Video Case Study - Acute Coronary Syndrome

Nurse Cameron works on a Cardiovascular Care Unit, or CCU, and is caring for Kevin, a 55-year-old male with a history of coronary artery disease for which he’s prescribed aspirin at home.

He was recently admitted to the CCU after undergoing Percutaneous Coronary Intervention, or PCI, with placement of one stent to treat an ST-segment myocardial infarction, or STEMI for short.

After settling Kevin in his room, 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 101/82 mmHg, heart rate 99 beats per minute and regular, respirations 19 breaths per minute, oxygen saturation 96 percent on 2 liters per nasal cannula, and temperature 98.8 F, or 37.1 C.

When asked about pain, Kevin reports a current pain level of 3 out of 10 in his groin incision. Upon assessment, Nurse Cameron notes that Kevin has a moderate amount of bright red blood on his groin dressing and the surrounding area is ecchymotic and tender to palpation.

He is also receiving an infusion of heparin through his peripheral IV that was initiated during the procedure. Next, Nurse Cameron analyzes these cues.

He reviews the electronic health record, or EHR, and notes that Kevin’s activated partial thromboplastin time, or aPTT, is elevated over the therapeutic range ordered by the health care provider.

Nurse Cameron realizes that although Kevin needs anticoagulation following stent placement, the combination of the heparin infusion and Kevin’s history of aspirin therapy places him at risk for bleeding.

Now, using the information he's gathered, along with Kevin’s medical history, Nurse Cameron chooses a priority hypothesis of risk for bleeding.

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

Nurse Cameron then takes action to implement these solutions. He contacts the health care provider and reports Kevin’s aPTT results, incisional bleeding, ecchymosis, and site tenderness.

The health care provider places orders for Nurse Cameron to pause the heparin infusion and redraw his aPTT level in one hour.

Nurse Cameron also plans to continue to monitor Kevin’s vital signs, assess the incision site for additional bleeding or ecchymosis; and evaluate Kevin’s pulses, sensation, movement, and skin temperature distal to the incision site every 15 minutes.

Then, Nurse Cameron enters Kevin’s room. Nurse Cameron: I’m going to pause your heparin infusion since your labs show that your blood is a little thinner than we’d like.

Kevin: Okay, I don’t want to have any bleeding problems. Nurse Cameron: I’m going to monitor you closely for bleeding, but in the meantime, it’s important that you remain lying flat to minimize the risk of bleeding.

Kevin: I understand, but what if I need to go to the bathroom? Nurse Cameron: Please ring your call bell and I’ll assist you with the bedpan or urinal.

Kevin: Okay, thank you. Nurse Cameron: I’ll be back soon to check on you and draw your blood again.

Before leaving the room, Nurse Cameron ensures that Kevin’s call light is in reach. One hour later, Nurse Cameron redraws Kevin’s aPTT and sends it to the lab.

When the results come back, Nurse Cameron notifies the health care provider that the results are now within the therapeutic range and receives additional orders to titrate the heparin infusion to maintain Kevin’s aPTT.

Then, Nurse Cameron enters the room to evaluate the outcome of his actions. He takes Kevin’s vital signs which are blood pressure 121/83 mmHg, heart rate 88 beats per minute, respirations 18 breaths per minute, and pain 2 out of 10.

Nurse Cameron also re-assesses the incision site and notes that the dressing shows no additional bleeding, and the surrounding ecchymosis is unchanged.

He also checks blood flow to Kevin’s extremity, which shows warm, dry skin; strong pedal pulses; and intact sensation and movement.

Nurse Kevin recognizes Kevin’s bleeding is under control and the expected outcome has been met. Nurse Cameron: Okay Kevin, it looks like we have your risk of bleeding controlled.

Kevin: Good, that makes me feel better. Alright, as a quick recap… Nurse Cameron recognized and analyzed cues related to Kevin’s risk for bleeding and prioritized hypotheses and generated solutions to address this problem.

Nurse Cameron then took action to pause the heparin infusion and monitor Kevin closely. Since Kevin didn’t experience additional bleeding during the shift, Nurse Cameron determined that the plan of