Critical care case study - ST elevation myocardial infarction (STEMI): Nursing

Nurse, Heidi works in the emergency department or ed and is caring for Fritz. A 65 year old male with a history of hyperlipidemia who was diagnosed with an ST segment elevation, myocardial infarction or stemi nurse.

Heidi goes through the steps of the clinical judgment measurement model to make clinical decisions about Fritz's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, Heidi recognizes important cues including Fritz's vital signs which are temperature 98.9 °F or 37.1 °C, heart rate 116 BPM respirations, 26 breaths per minute BP, 10 4/64 millimeters of mercury and oxygen saturation.

88% on 2 L per nasal cannula upon assessment. Nurse Heidi notes Fritz has cool clammy and pale skin, weak peripheral pulses and appears restless.

He reports a squeezing pain in his chest that radiates to his left arm and rates his pain as a nine on a 0 to 10 numeric pain scale.

Next, nurse Heidi analyzes these cues. She reviews the electronic health record or E hr and notes, Fritz's ECG shows ST segment elevation in two contiguous leads and his serum troponin and creatine kinase MB or CKMB levels are elevated.

She also notes aspirin and nitroglycerin were administered by emergency medical services or ems while transporting frits to the ed nurse.

Hiding knows that a myocardial infarction or mi occurs when a coronary artery is blocked, reducing blood flow to the myocardium or heart muscle.

She also knows that hyperlipidemia is a major risk factor for an mi because it contributes to atherosclerosis where plaque builds up in the arteries causing a blockage.

Nurse. Heidi recognizes that a stemi is a type of M where one of the coronary arteries is completely blocked and the ECG shows there's an elevation of the ST segment in at least two contiguous leads.

Nurse Heidi understands that as blood flow to the myocardium is reduced, the myocardial cells are deprived of oxygen and become hypoxic resulting in chest pain and an inability of the heart to pump enough blood to supply the body's needs.

In response, the heart rate increases in an attempt to improve blood flow to the tissues which further increases oxygen demand.

Then as oxygen deprived cells are damaged, they release proteins like troponin and enzymes like CKMB resulting in increased levels in the bloodstream.

As oxygen deprivation continues, myocardial cells become ischemic and begin to die or infarct. And irreversible cardiac damage occurs.

This results in decreased contractility which decreases cardiac output and further reduces tissue perfusion and oxygen delivery to the body.

Decreased perfusion manifests as cool clammy skin and restlessness. And if perfusion isn't restored, tissue damage can include more layers of the heart contributing further to cardiac damage and dysfunction.

Nurse Heidi realizes Fritz needs prompt restoration of coronary perfusion to prevent further cardiac damage. Now, using the information she's gathered, nurse Heidi chooses a priority hypothesis of ineffective tissue perfusion.

Then she generates solutions to address Fritz's ineffective tissue perfusion including pharmacologic and nonpharmacologic interventions.

And she establishes the expected outcome that after intervening Fritz will show signs of improved tissue perfusion within 15 minutes.

Then nurse Heidi takes action to implement these solutions. First, she reviews orders placed by the emergency provider that include preparing Fritz for percutaneous coronary intervention or PCI and to titrate oxygen to achieve an oxygen saturation above 90%.

There are also orders to administer IV nitroglycerin, morphine, sulfate and heparin as well as oral clopidogrel. Carvedilol and Enalapril.

After gathering the necessary supplies, nurse Heidi reenters Fritz's room. Fritz.

I spoke with the emergency provider who'd prescribed some medications that will help increase the blood flow to your heart and prepare you for your procedure.

There's also a medication that will help your pain. Ok?

I just want this pain to go away and I've heard I have to have this procedure, but I didn't really understand you're going to have a procedure to help open the blocked blood vessel in your heart.

I'll give you these medications and then I can explain more about the procedure and answer your questions. After Fritz agrees to the plan of care.

Nurse Heidi increases his oxygen to 4 L via nasal cannula and programs the vital signs monitor to record his BP every five minutes.

Then she administers the prescribed medications following the principles of safe medication administration. Next, nurse Heidi positions Fritz with the head of the bed at 15 degrees to facilitate blood return to the heart and then explains PCI to Fritz and answers his questions about the procedure.

The PCI surgeon meets with Fritz to obtain consent for the procedure. While nurse Heidi completes the pre surgical checklist.

Nurse Heidi verifies the informed consent for PCI has been signed and calls reports to the PCI team from Fritz's bedside.

15 minutes later, the PCI team arrives at Fritz's bedside to transport him for his procedure before Fritz is transferred.

Nurse Heidi evaluates the outcomes of her actions. She takes Fritz's vital signs which are temperature 98.9 °F or 37.1 °C, heart rate, 94 BPM respirations, 22 breaths per minute BP, 92/56 millimeters of mercury and oxygen saturation, 94% on 4 L, nasal cannula Fritz rates his chest pain as a six on a 0 to 10 numeric pain scale.

She also notes his skin is warmer, he's more relaxed and his peripheral pulses are stronger. All right.

As a quick recap. Nurse Heidi recognized and analyzed cues related to Fritz's ineffective tissue perfusion and prioritized hypotheses and generated solutions to address this problem.

Nurse Heidi then took action to implement pharmacologic and nonpharmacologic measures to manage Fritz's ineffective tissue perfusion and evaluated the outcomes compared with the expected outcomes.

Since Fritz showed signs of improved tissue perfusion. After 15 minutes, nurse Heidi determined the plan of care was successful.