Could it be a heart attack or Pneumonia?

Nurses General Nursing

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Patient M. Dean is a 53 years old male with a DX of CVA with Left sided weakness who came to the ER to be evaluated for chest pain, and respiratory discomfort which started two days ago, but suddenly escalated .... RR. 9 irregular and guarded, HR. 130 and regular, BP. 180/90, Oral Temp. 101 degrees (F) He also denies injury related to accident, however he thinks that he may be having a heart attack. How do we proceed to evaluate this patient, and what possible diagnosis medical,as well as nursing diagnosis would be made?

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Before I venture further I want to know if this is a class assignment? Or...A case study to run through for thoughts and experiences.

Dranger...what is the rationale for no Nitro post CVA? Nitropaste remind a part of HTN protocol in ACLS for tPA candidates. I understand the need for a higher perfusion and over correction of the HTN but I have not heard of the contraindication.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I don't see where pneumonia fits in here but BC x2, lactic acid (doubtful sepsis though) or sputum cultures if need be....empiric ABX

Go from there

Fever T101. Pain with breathing
chest pain, and respiratory discomfort which started two days ago, but suddenly escalated …. RR. 9 irregular and guarded, HR. 130 and regular, BP. 180/90, Oral Temp. 101 degrees (F)
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It could be just about anything. However, first things first and is the patient alert? GCS? With a rr of 9, you may have to assist with a BVM--which just as an aside, if patient came in via ambulance, would perhaps already be in progress. If the rr is hanging around 8 or 9, could mean intubation per policy. If this is homework, you priority is always airway.

From aspiration pneumonia to a fall with trauma. What you should expect as a nurse is to be putting this patient on a monitor,IV, urine, EKG, good head to toe--lung sounds, is their edema in his extremeties? Stat chest x-ray. You will more than likely draw blood cultures x2, send the urine for a culture and a tox screen, sputum if any, ABG, CBC, CMP, Sed rate, latic acid, cardiacs. Depending on the course of things, an amalayse, lipase may be indicated--as well as a d-dimer, u/s to r/o PE, PT, PTT, INR also a FBS. Depending on the results of the tox screen, could need narcan. Depending on results of x-ray, could need chest tube. Depending on results of labs, could need anything from heparin drip to antibiotics to cardiac drips. Be really careful of change in condition.

Be mindful about treating pain with narcotics with a rr that low.

That was really fun, made me think early in the morning! However, for homework purposes, I think that there are things to remember. AIRWAY, MD's order all of this per their thought process (which may differ from yours), assess and monitor, so not hesitate to get your team-mates involved with a condition change!! and last but not least a nursing diagnosis (or 2 or 3) that relate to this patient.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

If this was homework....I like to let students start first...get their thinking caps on. I find I can help them better when I know what they are thinking...then I can help them focus their thinking skills in the right direction.

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This is a case study..... Proceed by using the ABC method, that is obtain the O2 Sat, give emergency Oxygen, alert the MD,and the Respiratory team for possible intubation ,and establish an IV line.

“I do not have all the answers,but together we can find them.”

(M Ecallawh)

Thanks to all students,and nurses who have contributed answers to this thread.

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Specializes in critical care.

A couple of responders have discussed airway being first, but is it possible circulation might be here? O2 would be delivered per MI protocols probably, but IMO (which is backed by zero experience - which is why I'm asking), wouldn't ruling out the MI be top priority?

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Even in the case of a MI the patient needs oxygen,an iv line ,and he would be placed on monitor as one of our participants mentioned. We would still need the vitals,medical history etc as well as alerting the medical,and respiratory teams.

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Before I venture further I want to know if this is a class assignment? Or...A case study to run through for thoughts and experiences.

Dranger...what is the rationale for no Nitro post CVA? Nitropaste remind a part of HTN protocol in ACLS for tPA candidates. I understand the need for a higher perfusion and over correction of the HTN but I have not heard of the contraindication.

Rapid vasodilation can effect the watershed areas of the brain especially if pressure are dropped too fast causing an atypical infarct further compromising the penumbra. We already know that lowering BP within the first day or so is not best practice so nitro for undiagnosed CP especially without the presence of elevated enzymes. If nitro was used I would taper it low and watch the BP carefully or use morphine. but hey I am not a doc and I am sure used some have used it before.

For pneumonia all I see is a fever and chest discomfort. No lung sounds? I mean I know we treat empirically pretty often but I just don't see enough to go off of. Fever can be exacerbated by other issues.

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A couple of responders have discussed airway being first, but is it possible circulation might be here? O2 would be delivered per MI protocols probably, but IMO (which is backed by zero experience - which is why I'm asking), wouldn't ruling out the MI be top priority?

In the EMS and CPR genre, then circulation is first, however, in this setting, and in most nursing protocol, airway is usually first. With that, obtaining IV access is also a priority. Labs can be drawn off of the IV, EKG is also important--

There are chest pain protocols in the ED. However, in this instance with a rr of 9, this needs to take precedent in my opinion.

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Medical Management:

RE: Dranger :For lowering the BP and improving profusion Nitro drip can be titrated until a satisfactory BP is achieved, or once the patient is intubated Morphine drip could be considered, although he may need more medication for hemodynamic support.

NB. TX will be made according to the medical diagnosis.

Nursing Management:Implementing orders, titrating medication, measuring vitals, obtaining EKG's, assessing,evaluating patient response, reporting to medical/nursing teams, and writing nursing notes etc.

“I do not have all the answers but,together we can find them.”

(M Ecallawh)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

For me...Yes if the patients respiratory rate is really 9bpm...start thinking about intubation. What do you mean by guarded? It hurts to breathe? Do they have a decreased LOC?

Assess patient. First assess airway. What is the 02 stat. Intubate if necessary. Secure a IV line or 2. 02, Stat labs (Cap glucose, CBC, coag, enzymes, chem 18, BL culture, Stat PORT CXR, Stat EKG, Stat CT for the ED we do UDA)

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Specializes in ED, ICU, Education.

How about an EKG?

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