Pharmacology Made Easy 4.0: Perfusion
Problem Based Scenario
Directions: With your small group, complete this worksheet utilizing information from your Module Worksheet, the Active Medication Templates and class lecture.
Clinical Scenario:
Jacob Jameson is a 67-year old retired teacher, who presents to the emergency room with complaints of difficulty breathing, fatigue, dizziness and abdominal pain. Patient has a history of congestive heart failure and complains of heaviness to his chest. He reports feeling increasing fatigue, and dyspnea on exertion over the last 24 hours. Patient with a past medical history of hyperlipidemia. He frequently consumes a diet high in fat and smokes two packs of cigarettes per day.
Noticing:
- What are some risk factors for coronary artery disease (CAD) based on Mr. Jameson clinical scenario?
- What diagnostic test is necessary based on the patient clinical scenario?
- What are the manifestations of a myocardial infarction that Mr. Jameson might be presenting with?
Interpreting Client Chart:
| Last documented VS: |
| T: (oral) 98.9o |
| P:(regular)112/min |
| R:(regular)22/min |
| BP: 169/90 |
| O2 sat: 94% |
| Last documented Assessment: | |
| GENERAL APPEARANCE: | Resting in bed, sitting upright |
| RESP: | Breath sounds diminished in the lower bases, crackles noted on auscultation in upper lobes. |
| CARDIAC: | Pink, warm & dry, heart sounds regular with no abnormal beats, pulses strong. Patient with 2+ pitting edema noted to bilateral lower extremity. |
| NEURO: | Alert and oriented with periods of confusion |
| GI: | Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Client reports that he is having intermittent episodes of abdominal pain. |
| GU: | Urinating clear yellow urine. |
| SKIN: | Warm, dry, and intact. Decreased skin turgor |
| Basic Metabolic Panel (BMP:) | Current: |
| Sodium (135–145 mEq/L) | 138 |
| Potassium (3.5–5.0 mEq/L) | 3.2 |
| Chloride (95–105 mEq/L) | 99 |
| Glucose (70–110 mg/dL) | 100 |
| Calcium (8.4–10.2 mg/dL) | 8.8 |
| BUN (7–25 mg/dl) | 34 |
| Creatinine (0.6–1.2 mg/dL) | 1.2 |
| Complete Blood Count (CBC) | Current: |
| WBC (4500-10,000/ml) | 5400 |
| Hgb (12-18) | 11.5 |
| Hct (42-52%) | 37 |
| Platelets (150-400,000/ml) | 229,000 |
| Cardiac markers | Current: |
| Troponin(<0.4mg/ml) | 1.8 |
| CPK total (38-174U/I) | 594 |
| Ck-mb (<5%) | 55 |
| BNP less than 100pg | 1150 |
Evaluation of clients’ chart: Describe abnormal findings and describe your thoughts about these findings?
Noticing: Is there a finding that requires immediate follow up? If so, which finding did you notice?
Noticing: Which risk factors are modifiable or nonmodifiable for CAD based on reviewing the patient client scenario?
Interpreting: For each potential nursing intervention, click to specify whether the intervention is indicated, nonessential, or contraindicated for the care of the client (Place an “x” in the necessary boxes):
| Indicated | Nonessential | Contraindicated | |
| Obtain a 12 lead EKG per facility policy | |||
| Place the patient on bed rest | |||
| Administer oxygen via 2 liters NC | |||
| Administer morphine sulfate 4m IV push for pain unrelieved by nitroglycerin | |||
| Assess vital signs |
The health care provider prescribes the following medication orders for Jacob:
| Medication | Why was this ordered for Jacob? |
| Administer nitroglycerin 0.4 mg sublingually every 5 minutes for a maximum of 3 doses for chest pain. | |
| Insert 2 peripheral IV’S | |
| Oxygen at 2 liters via nasal cannula to maintain O2 sat >95% | |
| Administer Aspirin 325 mg by mouth X 1 |
Clinical Scenario Progression:
The next day Jacob Jameson is transferred to the medical surgical unit. Jacob has been diagnosed with myocardial infarction and worsening coronary artery disease. The patient requires education for both myocardial infarction prevention and managing coronary artery disease.
Interpret: Mr. Jameson has been prescribed the medications below. Complete the chart:
| Medication | Dose, Route, Frequency | Why is this medication ordered for Jacob? |
| Atorvastatin | 40 mg by mouth daily @ bedtime | |
| Amlodipine | 10 mg by mouth daily | |
| Aspirin | 325 mg by mouth daily | |
| Nitroglycerin | 0.4 mg SL prn for max of 3 doses | |
| Morphine Sulfate | 4 mg IV for chest pain unrelieved by nitroglycerin |
Responding: Mr. Jameson starts to complain of chest pain as you enter the room. What will be your first nursing response and why?
Responding: Which of the following prescribed medication(s) would you administer and why?
| Medication | Dose, Route, Frequency |
| Atorvastatin | 40 mg by mouth daily @ bedtime |
| Amlodipine | 10 mg by mouth daily |
| Aspirin | 325 mg by mouth daily |
| Nitroglycerin | 0.4 mg SL (sublingually) prn |
Responding: You are preparing to administer the medication for chest pain. What is an important nursing action prior to administering this medication?
Interpreting: What instructions should be provided for a client taking nitroglycerin?
Reflecting: What is your next nursing action after administering the nitroglycerin for the patient’s chest pain?
What contraindications are there for the use of nitroglycerin?
What instructions should be provided to a patient taking aspirin and what are some contraindications?
Interpret: Upon entering Jacob Jameson’s room, you assess that he is confused, and the patient’s telemetry reading is showing an ST-Segment elevation.
Interpreting: Below is the patient’s EKG
Noticing:
Why is it necessary to do a 12-lead EKG?
What does an ST-Segment elevation indicates?
Responding: What was your decision? How did you come to that conclusion?
Reflecting
Based on what you have learned about coronary artery disease and myocardial infarction, what would be your discharge teaching instructions to Mr. Jameson?
Describe the differences between stable, prinzmetal (variant) and unstable angina?
What would be your teaching to Mr. Jameson about side effects of taking atorvastatin and when he would need to notify his physician?
What instructions should the nurse include when teaching Mr. Jacob about using sublingual nitroglycerin?
What important patient information regarding side effects of cholesterol lowering medication, such as atorvastatin, should be included in the discharge teaching?