Assignment: Branching Exercise: Cardiac Case 1
For this Assignment, you will review the interactive media piece/branching exercise provided in the Learning Resources. As you examine the patient case, consider how you might assess and treat patients with the symptoms and conditions presented.

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To prepare:
• Review the interactive media piece/branching exercise provided in the Learning Resources.
• Reflect on the patient’s symptoms and aspects of disorders that may be present in the interactive media piece/branching exercise.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the interactive media piece/branching exercise. Advanced Care of Adults in Acute Settings Essay

• You will be asked to develop a set of admission orders based on the patient in the branching exercise.
The Assignment
Using the Required Admission Orders Template, write a full set of admission orders for the patient in the branching exercise.
• Be sure to address each aspect of the order template
• Write the orders as you would in the patient’s chart
• Make sure the order is complete and applicable to the patient
• Any rationale you feel the need to supply should be done at the end of the order set – not included with the order
• Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is appropriate standard of care for this patient.
• A minimum of three current, evidenced based references are required.
By Day 7 of Week 2
Submit your completed Assignment by Day 7 of Week 2 in Module 2.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
• Please save your Assignment using the naming convention “MD2Assgn1+last name+first initial.(extension)” as the name.
• Click the Module 2 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
• Click the Module 2 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “MD2Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Advanced Care of Adults in Acute Settings: Cardiac Case I

This paper is about the admission order for an 84 year-old Caucasian female with a history of hypertension and diabetes mellitus. She is diagnosed with acute MI but the treatment plan will not be aggressive since there is an advance directive given of a DNR (Do Not Resuscitate). For this reason, the patient will not even be admitted to the intensive care unit as would have been the case had there not been an advance DNR directive as the code status. She has a body mass index or BMI of 22.7 kg/ m² which is normal BMI. Her current medications are insulin, metoprolol, aspirin (acetyl salicylic acid or ASA), and calcium supplement. She has no known allergies against medications, foods, or environmental allergens.    Advanced Care of Adults in Acute Settings Essay

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The Admission Order

Primary Diagnosis: Acute myocardial infarction (acute coronary syndrome) in hypertension (HTN) and diabetes (DM)

Status/Condition (Critical, Guarded, Stable, etc.): Critical but stable

Code Status: Do Not Resuscitate or DNR

Allergies: She has no known allergies to drugs, food, and other environmental factors

Admit to Unit: The Medical Unit. There is a DNR advance directive by the person with the medical power of attorney (MPOA) and therefore aggressive management will not be performed. She cannot be admitted to the ICU because of this.

Activity Level: She is inactive and disoriented in person, place, space, and event. Her speech is incoherent and not goal directed.

Diet: She takes a diabetic and hypertensive diet (history of HTN and DM)

IV Fluids:

• Critical Drips

1. Normal or isotonic saline at 15 drops per minute.
2. Alternate with Hartman’s solution at 10 drops per minute.

Respiratory: Oxygen (If ordered, include type and rate.), pulmonary toilet needs, ventilator settings:

1. She has a SpO₂ pulse oxymeter reading of 85% on room air
2. She will require supplemental oxygen at 2.5L/ min by face mask, even though she is on a DNR directive.
3. No pulmonary toileting
4. No need for artificial ventilation (code status is DNR)

Medications

1. Aspirin (acetyl salicylic acid, ASA) 240 mg orally every day
2. Metoprolol (Lopressor) 50 mg intravenously q 6 hrs for 48 hours

• Sitagliptin (Januvia) 100 mg once a day orally

1. Metformin 500 mg orally twice daily
2. Calcium 500 mg orally daily (Katzung, 2018; Rosenthal & Burchum, 2018).

All oral medications to be crushed and administered via the nasogastric tube used for feeds

Nursing Orders

• Vital signs to be taken and recorded every two hours
• Skin care on the pressure areas to be done every two hours. Patient positioning to relieve pressure from pressure areas also to be done every two hours at the time of pressure area care
• Aseptic catheterization with an indwelling Foley’s catheter to enable documentation of output and to monitor kidney function
• For toilet needs, the patient to be fitted with adult pampers which are to be changed regularly
• Regular 4 hourly feeding to be done by way of liquid feeds through the inserted NG tube
• Catheter care to be undertaken daily using chlorhexidine solution to prevent catheter-acquired urinary tract infections (CAUTI)
• An input and output record to be maintained as per procedure for every critical patient
• Counseling and psychoeducation for the patient’s relatives to be performed at the opportune time.

Follow-Up Lab Tests:

• Diagnostic testing (CXR, US, 2D Echo, etc.):

1. A plain chest X-ray to determine the size of the heart an also rule out pulmonary pathology
2. An echocardiogram to determine hear function and confirm the ACS
3. An electrocardiogram (EKG) to also confirm the ACS (MI) for the record
4. A magnetic resonance imagery (MRI) of the head to rule out hypertensive stroke
5. A complete blood count (CBC) and its differentials as a baseline for the record and for future reference
6. Estimation of the levels of cardiac enzymes to confirm myocardial infarction and the suspected cardiac pathology

Consults:

• A cardiology consult conducted in order to get expert interpretation of the echocardiogram readings and confirm the diagnosis
• A nutrition consult also done to get the expert opinion on the best dietary composition of the liquid feeds that the patient will be given
• A family consult done to confirm the holder of medical power of attorney (MPOA) and to respect the principle of autonomy

Patient Education and Health Promotion

• The presence of the DNR advance directive (Fine, 2020) means that there will be no active patient education or health promotion given to the patient or the family
• The only education given will be to the family in the form of family therapy to assist them cope with the impending loss of a loved one and the psychological stress.

Discharge Planning and Required Follow-Up Care:

• Even though the patient is critically ill and would require discharge instructions if they survive, there is an active DNR directive and this clouds the outlook for a discharge. The prognosis is understandably poor and so discharge is unlikely (Hammer & McPhee, 2018).
• In the event that she survives with some disability, the discharge plan will be to continue with current medications at home. Only the metoprolol will be changed to an oral formulation. She will then be given a return date for review of four weeks.

References

Fine, L.E. (February 14, 2020). End of life decisions: Powers of attorney & living wills. https://www.lawpracticetoday.org/article/end-life-decisions-powers-attorney-living-wills/

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14^th ed. McGraw-Hill Education.

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. Elsevier.  Advanced Care of Adults in Acute Settings Essay