliance in utilising the drugs given to him. Further, the family forms the immediate environment for Mr. Bates. Advising them on the lifestyle changes required for Mr. Bates will allow the family to provide the ideal environment that fosters compliance. As such, family education is critical in the management of the patient.

Conclusion

The patient, Mr. Bates, was admitted to the emergency department following complaints of severe chest pain. Upon analysis of the patient’s ECG, it was determined that the affected coronary artery is the left one. The prescribed medical intervention for the patient involved the use of morphine, glyceryl trinitrate, and aspirin. Adjunctive therapy with the diuretic drug hydrochlorothiazide was determined to be effective in managing the patent’s hypertension. Further, surgical interventions in the form of angioplasty were also selected to be effective for the patient. Patient education was needed to make sure that he is aware of the importance of drug compliance and proper follow-up. Educating the family members was also appropriate due to their impact on the patient’s recovery.

References

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Arkansas State University. (2018). The nurse’s role in patient education. Arkansas State University. https://degree.astate.edu/articles/nursing/nurses-role-patient-education.aspx

Ç?nar, A., & Tuncer, S. A. (2021). Classification of normal sinus rhythm, abnormal arrhythmia and congestive heart failure ECG signals using LSTM and hybrid CNN-SVM deep neural networks. Computer Methods in Biomechanics and Biomedical Engineering, 24(2), 203-214. https://doi.org/10.1080/10255842.2020.1821192

Cirri, M., Maestrini, L., Maestrelli, F., Mennini, N., Mura, P., Ghelardini, C., & Di Cesare Mannelli, L. (2018). Design, characterisation and in vivo evaluation of nanostructured lipid carriers (NLC) as a new drug delivery system for hydrochlorothiazide oral administration in pediatric therapy. Drug Delivery, 25(1), 1910-1921. https://doi.org/10.1080/10717544.2018.1529209

Dittmar, M. S., Wolf, P., Bigalke, M., Graf, B. M., & Birkholz, T. (2018). Primary mass casualty incident triage: evidence for the benefit of yearly brief re-training from a simulation study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 26(1), 1-8. https://sjtrem.biomedcentral.com/articles/10.1186/s13049-018-0501-6

Downey, C., Ng, S., Jayne, D., & Wong, D. (2019). Reliability of a wearable wireless patch for continuous remote monitoring of vital signs in patients recovering from major surgery: a clinical validation study from the TRaCINg trial. BMJ open, 9(8), e031150. http://dx.doi.org/10.1136/bmjopen-2019-031150

Feng, C., Han, B., Liu, Y., Wang, L., Niu, D., Lou, M., & Lu, C. (2018). Effect of nicorandil administration on myocardial microcirculation during primary percutaneous coronary intervention in patients with acute myocardial infarction. Post?py w Kardiologii Interwencyjnej= Advances in Interventional Cardiology, 14(1), 26. https://dx.doi.org/10.5114%2Faic.2018.74352

Jenny, J. Y., Pabinger, I., & Samama, C. M. (2018). European guidelines on perioperative venous thromboembolism prophylaxis: aspirin. European Journal of Anaesthesiology| EJA, 35(2), 123-129. https://journals.lww.com/ejanaesthesiology/fulltext/2018/02000/european_guidelines_on_perioperative_venous.9.aspx

Katsiki, N., Banach, M., & Mikhailidis, D. P. (2019). Is type 2 diabetes mellitus a coronary heart disease equivalent or not? Do not just enjoy the debate and forget the patient!. Archives of Medical Science: AMS, 15(6), 1357. https://dx.doi.org/10.5114%2Faoms.2019.89449

Kokorelias, K. M., Gignac, M. A., Naglie, G., & Cameron, J. I. (2019). Towards a universal model of family centered care: a scoping review. BMC Health Services Research, 19(1), 1-11. https://link.springer.com/article/10.1186/s12913-019-4394-5

Ralph, D. J., Eardley, I., Taubel, J., Terrill, P., & Holland, T. (2018). Efficacy and safety of MED2005, a topical glyceryl trinitrate formulation, in the treatment of erectile dysfunction: a randomised crossover study. The Journal of Sexual Medicine, 15(2), 167-175. https://doi.org/10.1016/j.jsxm.2017.12.003

Serafini, R. A., & Zachariou, V. (2019). Opioid–galanin receptor heteromers differentiate the dopaminergic effects of morphine and methadone. The Journal of Clinical Investigation, 129(7), 2653-2654. https://www.jci.org/articles/view/128987

Sridharan, K., & Sequeira, R. P. (2018). Drugs for treating severe hypertension in pregnancy: a network meta?analysis and trial sequential analysis of randomized clinical trials. British journal of clinical pharmacology, 84(9), 1906-1916. https://doi.org/10.1111/bcp.13649

Trerotola, S. O., Lawson, J., Roy-Chaudhury, P., & Saad, T. F. (2018). Drug coated balloon angioplasty in failing AV fistulas: a randomized controlled trial. Clinical Journal of the American Society of Nephrology, 13(8), 1215-1224. https://cjasn.asnjournals.org/content/13/8/1215?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Clin_J_Am_Soc_Nephrol_TrendMD_1

Zaunseder, S., Trumpp, A., Wedekind, D., & Malberg, H. (2018). Cardiovascular assessment by imaging photoplethysmography–a review. Biomedical Engineering/Biomedizinische Technik, 63(5), 617-634. https://doi.org/10.1515/bmt-2017-0119