coronary vessel/vessels/available options for fibrinolytic therapy
The purpose of this assessment is to provide you with the opportunity to demonstrate your understanding of the content and readings for the subject and apply this theory to practice by way of a case analysis.
Work through the case study and answer the questions provided. Please note: You are encouraged to read both parts of this assessment (Part A & Part B) prior to commencement to minimise the risk of any repetition.
Case study
Mr Ben Long is a 58-year-old truck driver who presents to the emergency department with a two-hour history of chest pain.
History of presenting illness
Ben describes his pain as central and crushing, radiating to his left arm, associated with shortness of breath, nausea and diaphoresis. This awoke him at 3 a.m. Ben is a 25 pack years, smoker and consumes five to ten beers a week at the local club, he is not on any regular medication, he is 163 cm tall and weighs approximately 78 kg.
Initial Assessment
Ben is pale, appears anxious and his vital signs reveal:
Heart rate………..90 beats per minute
Blood pressure…..140/90 mmHg
Respiratory rate… 22 per minute
SpO2……………..98% on 6 L/minute oxygen via a face mask (93% on room air)
Ben rates his chest pain at 9/10
A 12-lead ECG is performed and it is determined that Ben has experienced an Anterolateral MI (STEMI), with inferior
reciprocal changes. (no Q waves evident).
The ECG performed on Ben is available by clicking here Ben Long’s ECG
Question 1 ( 250 words)
Taking Ben’s diagnosis into consideration discuss the following:
the coronary vessel/vessels involved
myocardium and conduction system at risk
potential complications.
After medical review of Ben, and since angiography is not an immediate option, the doctor orders:
Continuation of oxygen
Aspirin and Clopridogrel
Intravenous morphine
Fibrinolytic therapy
Heparin
Question 2 (750 words)
Considering Ben’s current clinical condition, history and ECG, analyse and evaluate the above treatment against available evidence in the current literature. Include in your answer:
actions, dose and appropriateness of each drug
the available options for fibrinolytic therapy
nursing management of the patient related to the administration of these drugs
On going patient status:
Despite fibrinolytic therapy, Ben develops signs of left ventricular dysfunction with hypokinesia of the left septal wall confirmed on echocardiogram. Ben’s left ventricular ejection fraction (LVEF) is 41%.
Clinical assessment reveals:
Heart rate………..110 beats per minute
Blood pressure…111/70 mmHg
Respirations……..26 per minute
SaO2……………96% on 6 L/minute oxygen via a face mask.
Management:
Ben was commenced on an ACE inhibitor and a beta blocker
Question 3 (700 words)
Discuss the actions of these drugs and rationalise their use for Ben Long.
In your discussion relate to the concepts of:
left ventricular dysfunction
myocardial oxygen supply and demand
preload, afterload and contractility.
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