Question

Mr. S. is a 56-year-old man who had an anterior wall myocardial infarction 5 years ago. His medical history is significant for diabetes type 2, obesity (body mass index of 35), and hypertension. He arrived on the cardiac care unit from the emergency room with three-pillow orthopnea, PND, and lower-extremity edema that has gotten progressively worse over the last week. He denies chest pain or pressure or palpitations. On examination, his vital signs are as follows: blood pressure 80/50, heart rate 110, respiratory rate 40, pulse oximetry 85%. He is sitting upright and appears to be distressed with intercostal retractions. Jugular venous distention is noted to his mandible. Cardiac examination reveals a point of maximal impulse in the anterior axillary line 6th intercostal space. Auscultation of the heart reveals an irregularly irregular rhythm, S1, S2, S3, and a grade III/VI systolic murmur at the apex. You note bibasilar crackles. The distal pulses are weak and the lower extremities have pitting edema to his knees. Skin is cool and moist. ECG reveals a sinus tachycardia with frequent premature ventricular contractions (PVCs) and an left bundle branch block (LBBB). There are no ST changes. Labs are as follows: Glucose 186 mg/dL T bilirubin 2.8 mg/dL Na 124 mg/dL AST/ALT 163 IU/L/152 IU/L K 5.8 mEq/L Troponins negative BUN 68 mg/dL BNP 3,068 pg/mL Creatinine 2.3 mg/dL EF of 25% Home medications include metoprolol XL 50 mg daily, lisinopril 10 mg daily, and atorvastatin 20 mg daily. His wife tells you he works full time as a business consultant and travels extensively. Most of his meals are eaten in a restaurant during the week. He drinks one to two glasses of wine daily and, while he has decreased the amount that he smokes from a full pack to half a pack per day, he has not been able to stop smoking completely since his myocardial infarction.

1.  What is your assessment of Mr. S.’s condition, and what are your nursing priorities?

2.  You have returned to work 2 days later, and Mr. S. is sitting in chair on room air feeling much improved. His wife is visiting with him and asks how Mr. S. should take care of himself at home. How would you educate Mr. and Mrs. S?

3.  The cardiologist would like to place a biventricular ICD in Mr. S. His wife and he do not fully understand why this would be an appropriate option for Mr. S. How would you educate Mr. and Mrs. S. about biventricular ICD placement?

Answer 1

1.Assessment includes

• Irregular rate and rythm.
• Decreased or incresed BP.
• Decreased oxygen saturation
• Chest, neck, shoulder, back, jaw or arm pain.
• Dizziness, syncope.
• Dyspnea.
• Numbness, tingling of arms.
• Cold, clammy skin.
• Diaphoresis.
• Pallor
• Palpitations
• Nausea and vomiting.

Nursing interventions

Initial

• Ensure patent airway.
• Administer Oxygen via nasal cannula or non-breather mask.
• Obtain baseline vitals.
• Obtain 12-lead ECG.
• Initiate continuous ECG monitoring.
• Identify underlying rythm.
• Identify dysrhythmia.
• Establish IV access.

Ongoing Monitoring.

• Monitor vital signs, level of consciousness, oxygen saturation and cardiac rhythm.
• Anticipate need for administration of antidysrhytmia drugs.
• Anticipate need for intubation if respiratory distress is evident.
• Prepare to initiate advanced cardiac life support, such as CPR, defibrillation, transcutaneous pacing.

2

• Advice the patient about prophylaxis for venous thromboembolism.
• Explain to the patient about the importance of cardiac diet.
• Prevention of skin breakdown are important.

3.The implantable cardioverter -defibrillator is an important technology for patients who have survived SCD, have spontaneous sustained VT, have syncope with inducible ventricular tachycardia during EPS and are at high risk for future life threatening dysrhytmias. Use of ICD has significantly decreased cardiac mortality rates. Explain to the patient that in addition to defibrillation capabilities, ICDs are equipped with antitachycardia and anyibradycardia pacemakers. These sophisticated devices use dysrhytmias algorithms that detect dysrhytmias and determine the appropriate programmed response. They also provide backup pacing for bradydysrhythmias that may occur after defibrillation discharges.