Acute Coronary Syndrome Case Study

Case Study 16 Acute Coronary Syndrome

Difficulty: Advanced

Setting: Emergency department, hospital, home care

Index Words: heart failure (HF), coronary artery disease (CAD), arm fracture, communication deficit, cultural diversity, geriatric, laboratory values, therapeutic nutrition, medications, electrolytes

Giddens Concepts: Care Coordination, Communication, Culture, Fluid and Electrolyte Balance, Perfusion

HESI Concepts: Assessment, Care Coordination, Communication, Cultural/Spiritual, Fluid & Electrolyte, Perfusion



You are just getting caught up with your work when you receive the following phone call: “Hi, this is Deb in the emergency department. We’re sending you M.M., a 63-year-old Hispanic woman with a past medi- cal history of coronary artery disease (CAD). Her daughter reports that her mom has become increasingly weak over the past couple of weeks and has been unable to do her housework. Apparently, she has had complaints of swelling in her ankles and feet by late afternoon ‘she couldn’t wear her shoes’ and has nocturnal diuresis× 4. Her daughter brought her in because she has had heaviness in her chest off and on over the past few days but denies any discomfort at this time. The daughter took her to see her family physician who immediately sent her here. Vital signs are 146/92, 96, 24, 99 ° F (37.2 ° C). She has an IV of D5W at 50 mL/hr in her right forearm. Her laboratory results are as follows: Na 134 mEq/L, K 3.5 mEq/L, Cl 103 mEq/L, HCO3 23 mEq/L, BUN 13 mg/dL, creatinine 1.3 mg/dL, glucose 153 mg/dL, WBC 8300/mm3, Hct 33.9%, Hgb 11.7 g/dL, platelets 162,000/mm3. PT/INR, PTT, and urinalysis are pending. She has had her chest x-ray and ECG, and her orders have been written.”

· Scenario


1. What additional information do you need from the emergency department (ED) nurse?



2. How are you going to prepare for this patient?



1 Cardiovascular Disorders


3. M.M. arrives by wheelchair. As she transfers to the bed, what observations will you make? Why?



4. Given the previous information, you can anticipate orders for M.M. Carefully review each order to determine whether it is appropriate or inappropriate as written. If the order is appropriate, mark it as A; if the order is inappropriate, mark it as and change the order to make it appropriate. Provide any other orders that might be appropriate for M.M.

1. Routine VS

2. Serum magnesium (Mg) STAT

3. Up ad lib

4. 10 g sodium (Na), low-fat diet

5. Change IV to a saline lock

6. Cardiac enzymes on admission and q8h × 24 hr, then daily every morning

7. CBC, BMP, and fasting lipid profile in morning

8. Schedule for abdominal CT scan for am

9. Heparin 10,000 units subcut q8h

10. Docusate sodium (Colace) 100 mg/day PO

11. Ampicillin 250 mg IV piggyback q6h

12. Furosemide (Lasix) 200 mg IV push STAT

13. Nitroglycerin (NTG) 0.4 mg 1 SL q4h prn for chest pain

14. Schedule echocardiogram


1 Cardiovascular Disorders


5. Which interventions are appropriate for administering subcutaneous heparin? Select all that apply.

a. Rotate injection sites with each dose.

b. Monitor activated partial thromboplastin time (aPTT) levels daily.

c. Massage the area after the injection.

d. Give the injection at least 2 inches away from the umbilicus.

e. Do not aspirate the syringe before injecting the heparin.



Shortly after admission, M.M.’s call light comes on. When you respond to M.M.’s call light, you observe she is talking rapidly in Spanish and pointing to the bathroom. Her speech pattern indicates she is short of breath; she is having trouble completing a sentence without taking a labored breath. You help her use a bedpan and note that her skin feels clammy. While sitting on the bedpan, she vomits.


6. On a scale of 0 to 10 (0 being no problem, 10 being a code-level emergency), how would you rate this situation, and why?




7. Identify at least four actions you should take next, and state your rationale.



1 Cardiovascular Disorders


8. M.M.’s physician calls your unit to find out what is happening. Using SBAR, what information would you need to convey at this time?



9. The hospital’s staff physician is coming to the floor immediately to evaluate the patient. In the meantime she orders furosemide (Lasix) 40 mg IV push STAT. You have only 20 mg in stock. Should you give the 20 mg now, and then give the additional 20 mg when it comes up from the pharmacy? Explain your answer.



10. M.M. continues to experience vomiting and diaphoresis that are unrelieved by medication and comfort measures. A STAT 12-lead ECG reveals ischemic changes, and she is transferred to the coronary care unit (CCU). As you give the report to the receiving registered nurse, what laboratory value is the most important to report, and why?



11. You are monitoring while a new nurse prepares to administer IV potassium to M.M. Which technique is correct? Explain why the other answers are incorrect.

a. Give the IV potassium by slow IV push.

b. Add potassium to a hanging IV bag as needed.

c. The rate of IV administration should not exceed 10 mEq/hr.

d. Administer the IV potassium by gravity drip.





1 Cardiovascular Disorders



While recovering in the CCU, M.M. tried to get up out of the bed, fell, and fractured her right humerus. Because of the surgical risks involved, M.M. was treated conservatively and put in a full arm cast. She is transferred back to your floor.


A case manager (CM) has been asked to evaluate M.M.’s home to see whether she can be discharged to her own home or will need to stay in a long-term care facility.


12. Identify at least eight things that the CM would assess.




13. M.M.’s nutritional intake over the past few weeks has been poor. She also has increased nutritional needs because of her fractured arm. What are some of the nutritional needs that should be met? What would you recommend to help her with this?




Because the case manager determined that M.M. lived in an apartment with poor access, M.M. elects to stay with her daughter and five grandchildren in their small home. A home care nurse comes three times a week to check on her. M.M. is easily fatigued, and the children are quite lively. School is out for the summer.


14. Suggest some ways for M.M.’s daughter to ensure that her mother is not overwhelmed and does not become exhausted in this situation.


Step-by-Step explanation

Current medications she is on, any advance directive information, code status, family history, allergies, and if any cardiac markers had been ordered as well. I would also ask more in-depth questions about the cardiac symptoms and their onset, whether there’s any pain, indigestion, etc.


Patient’s height/weight, precipitating events for the chest pain, O2 sat, IV gauge, has this happened before, admitting diagnosis, cultural considerations and possible need for an interpreter, CXR results and any sign of change, LOC.




  1. Have the oxygen set up ready in case it needs to be used
  2. I would check any doctor orders for medicine that needs to be given; ex/ morphine, nitrate, aspirin
  3. Ask patient if she has any pain upon arriving to unit
  4. Also look for orders pertaining to high glucose; plan on taking her glucose at appropriate times
  5. If ECG monitoring not done yet, prepare for this


Step-by-Step explanation


  1. Have the oxygen set up ready in case it needs to be used
  2. I would check any doctor orders for medicine that needs to be given; ex/ morphine, nitrate, aspirin
  3. Ask patient if she has any pain upon arriving to unit
  4. Also look for orders pertaining to high glucose; plan on taking her glucose at appropriate times
  5. If ECG monitoring not done yet, prepare for this



The following are the most common and significant cardiac symptoms and histories:


○Pain, tightness, or discomfort in the chest.
○Breathing difficulty.
○Palpitations are heart palpitations.
○Dizziness or syncope
○Transient ischaemic attacks, stroke, peripheral arterial disease, and peripheral oedema are all examples of related cardiovascular history

Step-by-Step explanation

First, inquire about any symptoms of high blood pressure, heart problems, fainting fits, dizziness, or collapses. Take note of any previous heart attacks, a history of angina, and any cardiac procedures or operations (type and date of intervention and outcome). Check the previous lipid levels, if ever checked or known. Lastly, inquire about any history of rheumatic fever or heart problems when she as a child.


Note any additional procedures or diseases, in particular myocardial infarction history, hyperlipidaemia, hypertension, stroke, diabetes.



a . and b . and d . and e .

Step-by-Step explanation

Option a: This option is correct  because rotation of sites avoid the building up of fatty tissue which can occur when shots are given at same site. In this condition fats breaks down and build it under the skin.


Option b: This option is correct because PTT monitoring is essential to target the therapeutic range of anti-coagulation. Heparin is an anticoagulant and will affect the PTT.


Option c: This option is incorrect because massaging may damage the underlying tissue. Do not massage the site instead apply gentle pressure which improves absorption.


Option d: This option is correct because  the tissue immediate the navel is tougher which cause the absorption of heparin slower. The place 2 inch away from navel is  best for heparin as this area absorb heparin consistently.


Option e: This option is correct because aspiration of needle causes tissue damage, hematoma formation and bruising



This situation would receive a 7 on a scale of one to ten. Her chest has already felt heavy; increased shortness of breath, laborious breathing, clammy skin, & vomiting could all be indicators of worsening HF or an approaching MI. Her need for oxygen is growing. We want to act quickly to improve the chances of a positive patient outcome.

Step-by-Step explanation

Shortness of breath might occur even without chest pain after a heart attack. While certain signs as well as symptoms of a heart attack may not even be life threatening, they might develop if you do not act swiftly. Most individuals are unsure that this can develop or during a heart attack, particularly among women.
Difficulty breathing is indeed the third most popular sign before the first heart attack amongst women, as well as the most common symptoms throughout a heart attack, according to research.




S- I am calling for px MM a 63 yo woman who came in for cardiac symptoms, she is currently complain of shortness of breathing, clammy and showing Increase in work of breathing.  She has difficulty in completing her sentence and vomited once.


B- she has previous coronary artery disease, and noted to have she tightness in the pass week


A- I think the patient is suffering from Acute Myocardial Infarction.  There is an impenting major cardiac event, possible cardiac arrest.


S- I request you to come see the patient.  In the mean time do you need any diagnostic proceedure done, such as ecg, cxr, Trop i, pro BNP, PT, APT, electrolyte (na, k, ma, ca)? Are there any emergency medication you would like to to give?


Step-by-Step explanation

S- stand for situation. Relay the patient current status including the vital signs, sign and symptom.

B- background- always include significant medical history or medication that can contribute to patient status.  Also include other fact known about the patient

A- stand for assessment.  This part should include your assessment for the patient or what you think is causing the patient signs and symptoms. Must be Specific.

R – stand for the recommendation. It should include suggestions to what could be done for the patient to correct the problem.  Suggestions of any diagnostic procedure if needed.



The cardiac indicators of MM would be crucial. These biomarkers are measured to aid in the diagnosis of acute coronary syndrome (ACS) and myocardial ischemia.

Step-by-Step explanation

The cardiac indicators of MM would be crucial. These biomarkers are measured to aid in the diagnosis of acute coronary syndrome (ACS) and myocardial ischemia.

When the heart is damaged or strained, molecules called cardiac biomarkers are released into the bloodstream. Acute coronary syndrome (ACS) and cardiac ischemia, both of which are caused by a lack of blood supply to the heart, are diagnosed using these biomarkers.
Cardiac marker tests detect substances in the blood that are linked to myocardial infarction (MI), sometimes known as a heart attack. The myocardium, which is made up of heart muscle, is the middle layer of the heart wall. A tissue death induced by a disruption in the blood supply to a region is known as an infarction.