Transcript Document

CCU Case Studies
The following is a series of case studies to review different patient
types and how they are captured on the form. The information is
provided in sequence to reflect the natural progression of a patient’s
care.
As the case is presented, mark off the required information in the
appropriate fields on your Macstrak form.
At the end of each case study, the form will be reviewed with the
correct answers supplied.
If you have any questions, please refer to your Macstrak manual or
contact us at the Macstrak Project Office.
The Macstrak Project
CCU Case Study
The Macstrak Project
CCU Case Study
MLA is a 56-year-old man (19/02/50) with no previous cardiac
history.
The Macstrak Project
CCU Case Study
MLA is a 56-year-old man (19/02/50) with no previous cardiac
history.
On the morning of 15/03/06 MLA starts out for his regular
10:00 walk when he experiences extremely fast, irregular
heartbeats. A neighbour sees him and, even though his heart
rate returns to normal, drives him to the hospital where they
arrive at the ER at 10:25. While waiting to be assessed, MLA has
another episode of fast, irregular heartbeats and shortness of
breath. Nursing assessment reveals blood pressure 90/55, heart
rate 130, and moderate dyspnea. He is placed on a monitor
which shows atrial fibrillation. He receives metoprolol 5 mg IV
with a reduction in HR to 104. He is transferred to your CCU.
The Macstrak Project
CCU Case Study
In CCU, he is treated with heparin (LMWH) sc and loaded with
amiodarone IV. Later that evening he converts to NSR but with a
slow rate at 30/min and becomes hypotensive. A temporary
transvenous pacemaker (TTVP) is placed with the rate set at 70. He
is then alert and responsive and BP is 110/70. He remains stable
over the next 24 hours and the TTVP is removed. He has had no
chest pain and his CK and troponins are negative throughout his
stay. Coumadin is started on day 2.
The Macstrak Project
CCU Case Study
In CCU, he is treated with heparin (LMWH) sc and loaded with
amiodarone IV. Later that evening he converts to NSR but with a
slow rate at 30/min and becomes hypotensive. A temporary
transvenous pacemaker (TTVP) is placed with the rate set at 70. He
is then alert and responsive and BP is 110/70. He remains stable
over the next 24 hours and the TTVP is removed. He has had no
chest pain and his CK and troponins are negative throughout his
stay. Coumadin is started on day 2.
On the 17/03/06 at 09:30 MLA is discharged home with a diagnosis
of atrial fibrillation. His discharge medications are:
amiodarone
coumadin
The Macstrak Project
CCU Case Study
MACSTRAK
Patient Initials: M
F
Birth Date:
CCU
Gender:
L
A
M
L
19
02
Day
Month
X Male
Centre:
19 50
Year
CCU
Date:
ICU
20
Day
Month
Year
Female
MLA is a 56-year-old man (19/02/50) with no previous cardiac
history.
The Macstrak Project
CCU Case Study
MACSTRAK
Patient Initials: M
F
Birth Date:
CCU
Gender:
L
A
M
L
19
02
Day
Month
X Male
Centre:
19 50
Year
Date:
CCU
15
03
Day
Month
20
ICU
06
Year
Female
On the morning of 15/03/06 MLA starts out for his regular 10:00
walk when he experiences extremely fast, irregular heartbeats. A
neighbour sees him and, even though his heart rate returns to
normal, drives him to the hospital where they arrive at the ER at
10:25.
The Macstrak Project
CCU Case Study
<30 days
MI …………………………….
Angina ………………………..
CABG ………………………..
PCI ……………………………
CHF …………………………..
TIA/CVA ……………………..
Diabetes (oral agents/insulin) ...
None of the Above…………….
>30 days
MLA is a 56-year-old man
(19/02/50) with no
previous cardiac history.
X
Past Medical History:
The Macstrak Project
CCU Case Study
Patient Origin:
EMS
X Walk In
Dr.’s Office/Clinic (Direct)
Other Hospital
Inpatient
Medical Ward
Surgical Ward
Other ICU
Other: ………………
X ER
On the morning of 15/03/06 MLA starts
out for his regular 10:00 walk when he
experiences extremely fast irregular
heartbeats. A neighbour sees him and,
even though his heart rate returns to
normal, drives him to the hospital where
they arrive at the ER at 10:25.
The Macstrak Project
CCU Case Study
VS at Presentation: (complete for all patients)
Dyspnea/Rales:
Systolic BP:
Heart Rate:
None
Mild
X Mod/Severe
X < 100
101-130
131-160
161-190
>190
< 80
80-100
X >100
While waiting to be assessed, MLA has
another episode of fast, irregular
heartbeats and shortness of breath.
Nursing assessment reveals blood
pressure 90/55, heart rate 130, and
moderate dyspnea. He is placed on a
monitor which shows atrial fibrillation.
He is transferred to your CCU.
The Macstrak Project
CCU Case Study
Admitting Diagnosis: (Check one only)
Acute AMI (48 hrs)
UA R/O MI
ACS
UA
RSCP NYD
CHF
X Arrhythmia
Aortic Dissection
Non ACS
Pericardial Disease
Other: …………………
While waiting to be assessed, MLA has
another episode of fast, irregular
heartbeats and shortness of breath.
Nursing assessment reveals blood
pressure 90/55, heart rate 130, and
moderate dyspnea. He is placed on a
monitor which shows atrial
fibrillation. He is transferred to your
CCU.
The Macstrak Project
CCU Case Study
16
17
15
Date:
D N D N D
N
Acuity:
Shift:
Diuretics………………………
Inotropes IV…………………..
ETT/Vent……………………..
PA Line……………………….
X X
TTVP…………………………
IABP………………………….
ACS:
RSCP - Ischemia – Definite….
– Probable…
CK (+ve)………………...……
Troponin (+ve)………………..
NTG IV……………………….
Heparin – UFH…………….....
X X
X X
– LMWH……………. X
Other Antithrombin………...…
GP 2b/3a Inhibitor IV……...…
Clopidogrel (or ticlopidine)..…
Cardiac Cath………………....
PCI…………………………...
Outcomes:
VF/Sustained VT………….…
Infarction (new/repeat)*(1) …...
Thrombolysis (new/repeat)*(2)..
Stroke*(3) …………………….
Major Bleed*(4) ………………
Transfusion…………………..
Crs1: ………………………....
Crs2: ……………………..…..
None of the Above……….…..
RN Initials ………………..…. KD S KD S KD
M
M
In CCU, he is treated with heparin
(LMWH) sc and loaded with
amiodarone IV. Later that evening
he converts to NSR but with a slow
rate at 30/min and becomes
hypotensive. A temporary
transvenous pacemaker (TTVP)
is placed with the rate set at 70. He
is then alert and responsive and BP
is 110/70. He remains stable over
the next 24 hours and the TTVP
is removed. He has had no chest
pain and his CK and troponins are
negative throughout his stay.
Coumadin is started on day 2.
The Macstrak Project
CCU Case Study
03
Date: 17
Day
Month
06 Time: 0930
20 Year
Discharge Diagnosis:
Acute MI
Peak CK:
Unstable Angina
Trop:
Chest Pain NYD
CHF
X Arrhythmia
Other Cardiac Problem: …………..................
Non Cardiac Problem: …..….............……….....
On the 17/03/06 at 09:30
MLA is discharged home with
a diagnosis of atrial
fibrillation. His discharge
medications are:
amiodarone
coumadin
The Macstrak Project
CCU Case Study
Discharged To:
Discharge Meds:
Cardiac Ward
Med/Surg Ward
Step Down Unit
CV Surgery
Other ICU
Other Hospital
X Home
Death
Other:..............
ASA
Clopidogrel (or ticlop.)
Heparin (UF or LMW)
Nitrates (po/top)
B Blocker
ACEI
A2 Blocker
Statin
X None of Above
On the 17/03/06 at 09:30
MLA is discharged home
with a diagnosis of atrial
fibrillation. His discharge
medications are:
amiodarone
coumadin
The Macstrak Project