Case Study A 67 year old female patient you have in your assignment…

Case Study

A 67 year old female patient you have in your assignment turns her call light on. Upon walking into her room, she asks for help to the bathroom. You notice that upon rising, she is dizzy and she says, “Woah! I just felt my heart skip a beat.” You tell her to sit for a moment and then rise again. You walk her to the bathroom and notice that she is diaphoretic and dyspneic. She says to you, “I’ve been feeling a lot of heartburn after I eat. The funny thing is, I haven’t had breakfast yet and I already feel heartburn.”

After a few minutes of being in the bathroom, she pulls the call bell and you come back in to help her wash up. She then says, “This heartburn is getting worse. You notice on inspection that her face is drenched with perspiration and she’s even more diaphoretic. You quickly get a wheelchair and bring her back to bed. You take a set of vital signs and they are the following:

BP – 189/99, HR – 135, R – 28, SPO2 – 91% (room air) – You ask her if she’s feeling any pain and she says “Just some pain in my stomach, like really bad heartburn.”

Another nurse calls her physician and puts you on the phone, while at the bedside, you explain the situation, give background, relay your assessment, and ask for recommendations. The MD orders the following and states, “Please call me back with the results as soon as you get them.”

ECG
Labs – CBC, CMP, troponin I, CK-MB, CRP, PT/INR, aPTT
Medications:
Morphine 4mg IV now
Aspirin 325mg PO now
NTG 0.4 SL q 4 min (max 4 doses) x1 dose now
Plavix 300mg PO now
Atorvastatin 300mg PO now
Lopressor 100mg PO now
Oxygen 2L NC
Infusion of Heparin 25,000u/250ml 0.45% NS, start as per ACS protocol
Answer the following regarding the results,

When the tech does the ECG, you see this:

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How would you interpret this ECG? What is the significance of this as it pertains to the patient’s treatment?

The following are the results of the labs you were asked to obtain:

CBC: Hgb – 7.9, Hct – 29%, PLT – 450, WBC – 17.9
CMP: Na 133, K 5.5, Cl – 92, Ca 10.7, Mg 1.2, BUN – 35, Creat – 2.0
PT/INR – 9 sec/0.5, PTT – 15
Trop – 1.13, CK-MB 250, CRP – 3.0
Identify any abnormal lab values. Explain why they are significant for this patient? Explain how this affect treatment?

Identify the use and mechanisms (i.e. what they do in the body) of these medications and explain why they might be ordered for this patient? Does this give you any insight as to what might be happening with her?

Lastly, based on the subjective and objective data presented, what do you think is happening to her?

Explanation & Answer

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