Jose Martinez Scenarios

Jose Marti nez 1 Jose Martinez | Room 302 Patient Overview Jose Martinez43-year-old male experiencing chest pain while watching a state rivai football game earlier in the evening. Chest pain became progressively worse, so he called for an ambulance to bring him to the Emergency Department. Once the ambulance anved, he reported his pain as 10/10. The 12-lead EKG showed Sinus Tachycardia, Vital signs were HR 110, BP 145/102. Respirations 23, and Pulse Ox 95%. He was given nitroglycerin during transport to the hospital with little relief. He complained of feeling "light headed. He has been admitted to the unit, and the pain has subsided. He does have a 10-year history of hypertension. He was transferred here to the cardiac stepdown unit from the ER, because no beds were open in cardiac ICU. Ambularice report: Nitroglycerin SL x 3, 12 lead EKG, Elood drawn for cardiac enzymes, Peripheral IV started to left forearm. You responded correctly to 4 out of 6 evaluations: Category Your response Educational Needr Increased arity Foll Rick increased acuity Health change increased acuity Neuralogical XNormal Paan vel Xfncrused acuity Psychological Needs increased arsity Explanation Mr. Martinez needs further understanding of why he is having chest pains ane the risks associated with cardiac injury Due to Mr. Martinez feelingt headed as well as an increased level in pair, he in at sk for falling Due to the risk of cardiac njury, possible vessel blockage, and history of hypertension Mr. Martinez is more sunceptible for further candies, injury. low pulse es and aghtheadedness puts the potient at an increasest need Norial Gattunade Fettend states the bal has subsided Patient is anxious Physiological Jose Marti nez 2 Description Explanation True Acute discomfort Your Response Angina (chest pain) is the pain associated with decreased blood flow to the heart muscle. Assessment above says pain has subsided Alteration in gas exchange X False Oxygen saturation is 89%. No new vital assessment to show this Alteration in tissue perfusion True Due to altered cardiac blood flow circulation. No new vital assessment to show this Altered body image False True Scenario does not support this Araxiety Patient expresses he is experiencing anxiety. Where id? Ineffectual health maintenance Toue High blood pressure, high cholesterol, and high triglycerides. Loss of power This is related to acute illness and inability to control pain. This can also be due to lack of knowledge regarding medical conditions. No new assessment to show this Potential for disturbed thought process X False Patient is lightheaded and has low pulse ox Safety Description Your Response Explanation True Drug therapy True Monitor patients for antithrombotic therapy due to increased risk for bleeding and bruising. Potential for social isolation False Scenario does not support this. Jose Marti nez 3 Jose Martinez Scenario 1 At 2200, you enter the room, and the patient states pain is now 10/10 after not having any pain for 3 hours. The HCP orders an EKG. The 12-lead EKG showed ST elevation. Vital signs were HR 160, BP 145/102, Respirations 23, and Pulse Ox 89%. Rapidly prioritize the following: Drag the following actions into the correct order. (The first item should be on top.) 1 Assess airway, breathing, circulation. 2 Reassess patient's vital signs and pain level. 3 Administer oxygen therapy to make sure oxygen saturation is greater than 90% 4 Provide Morphine Sulfate IVP as prescribed. 5 Ensure continuous EKG monitoring. Jose Martinez Scenario 1 At 2200, you enter the room, and the patient states pain is now 10/10 after not having any pain for 3 hours. The HCP orders an EKG. The 12-lead EKG showed ST elevation. Vital signs were HR 160, BP 145/102, Respirations 23, and Pulse Ox 89%. Rapidly prioritize the following: You correctly ordered 3 out of 5 actions: Your order Correct order Step x2 4 1 2 Assess airway, breathing, circulation. Administer crygen therapy to make sure oxygen saturation is greater than 90% Ensure continuous EKG monitoring Explanation Assasament is always the fiest step in the nursing process. Myocardial oxygen demand is increased during an acute event. Analyses of the EKG is essential to0 ensure appropriate patient care management. Provide Morphine Sulfate IVP as prescribed. Pain relief helps increase the oxygen supply and decrease myocardial oxygen demand. Reassess patient's vital signs and pain level, After proper treatment, reassess patient's respose to interventions Jose Marti nez 4 Jose Martinez Scenario 2 Mr. Martinez was taken emergently to the Cath-lab and had 3 stents inserted in his heart. The pain was relieved post-op. He has been informed that for the next 18 months he should take antithrombotic therapy daily. Drag the following actions into the correct order. (The first item should be on top.) 1 Monitor aPTT 2 Observe for bleeding. 3 Initiate IV Heparin. 4 Assess for the abrupt cessation of pain 5 Give ASA You correctly ordered 5 out of 5 actions: Your order Correct order Step 1 1 Assess for the abrupt cessation of pain Initiate IV Heparin. 3 3 Give ASA V4 4 Observe for bleeding, S 5 Monitor aPTT Explanation Indicates that the clot has been dissolved. 2 2 Large amounts of thrombin are released increasing the risk for vessel reocclusion. Maintain the patency of the coronary artery after percutaneous coronary intervention. During thrombolytic administration immediately report any indications of bleeding to the Healthcare Provider, Used for evaluation of Heparin therapy.