Med Surg Case Study #28: Tracey Steems

Tracey Steems | 68 years old

Chief Complaint: Tracey presents with episodes of chest pain.

Medical History:

• Tracey has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus.

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0900

Nurse's Note: Tracey reports experiencing intermittent episodes of chest pain over the past 24 hours. She describes the pain as pressure-like, radiating to her left arm and jaw. Pain intensity is rated 7/10 on the pain scale. The episodes occur at rest and with minimal exertion. Vital signs stable.

Vital Signs:

• Blood pressure: 150/88 mmHg

• Heart rate: 84 bpm

• Respiratory rate: 16 breaths/min

• Temperature: 98.2°F (36.8°C)

Provider Orders:

• Administer oxygen via nasal cannula at 2 L/min.

• Obtain 12-lead electrocardiogram (ECG).

• Start continuous cardiac monitoring.

1130

Nurse's Note: Tracey's chest pain persists despite oxygen therapy. She appears anxious and diaphoretic. ECG shows ST-segment depression in leads II, III, and aVF consistent with myocardial ischemia. Troponin levels are within normal limits.

Vital Signs

• Blood pressure: 152/92 mmHg

• Heart rate: 92 bpm

• Respiratory rate: 20 breaths/min

• Temperature: 98.6°F (37.0°C)
  

Provider Orders:

• Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a maximum of 3 doses.

• Initiate intravenous beta-blocker therapy with metoprolol 5 mg slow IV push.

• Notify cardiology for urgent evaluation.

0930

Nurses Note: Tracey's chest pain persists despite nitroglycerin and beta-blocker therapy. She remains hemodynamically stable but anxious. Cardiology team at bedside for evaluation.

Vital Signs:

• Blood pressure: 164/86 mmHg

• Heart rate: 101 bpm

• Respiratory rate: 18 breaths/min

• Temperature: 98.4°F (36.9°C)
  

Provider Orders:

• Transfer Tracey to the cardiac care unit for further management.

• Continue cardiac monitoring and oxygen therapy.

• Order laboratory studies including complete blood count (CBC), comprehensive metabolic panel (CMP), and coagulation studies.

Question 1: Why was sublingual nitroglycerin administered to Tracey?

Question 2: What is the rationale for initiating beta-blocker therapy with metoprolol?

Question 3: Why was Tracey transferred to the cardiac care unit?

Question 4: Why was Tracey transferred to the cardiac care unit?

Answers to Questions Below

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Answers

Question 1: Why was sublingual nitroglycerin administered to Tracey?

Common signs and symptoms of pneumothorax include sudden onset chest pain, dyspnea, and decreased breath sounds on the affected side. The patient may appear anxious and may have tachypnea and tachycardia.

Question 2: What is the rationale for initiating beta-blocker therapy with metoprolol?

Supplemental oxygen is administered to Hemalade to improve oxygenation and alleviate hypoxemia associated with pneumothorax. Increasing the fraction of inspired oxygen helps compensate for the reduced lung function due to lung collapse.

Question 3:Why was Tracey transferred to the cardiac care unit?

Tracey was transferred to the cardiac care unit for closer monitoring and specialized care due to the severity of her unstable angina. In the cardiac care unit, she can receive continuous cardiac monitoring, frequent assessment, and prompt intervention in case of deterioration or the need for further interventions such as cardiac catheterization.

Question 4:Why was Tracey transferred to the cardiac care unit?

Laboratory studies including complete blood count (CBC), comprehensive metabolic panel (CMP), and coagulation studies are ordered to assess Tracey's overall health status, electrolyte balance, renal function, and coagulation profile. These tests help to identify any underlying conditions or factors that may contribute to her unstable angina and guide further management.

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