Real Life 3.0 Scenario as Substitute for Bedside Clinical Practice Medical Surgical: Myocardial Infarction.

Materials

Computer, Internet connection, Real Life Scenario Medical Surgical Myocardial Infarction, reference books, classroom with computer and overhead display, i>clickers (if available), polling cards (if available) Active Learning Templates for Medication, Nursing Skill, System Disorder, Therapeutic Procedure, and Diagnostic Procedure located on ATI faculty website under “Integration Resources,” “Active Learning Templates” (for students, these templates are available on their ATI pages under “Product Support Materials,” “Active Learning Templates”).

Objectives

After completion of the lesson, the student will be able to:

• Use clinical reasoning to promote a positive outcome for a client with a myocardial infarction. ● Identify appropriate nursing actions and prioritize care for the client with a myocardial infarction.
• Identify important nursing considerations for medications and diagnostic testing used in treating clients who have experienced a myocardial infarction.
• Intervene effectively and therapeutically with a client experiencing anaphylaxis, post-catheterization access hematoma, and cardiogenic shock.
• Provide client education regarding the treatment and management of a myocardial infarction, medications, and lifestyle changes.
• Communicate effectively and therapeutically with the client, family, and interprofessional team.
• Determine the correct dosage for a prescribed medication.
• Complete an accurate and effective SBAR communication.

Scenario Overview

This scenario focuses on a 54-year-old male client who has a diagnosis of myocardial infarction. It addresses client- centered concepts related to cardiac and respiratory status, allergic reactions, anaphylaxis reaction, and cardiogenic shock. Nursing-focused concepts include organizing the plan of care for the client, prioritizing nursing actions, and interprofessional collaboration. Students will be expected to be knowledgeable of therapeutic communication, safe medication administration, and drug calculation. For additional information, refer to the content topics table.

INDIVIDUAL STUDENT ASSIGNMENT

TASKS

Take report as the scenario begins, stopping and replaying as needed. You must identity three priorities/ top problems noted during the report and state an action plan for each priority. Identify assessments information related to each priority and determine appropriate nursing actions and the associated rationale.

TASK
Prior to clinical day, spend at least 60 minutes in the Real Life Myocardial Infarction scenario.
Sign into MyATI, go to APPLY, simulations Real Life RN Medical Surgical 3.0	Myocardial Infarction

Complete 15 of the following Active Learning Templates.choose any 15.

Medication: Nitroglycerin, acetylsalicylic acid, diphenhydramine, epinephrine, potassium, dobutamine, norepinephrine, furosemide, morphine sulfate, naloxone, albuterol inhaler, lisinopril, clopidogrel

Nursing Skill: cardiac assessment

Therapeutic Procedure: angioplasty

Diagnostic Procedure: Electrocardiogram, cardiac catheterization, lab studies ordered

System Disorder: Myocardial infarction, angina, anaphylaxis, cardiogenic shock, coronary artery disease, hypertension, asthma

Answer these questions and submit to canvas along with the completed transcript for Real
Life RN Medical Surgical 3.0 MI and completed active learning templates.

1. You must identify three priority/ top problems and state an action plan for each priority with rationale for each. SO, write top three problems, three actions/ or interventions, & a rationale for each of those interventions (3).

• Ineffective airway clearance
• Ptn was having an allergic reaction from contrast dye and was beginning to experience dyspnea and wheezing. Diphenhydramine was given to reduce itching, swelling, and other allergic symptoms. Epinephrine IV was given for bronchodilation and to prevent anaphylactic hypotension.
• Ineffective breathing pattern. Ptn was having difficulty breathing due to his allergic reaction and had a low O2 sat on 2LNC. Ptn had dusky skin and other symptoms of hypoxia. Switch to nonrebreather to administer higher FiO2 and then treat underlying cause (allergic reaction, hypotension).
• Bleeding
• Ptn was actively bleeding at the insertion site in his right groin. Apply pressure for 10 minutes to allow clotting at the site and stop further bleeding.

2. What were some of the challenging decisions the nurses made? Describe the rationale behind these decisions.

• The decision to call 911 after the first nitro. I knew that nitro can be given every 5 minutes for 3 doses and I would have waited to call until after the 3 doses. However, that takes up more time and it is better to be safe and call 911 if symptoms do not resolve after the first nitro.

3. What influenced your decisions during the scenario?

• I had to use my knowledge of allergic reactions, medications, breath sounds, and knowledge of risk factors for MI. There are more questions about medications in this case study than the COPD one.

4. If a wrong decision was made during the scenario, what were you thinking that led you down an incorrect path?

• I chose pitting lower extremity edema as a manifestation of cardiogenic shock, however this is incorrect because edema is a manifestation of R side heart failure.
• I did not know that yogurt had that much sodium in it.

5. Share some of the issues that affected your clinical reasoning.

• I did not read the scenario well enough before choosing an answer.
• I knew that he was having an allergic reaction but I did not know from what. I knew that his shrimp allergy had to be a factor but I did not think about the contrast dye.

Part II. Clinical Reasoning and Application

I.Scenario 1:

A 70-year-old woman was admitted the hospital 2 days ago and underwent a right total hip replacement. The patient has a history of hypertension, degenerative joint disease, pulmonary embolism, and coronary artery disease. She just finished a physical therapy session and has been resting in her hospital room. When you walk into the room to check your patient, you notice that she is unresponsive with no respiration or pulse. You immediately start CPR and call a code. When the emergency team arrives, the patient is attached to the ECG monitor, which displays the rhythm shown in ECG 1. Answer the following questions:

ECG 1

1. The interpretation of this rhythm is:

a. Ventricular fibrillation

b. Ventricular tachycardia

c. Accelerated idioventricular

d. Asystole

2. Your FIRST treatment of the patient is to:

a. Administer 300mg of amiodarone

b. Defibrillate at 120 Joules (diphasic)

c. Consider 1 mg of atropine

d. Synchronized cardioversion at 360 joules

3. Following the appropriate treatment in question 2, ECG 2. What is the following rhythm?

ECG 2

a. Ventricular tachycardia

b. Atrial tachycardia

c. Fine Ventricular fibrillation

d. Coarse Ventricular fibrillation

4. Your next appropriate treatment of choice for this patient is to

a. Provide five cycles (2 min) of CPR.

b. Defibrillate at 360 J (or equivalent biphasic energy).

c. Consider 1-2 g of magnesium sulfate.

d. Defibrillate at 200 J (or equivalent biphasic energy).

5. Following the appropriate treatment in question 4, ECG -3 shows on the monitor as:

ECG 3

a. A Torsade de pointes.

b. Asystole.

c. Ventricular fibrillation.

d. Ventricular tachycardia.

6. Your next appropriate treatment for this patient is to

a. Defibrillate at 200 Joules

b. Administer Amiodarone 300 mg bolus

c. Administer epinephrine 1 mg (10 mL of 1:1000).

d. Either A or C

7. The patient is still pulseless with no respirations at this time. The next most appropriate treatment includes:

a. Administer Amiodarone 300 mg bolus

b. Administer Atropine 300 mg bolus

c. Administer epinephrine 1 mg (10 mL of 1:1000).

d. Either A or C

8. After administering the above treatments including medications, CPR, and defibrillation the rhythm shows as:

a. Ventricular fibrillation converting to a sinus rhythm. (VTach into sinus)

b. Ventricular tachycardia converting to asystole

c. Torsade de pointes.

d. Atrial tachycardia converting to a sinus

9. What are 4 possible reversible causes this patient may have experienced?

a. Include a rationale or additional labs, assessments and information you would like to have to determine a likely reversible cause.

• Hypoxia: Ptn has a hx of htn, CAD, and just had a hip replacement. The increased physical activity from her physical therapy may have increased the oxygen demand of her heart. Need an ABG for accurate results of oxygen saturation. Count respirations.

• Hypovolemia: She had a recent total hip replacement and may have experienced blood loss. Her physical therapy could have opened the surgical site and she may have bled in her room. Need a CBC to look at hematocrit and visual inspection of the surgical site. Blood pressure and MAP to see if organs are being perfused.

• Thrombosis, Pulmonary: She has a history of pulmonary embolism and

has been in bed from the surgery. Her physical therapy could have

moved the clot into her lung, causing respiratory arrest. Need a CT or US to look for clot, d-dimer blood test, listen to lung sounds

• Thrombosis, Coronary: Ptn has a history of CAD and has been immobile following her surgery. The CAD would cause stenosis of her coronary arteries and would make it easier for a embolus to block blood flow. Need EKG to see ischemia, injury, or infarction, ECHO to look at ejection fraction, CT or US, d-dimer, heart sounds

II. Scenario 2:

You come on shift and walk in your room to assess your 48-year-old female patient. Upon walking in the room she appears to be asleep. You quietly cycle the blood pressure monitor and try to locate her pulse oximeter that appears to be disconnected. Your blood pressure will not give you a reading. You try to wake your patient up and find that she is unconscious without a palpable pulse.

ECG 1 

1. Identify the following rhythm:

a. Junctional rhythm

b. Sinus rhythm

c. Accelerated junctional rhythm

d. Pulseless electrical activity

2. Your initial treatment is to start CPR and:

a. Defibrillate at 120 Joules (monophasic)

b. Consider and treat possible causes

c. Administer 300mg of Amiodarone

d. Administer 6mg Adenosine

3. Following appropriate treatment in question 2, the patient still does not have a pulse or respirations and the ECG monitor shows: ECG 2

a. Junctional Tachycardia with PEA

b. Atrial tachycardia with PEA

c. Accelerated junctional rhythm with PEA

d. Sinus tachycardia with PEA

4. Your next treatment of choice is to administer:

a. Epinephrine 1 mg

b. Hold the digoxin

c. Vasopressin 40 Units

d. Amiodarone 300 mg

5. Following the appropriate treatment in question 4, the patient is still not breathing but does have a pulse. The monitor shows:

ECG 3

a. Accelerated junctional rhythm

b. Atrial tachycardia

c. Sinus bradycardia

d. Junctional tachycardia

6. Your next appropriate treatment for this patient is to:

a. Begin chest compressions

b. Administer 0.5mg of atropine

c. Stop ventilating the patient

d. Administer 6 mg of adenosine

7. Following the correct treatment in question 6, the patient now has an advanced airway in place and has a blood pressure of 110/70 mm Hg. The rhythm interpretation is:

ECG 4

a. Sinus tachycardia

b. Sinus bradycardia

c. Junctional Rhythm

d. Normal sinus Rhythm

Scenario III

You float to the Emergency room and receive report for the paramedics. An 80-year old female was found lying in an alleyway. She had an unwitnessed arrest, and currently has no pulse or respiration. ECG 1

1. The interpretation of this rhythm is:

a. PEA

b. Asystole

c. Agonal Rhythm

d. Third degree AV block

2. After taking over CPR the next best treatment would be:

a. Defibrillating with 120 Joules (monophasic)

b. Administering 6mg of Adenosine

c. Consider the reversible causes

d. Consider beta blockers

3. Your next appropriate treatment includes:

a. Amiodarone 300mg

b. Epinephrine 1 mg

c. Magnesium sulfate 1-2 grams

d. Amiodarone 150mg

4. While CPR is continued your next medication choice would be:

a. Amiodarone 300mg

b. Epinephrine 1 mg

c. Atropine 1 mg

d. Amiodarone 150mg