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Please read through the following case analysis and answer the six questions. Submit a written discussion and analysis of the patient’s presentation, management regimes and clinical outcomes. Use recent research literature and best practice guidelines in your discussion. You can use the grading criteria to guide the depth of your discussion. This assessment item will be graded using the Case Analysis Rubric, which you can see in CNnect. Please note: the word count in each section is a rough guide. However, overall count should be as stated above.

Case study

Mr Wren, aged 48-years-old, is admitted to your unit through the emergency department. He has diet controlled type II diabetes mellitus, no previous cardiac history, but has a strong family cardiovascular disease background. Both of his parents died of acute myocardial infarctions in their fifties. His pain was of sudden onset and occurred while he was driving. He described the pain as central and crushing, not relieved by antacids. The pain has got progressively worse and is now rated 9 out of 10. Mr Wren is a truck driver, married with three teenage children. He has never smoked and drinks moderate alcohol on weekends only

Clinical observations

RR……………………………….. 24 per minute

HR………………………………. 60-70 beats per minute, regular, pulse weak and thready

BP……………………………….. 120/90 mmHg, peripheries are cool and clammy

BSL……………………………. 9 mmol/L

JVP (jugular venous pressure) is not elevated, ECG No: 1 was recorded in the ED

The patient is alert, orientated and anxious

Question 1 (400 words)

Discuss the significance of the 12 lead ECG findings in the context of Mr Wren’s presentation. In view of these abnormalities, discuss the following: (You do not need to submit a written step by step systemic ECG analysis)

• coronary vessels involved
• myocardium at risk
• conduction tissue at risk
• potential rhythm disturbances you would anticipate.

Figure 1, Mr Wren’s initial 12 lead ECG

Question 2 (500 words)

The medical officer orders:

• morphine 5 mg IV bolus prn (titrate to pain)
• aspirin 300 mg
• aggrastat – as per ACS protocol
• heparin 5000 units IV bolus followed by heparin 25 000 units in 500 mls titrated to APTT.

Discuss the rationale for this medical therapy and critically reflect on the nursing management required to ensure optimum patient care.

 

Question 3 (500 words)

 

Shortly after Mr Wren is commenced on the above medical therapy he becomes clammy and dyspnoeic. He is conscious, but difficult to rouse.  A 12-lead ECG is recorded, see Figure: 2, and his observations are as follows.

Clinical observations

RR……………………………….. 34 per minute

BP……………………………….. 70/40 mmHg

HR………………………………. 40 beats per minute

 

The patient is transferred to the Cath Lab for a coronary angiogram. Mr Wren is found to have triple vessel disease, with the following lesions: Mid LAD – 85%, proximal Circumflex – 80% and completely occluded RCA. An Intra Aortic Balloon Pump and a temporary pacing wire are inserted. Despite this, his PB remains low – systolic 90 – 100 mmHg. He is transferred to CCU for and commenced on Dopamine and Dolbutamine protocol. He is scheduled for urgent CABG surgery.

Discuss the significance of these findings in the context of Mr Wren’s current status, focusing on the role of inotropes in this patient’s ongoing medical and nursing management.

 

Figure 2: Mr Wren’s second 12 lead ECG

Figure 3: Mr. Wren’s final ECG

Question 4 (400 words)

Mr Wren was transferred to operating theatres for a three vessel bypass graft. He received a LIMA graft to the LAD, and a saphenous vein grafts to the RCA and the Circumflex arteries. The patient was extubated 24 hours post surgery and maintain his PaO2 above 95% using supplemental oxygen. However, he is intermittently paced via epicardial wires and requires an IABP to maintain his mean PB above 70mmHg.

Critically evaluate the use of temporary pacing and IABP as means of providing haemo-dynamic support in this patient.

Question 5 (400 words)

After four days Mr Wren’s status has significantly improved and he does not require permanent pacing. He is now ready for discharge to a subacute area. An ECGs is recorded, see Figure: 3. In view of your findings, discuss Mr Wren’s ongoing health management, patient education and discharge planning.