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This case study describes
about Mr. X, a 76-year-old male patient who presented to emergency department
(ED) at 08:00 hours with complaints of two episodes of chest heaviness in
24-hour duration. He had self-administered glyceryl trinitrate pump spray twice
totaling 800mcg resulting a poor relief. Mr. X who on general assessment
appeared pale, diaphoretic and short of breath upon arrival to the ED was
allocated a bed. The vital signs were checked and recorded — core body temperature of 36.8C (tympanic),
Blood Pressure (BP) 172/86, irregular heart rate of 103 beats per minute (bpm),
respiratory rate of 24 breaths per minute (b/min), oxygen saturation (SPO2) of
97% in room air (RA), and a perfect Glasgow Coma Scale (GCS) score of 15/15
that is, Eye opening response = 4, Verbal response = 5, Motor response =6 (E4V5M6).

The paper attempts to
identify gaps, if any, in the management of the case aforementioned. It further
presents recommendations in accordance with evidence based care so that it will
ease in the process of speedy recovery. In totality, the case study imparts
light on the significance of a comprehensive assessment, appropriate care plan
and evidence based practice in nursing interventions.

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The past medical
history of Angina, Non-ST Elevated Myocardial Infarction (NSTEMI), Hypertension
(HTN) and Hypercholesterolemia were documented along with the last intake of
toast and tea at 06:30 hours and 2 episodes of chest heaviness in 24 hours
preceding the admission to ED. Similarly, the case’s allergic reaction to
Amiodarone has been noted down. Amiodarone is classified as a Group III
Antiarrythmic agent.  (Broyles, Reiss,
Evans, Mickenzie, Pleunik, & Page, 2017, p. 443). It is indicated for
severe cases of tachyarrhythmias unresponsive to other treatment, the drug is
partially absorbed post-oral administration with a steady plasma level around
1-2 mcg/ml, is highly protein bound, accumulates in adipose tissue and richly
perfused organs. The first-pass metabolism takes place in the gut wall and/or
in the liver and most of the drug is excreted by biliary excretion. (eMIMS Sign In, 2017)

 Mr. X is reported to have
been on regular medications namely Aspirin 100mg PO OD, Metoprolol 50mg PO OD,
Rosuvastatin 10mg PO OD and Glyceryl Trinitrate pump spray PRN. Beside these
medications, he has also been prescribed administered Aspirin 300mg PO, Morphine
Sulphate IV 2.5mg on 4 occasions PRN, Low Molecular Weight (LMW) Heparin
infusion and Fentanyl 50mcg IV x2 STAT doses post-arrival to the ED. Bryant
& Knights (2017) describes Morphine as an opium alkaloid from natural
sources while Fentanyl as a synthetic product, both of these opioids have
morphine-like agonist effects on opioid (enkephalin) receptors.

Assessment and investigations

The vital signs (BP-172/86 mm of Hg, pulse-103 beats/minute, respiratory
rate-24/minute, core temperature-36.8 degree centigrade, oxygen saturation-97%)
were within normal limit except blood pressure (BP), which was slightly higher
(Systolic BP). The patient reported history of HTN also, that of NSTEMI, Hypercholesterolemia
and Angina. A perfect Glasgow Coma Scale (GCS) score of 15/15 was recorded at
the ED. General physical examination revealed pale appearance, diaphoresis and
shortness of breath. Interpreting Signs and Symptoms, 2018 suggests that MI is a fatal condition where
nausea, vomiting, shortness of breath and diaphoresis take place and, the skin
become cool and pale. The history reported and clinical manifestations
exhibited imply that the case most probably is an MI.


As per the past
history collected, assessments made and the presenting problems described, Mr.
X is shown to have been suffered from MI. The common conditions that affect
half a million Australians is heart attack  (Henry Krum, 2013).. Acute myocardial
infarction (AMI) is referred to the constant and irrevocable cell death in a
part of myocardium, which is due to the loss of blood flow and occurrence of a
severe ischemia in that part. (Mirian
NS, Sedehi M, Kheiri S,Ahmadi A: EBSCOhost,” n.d.)
MI is the most common cause of death in many communities .According to WHO
report, AMI is the leading cause of mortality in the world. (Mirian NS, Sedehi
M, Kheiri S, Ahmadi A: EBSCOhost,” n.d.).

Mr Ferguson
caseis that the gradual development of atherosclerosis formation in the vessels
has increased which leads to obstruction in the blood flow through the vessels.
(Farrell, 2017) . Atherosclerotic plaque rupture promotes atherothrombosis,
vessel occlusion and consequent ischaemic organ damage. This pathophysiological
sequence is the primary cause of acute cardiovascular events (such as
myocardial infarction MI. (Federico Carbone1; Alessio Nencioni1; François Mach; icolas Vuilleumier;
Fabrizio Montecucco, 2013). This obstruction is
leading to decrease in blood supply to the heart muscles. (Farrell, 2017) This
decrease in blood flow causes hypoxia and reduced oxygen demand leads to Angina
(Farrell, 2017). Due to hypoxia Mr ferguson was looking pale and he had
shortness of breath. The moving clot in vessels causes the unstable angina
which gets thrombus permanently later on (due to this reason he had chest
heaviness twice in a day). This leads to necrosis of the organ ending with
myocardial infarction. (Farrell, 2017).  

Interventions and Nursing Consideration


(acetylsalicylic acid) is a pharmaceutical drug used to reduce pain or
inflammation. It is classified as a non-steroidal anti-inflammatory drug
(NSAID). (“Alcohol &Drug Foundation (ADF) – Drug Facts –
Asprin,” n.d.)

Indications: used in the prevention of blood clots, heart
attacks, strokes and bowel cancer. (“Alcohol &Drug Foundation (ADF) – Drug
Facts – Asprin,” n.d.) Headache with upset stomach; body aches and pain;
neuralgia; sore throat.(“Alka-Seltzer – Full PI,” n.d.)

Pharmacokinetics: Aspirin taken orally is rapidly absorbed, partly
from thestomach,and also from intestine. peak serum levels is reached within
20-40 minutes. Rapid metabolism by tissue and blood esterases occurs ,
hydrolysing aspirin to acetic acid and salicylate;the peak level is reached in
2-4 hours. (Bronwen Bryant,
Kathleen Knights, 2017)Salicylate
is distributed throughout most body tissues and fluids, including synovial
fluid and cerebrospinal fluid, and is 50-90% bound to plasma proteins. It then
undergoes hepatic metabolism to inactive metabolities. The plasma salicylate
level require 100mg/l for anti-inflammatory effects.( this is why mrferguson
was on regular medication as 100mg). higher doses is needed for more
anti-inflammatory effects(Bronwen Bryant,
Kathleen Knights, 2017).(so
he was administered 300mg in emergency department). Diane Brown. (2015)

effect:  Rarely, hypersensitivity reactions
(bronchospasm, skin reactions). Very rarely, thrombocytopenia (“Alka-Seltzer –
Full PI,” n.d.).  There is no safe level
of drug use. Use of any drug always carries some risk – even medications can
produce unwanted side effects. It’s important to be careful when taking any
type of drug. (ADF – Drug Facts – Asprin, n.d.) Aspirin affects everyone differently,
based on: Size, weight and health whether the person is used to taking it, whether
other drugs are taken around the same time, the amount taken (ADF – Drug Facts
– Asprin, n.d.)

consideration: The effect of
severe overdose of a aspirin can be fatal which can be treated by gastric
lavage and forced alkaline diuresis, with close monitoring of vital functions (Bronwen
Bryant, Kathleen Knights, 2017).
Fluid, electrolyte and acid-base imbalances must be corrected and hyperthermia,
hyperglycemias and hypoglycaemia treated (as Mr. was administered 300mg, he
should be under consideration as mentioned above) (Bronwen Bryant,
Kathleen Knights, 2017)


is practically devoid of membrane stabilising activity and does not display
partial agonist activity (i.e. intrinsic sympathomimetic activity = ISA) at
doses required to produce ?-blockade.(“Metrol-XL – Full PI,” n.d.)
?-Adrenergic blockade of the smooth muscle of bronchi
and bronchioles may result in an increased airways resistance.

Indications: Stable, chronic heart failure as an adjunct to other
heart failure therapy.

Pharmacokinetics: rapid disintegration within the gastrointestinal
tract, metoprolol is continuously released for approximately 20 hours, and a
stable metoprolol plasma concentration is achieved over a dosage interval of 24
hours. Approximately 12% of metoprolol is bound to human serum proteins.
Metoprolol undergoes oxidative metabolism in the liver. Over 95% of an oral
dose can be recovered in the urine. Only approximately 5% of the administered
dose is excreted unchanged (“Metrol-XL – Full PI,” n.d.)

Contraindication: ?-blockers are contraindicated in any patient with a
history of airways obstruction or a tendency to bronchospasm. Use of
cardioselective ?-blockers can also result in severe bronchospasm. If such
therapy must be used, great caution should be exercised. Alternative therapy
should be considered. ?-Blockers should not be used in patients with
unstabilised heart failure, severe peripheral arterial circulatory disorders, suspected
acute myocardial infarction with a heart rate of 0.24 seconds or a
systolic blood pressure of

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