What information did you receive from the hand-off communication and your observation?

Mr. Sanborn is a 55 year old male who experienced substernal chest pain and was brought to the hospital by ambulance. A STEMI alert was called and the goal is that the patient will be brought to the cath lab with a door to balloon time of 45 minutes.

1.            What information did you receive from the hand-off communication and your observation?

2.            What are the initial nursing interventions that need to be performed when Mr. Sanborn arrives in the emergency room? Why?

3.            What are the apparent risk factors that Mr. Sanborn has for cardiac disease?

4.            The physician orders a Nitro drip and the IV bag has 25mg in 250ml. What rate and dose will you start the Nitroglycerine at?

5.            What complications can result before you get Mr. Sanborn to the cath lab?

6.            What type of EKG changes do you anticipate? Rhythms?

7.            Upon transfer to the cardiac cath lab, the nurse explains that he may have a balloon or stent inserted in the coronary artery. What is a cardiac catheterization, PCTA, stent, rotoblator or intravascular ultrasound?

8.            What is the difference between a bare metal stent and a drug eluting stent? What drug will be required after the stent is employed?

The cardiac catheterization reveals significant disease with 75% occlusion in the distal portion of the left anterior descending (LAD), 80% in the circumflex, and the left main is 95% occluded.   A drug eluting stent was inserted in the left anterior descending and the circumflex artery. The left main requires surgery and the patient was transferred to the telemetry floor and is scheduled for surgery in the morning.

9.            What type of assessment does the patient require post cardiac cath and what type of complications may result?

10.          When would you call the rapid response team (RRT)? What type of drugs would you anticipate if the patient codes?

The patient continued to have refractory chest pain, an intraaortic balloon pump was inserted into the right groin, and the patient was transferred to OR for immediate CABG surgery.

11.          What is the purpose of an intraaortic balloon pump? Describe the nursing care that is essential for this patient.

12.          What is the purpose of the cardiopulmonary bypass machine and cardioplegia solution?

13.          What are the advantages and disadvantages of using an IMA rather than the SVG?

14.          What is the purpose of the arterial line and what nursing interventions are essential?

Mr. Sanborn has just been transferred to the ICU after successful CABG with a LIMA graft to the left anterior descending and saphenous vein grafts to the right coronary artery, circumflex and obtuse marginal artery. The total pump time was 200 minutes and was under general anesthesia for 4 ½ hours. Currently he is intubated, not responding to verbal or painful stimuli, has two chest tubes on 20cm wall suction, pacer wires, right arterial line, pulmonary artery catheter, two peripheral IV’s, and a foley catheter.

History and physical includes a strong family history of cardiac disease, hypertension, high cholesterol, an unfavorable HDL/LDL ratio.

Review the attached physican order sheet.

15.          Why does this patient have chest tubes? Describe the nursing care that is required while caring for a patient with chest tubes. Should the chest tubes be stripped/milked postoperatively?

16.          What is the purpose of pacer wires in a post-op CABG pt?

17.          Discuss the nursing care of a mechanically ventilated patient. Explain TV, FIO2, PEEP, respiratory rate and required oral care (refer to physician orders).

18.          What is the purpose of a pulmonary artery catheter? What nursing care is essential in caring for a patient with a pulmonary artery catheter? What are the normal values of the PAP, PAWP, and CVP?

19.          Why is it necessary to maintain normotension ? How about laboratory values? (refer to physician orders)

20.          Mr. Sanborn is not maintaining an adequate blood pressure. The monitor reveals:

B/P         78/46                                     CVP        6                              CT drainage 30 – 50ml/hr

HR          130                                         PaO2     90                           Urine output – 15ml/hr

PAWP   25                                           SaO2-98%                            CO – 3.2

Hgb        9.0 grams

Calculate the MAP and the Stroke Volume. Interpret all the data.

21.          What medications would you consider beneficial?

22.          What are the signs and symptoms of cardiac tamponade?

23.          What should be included in Mr. Sanborn’s discharge teaching? Health Promotion?

24.          Prioritize and list pertinent nursing diagnoses.

25.          Document your care on the flow sheet and also narrative format.