Case study - Acute coronary syndrome: Nursing

Nurse Cameron works on a cardiovascular inpatient unit, and is caring for Kevin, a 55-year-old with a history of coronary artery disease for which he’s prescribed aspirin at home. He was admitted the previous day after undergoing percutaneous coronary intervention, or PCI, with placement of one stent to treat an ST-segment elevation myocardial infarction, or STEMI for short. In collaboration with the registered nurse, RN Rachael, Nurse Cameron goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Kevin’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Cameron recognizes important cues including Kevin’s vital signs, which are blood pressure 101/80 mmHg, heart rate 99 beats per minute and regular, respirations 17 breaths per minute, oxygen saturation 96 percent on 2 liters per nasal cannula, and temperature 98.2 F or 36.8 C

When asked about pain, Kevin reports a current pain level of 3 out of 10 in his groin incision. Nurse Cameron notes that Kevin has a small amount of dried blood on his groin dressing and the surrounding area is ecchymotic and tender to palpation. Nurse Cameron also notes Kevin is prescribed the antiplatelet medication clopidogrel.

Next, Nurse Cameron analyzes these cues. He understands that PCI is a minimally invasive procedure that involves inserting a catheter through the radial or femoral artery to locate blockages in the coronary arteries. After the blockage is located, a tiny balloon is inserted in the obstructed coronary artery to compress plaque against the artery wall. If needed, a stent can be placed during PCI to keep the artery patent. After the procedure, patients are typically given antiplatelet medications, like clopidogrel, to prevent additional clot formation, especially around the new stent. Nurse Cameron realizes that Kevin’s history of aspirin therapy, combined with clopidogrel, places him at risk for bleeding. Nurse Cameron recognizes that Kevin needs management of his bleeding risk to maintain perfusion and support healing and recovery.

Now, using the information he's gathered, along with Kevin’s medical history, Nurse Cameron reports his findings to RN Rachael, and together they choose a priority hypothesis of risk for bleeding.

Then, they generate solutions to address Kevin’s risk for bleeding and they establish the expected outcome that after intervening, Kevin will not experience complications from bleeding during the shift.

Nurse Cameron and RN Rachael then take action to implement these solutions.

They review the electronic health record, or EHR, and note that Kevin’s clopidogrel is due within the hour. They also note an order to monitor Kevin’s groin incision and to gradually increase activity while following their facility's protocol for post-PCI care.

Then, Nurse Cameron and RN Rachael work together to care for Kevin. RN Rachael plans to re-assess Kevin’s incision site, pulses, sensation, movement, and skin temperature distal to the incision site every four hours. Meanwhile, Nurse Cameron will continue to monitor Kevin’s vital signs and administer Kevin’s clopidogrel.

Together, they enter Kevin’s room.