Hypertension

hyperlipidaemia

diabetes, and one pack/day smoker for 40 years.

EKG in the ER showed a STEMI, code "STEMI" called, and she was quickly taken to the Cath lab, She received four 81mg baby aspirin in the squad as well as 2 sublingual nitro-glycerine with pain relief, in the ER she received 180mg of Brilinta (Ticagrelor), a 4,000 unit bolus of heparin, and a heparin drip started at 12units/kg/hr. The patient weighs 80 kg Mrs.

Marsh underwent an emergent cardiac catheterization with stent placement to her left anterior descending (LAD) artery. During the procedure, the patient experienced a ventricular fibrillation (VF) arrest. The patient was defibrillated twice with 200 and 300 joules, 1 mg of epinephrine and 300 mg of amiodarone was administered, followed by an amiodarone drip at 1 mg/min and ROSC was achieved. She is now intubated, and a balloon pump was placed via the right femoral artery. Ejection Fraction (EF) estimated at 15-20%, M. Access includes pulmonary artery catheter via right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

• Mode: Assist-control (A/C)
• Respiratory rate: 14/min
• Tidal volume: 500 mL
• PEEP: 5 cm H₂O
• FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

• Pulmonary artery pressure: 45/20 mm Hg
• Central venous pressure (CVP): 10 mm Hg
• Pulmonary artery occlusion pressure (PAOP): 22 mm Hg
• Cardiac output: 3 L/min
• Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped. Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

• Heparin 12 units/kg/hr
• Amiodarone 1 mg/min
• Dobutamine 2.5 mcg/kg/min
• Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

Mode: Assist-control (A/C)

Respiratory rate: 14/min

Tidal volume: 500 mL

PEEP: 5 cm H₂O

FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped. Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 34 g/dL

Hematocrit: 11%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

Mode: Assist-control (A/C)

Respiratory rate: 14/min

Tidal volume: 500 mL

PEEP: 5 cm H₂O

FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped.

Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

Mode: Assist-control (A/C)

Respiratory rate: 14/min

Tidal volume: 500 mL

PEEP: 5 cm H₂O

FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped.

Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped.

Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Cardiac

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% non-rebreather mask

Pain: 0/10

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

0930

Client was intubated with a #6 endotracheal tube and placed on assist-control mechanical ventilation.

Rate: 14/min

PEEP: 5 cm H₂O

FiO₂: 60%

1000

Chest X-ray obtained.

IV placed and midazolam administered.

EKG shows sinus tachycardia.

0900

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

0930

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 14/min

Blood pressure: 180/90 mm Hg

Pulse oximeter: 96%

Client is restless.

Nursing Orders

Insert urinary catheter

Titrate oxygen to maintain pulse oximeter reading ≥ 95%

Start IV of 0.9% normal saline at 75 mL/hr

Amoxicillin 500 mg IVPB every 12 hours

Midazolam 2–4 mg IVP every 1 hour as needed for agitation

Acetaminophen 650 mg per rectum every 8 hours as needed for temperature > 100.8°F

Suction endotracheal tube as needed

Perform 12-lead EKG

Call for chest X-ray

Obtain arterial blood gas (ABG) in 30 minutes