The ISBAR Handover:
Introduction: Mrs Helen Georgopoulos is a 64-year-old lady.
Situation: Mrs Georgopoulos arrived at the Emergency Department at 1130 hrs with central crushing chest pain radiating to her jaw since 1100 hrs. Findings from the 12 lead ECG recorded by paramedics showed ST elevation in leads V2, V3, V4. Aspirin 300mg administered on route to hospital.
Background: Hypertension (Captopril 12.5mg bd); Hyperlipidaemia (Simvastatin 40mg nocte); Type 2 Diabetes Mellitus (DM) (diet controlled) and Allergy – Penicillin.
Assessment:
-Airway patent
– Breathing: Respiratory rate 24, bilateral air entry, breath sounds clear. SpO2 on room air 91%
– Circulation: Sinus Tachycardia 120 bpm. BP 110/60. Diaphoretic and peripherally cool. Central crushing chest pain radiating to the jaw.
COLDSPA:
Character: crushing chest pain
Onset: 11am
Location: Central, radiating to jaw
Duration: ongoing
Severity: 8/10
Pattern: at rest, not relieved by SL Anginine Spray x 2
Associated symptoms: diaphoresis
Disability: Alert & oriented. Pupils equal and reacting to light (PEARL); Equal strength in all four limbs.
– Exposure: IVC Left cubital fossa.
– Fluid: NBM. NO IVF
– Glucose: 14.0 mmol/l
– Weight 88kg
Nursing Interventions:
1. Perform venepuncture to collect pathology – Troponin, UEC, FBC, TFTs, LFTs, BSL
2. Initiate supplemental oxygen if SpO2 < 93%
3. Attach Continuous Cardiac Monitoring
4. Record a 12-lead ECG
5. Monitor blood pressure and report systolic BP
Pathology Results:
– Elevated Troponin 35ng/L troponin
– 12 lead ECG: ST elevation (>2mm) V2, V3, V4
The diagnosis of Acute Anterior STEMI is made
Medications:
Morphine 2.5mg IVI 2/24 (PRN maximum 4 x 2.5mg doses = 10mg total)
Nitro-glycerine 600mcg SL (PRN maximum 3 doses); monitor systolic BP >100 mmHg
Clopidogrel 300mg PO STAT
Heparin 5000IU IV STAT
As per STEMI reperfusion flowchart:
Transfer to Cardiac Cath Lab for urgent primary PCI when ready (<90min)
If PCI delayed, give Tenecteplase 45mg IV as per PACSA @ 1230pm
Short Answer Questions:
1. You are the registered nurse caring for this patient. List and prioritise the order that you will complete each of the five Nursing Interventions (indicated above):
2. (200 words)Critically analyse, and then concisely explain using your own words, each of the clinical manifestations and related pathogenesis for the following: i) Central crushing chest pain with radiation to the jaw (ii) ST elevation (iii) elevated Troponin (35ng/L)
3. Question 3: (500 words)
(i) Select one Category only, from the three (3) categories given below.
(ii) Provide a rationale for each of the interventions listed for the category that you have selected.
(iii) You must critically analyse the available evidence-based literature and/or pathophysiology texts to support your rationale. You must then concisely explain the rationales using your own words.
Category 1 Non-pharmacological interventions
• Supplemental oxygen if SpO2<93%
• 12 lead ECG within 10 minutes of arrival and then every 30 minutes.
• Troponin at 0 and 2 hours
Category 2 Pharmacological interventions
Morphine 2.5mg IV
• Nitro-glycerine 600mcg SL
• Aspirin 300mg
• Heparin 5000iu IV
• Clopidogrel 300mg
Category 3
Reperfusion interventions
• Tenecteplase 45mg IV
• Primary Percutaneous Coronary Intervention
