Grand Rounds: Plan of Care

Created and Presented by Sarah Sawhook

 Admitting DX

A 64 Year Old Patient was discharged from

hospital after a coronary artery stent was
placed in the circumflex artery. The next
morning he woke up with SOB, Weakness,
Dizziness, Palpitations, and Left Chest Pain
(angina) and thus was admitted to the
hospital on 02/26/2023. Patient also
developed facial numbness on his right side
shortly after his admission.
 PMH
Cardiovascular:
- Acute Non-ST Elevation Respiratory:
- CAD - COPD
- Diastolic CHF - Obstructive Sleep Apnea (OSA)
- HTN - Pulmonary Nodule
- Hyperlipidemia - Previous Respiratory Failure
- Left Circumflex Coronary Stenosis
- Occlusion and Stenosis of Right Coronary Artery
- Unstable Angina

GI: Other:
- GERD Neuromuscular: - Hemoptysis in Past
- Alcoholic Pancreatitis - Chronic back pain - Near Syncope

Code Status: Full Resuscitation

 FAMILY HISTORY:
SIGNIFICANT PAST SURGICAL HISTORY:
- (+) for DM & CAD
- Presence of Coronary Angioplasty Implant & Graft
- His Daughter is a RN
- Heart Stents

SOCIAL HISTORY:
- Lives at Home w/ Family
- Smoked 1-1.5 packs a day and
sometimes smoked 2 packs a day;
claimed he stopped but occasionally
smokes; claims no cig for a year now
but he gets one “here and there”
- Used to Drink Alcohol but claims not
anymore
- History of Alcohol Abuse
 Vital Signs
March 2, 2023 @ 1100
Date: March 2, 2023 @ 0800: Temperature: 36.6 Degrees Celsius
Temperature (Temporal): 36.3 Degrees Celsius (97.4 degrees Respirations: 14 Breaths/Minute
Farenheit) Pulse-Ox: 97% SPO2 Room Air
Respirations: 16 Breaths/Minute Heart Rate: 58 BPM *
Pulse-Ox: 96% SPO2 Room Air Blood Pressure: 123/71 (52) mmHg
Heart Rate: 48 BPM *
Blood Pressure: 138/62 mmHg (76) * Patient noted there was pain on his back
- Reason: Degenerated Disc
Orthostatic Blood Pressure & Pulse: - Cause: Lay Brick for 35 years
- Laying = 138/62 (78) mmHg, 48 BMP * - Pain Quantity: 6-7
- Sitting = 158/62 (96) mmHg, 52 BPM * - Alleviates Pain: Pain Medication, Pain Clinic
- Standing #1 = 165/63 (102) mmHg, 58 BPM * Massage & Sometimes Chiropractic
- Standing #2 = 156/63 (93) mmHg, 54 BPM * - Aggravates: Twisting Head
- Quality of Pain: aching
Pain Assessment: Patient Denied any Pain

Analysis: Pulse and Blood Pressure are not within normal parameters. He has
bradycardia since HR is under 60 BPM, which could reduce CO. Patient has “Isolated
Systolic Hypertension” since Systolic BP is elevated and Diastolic Blood Pressure is
low. This is common in older patients.
Laboratory Values 03/01/2023 @ 04:43
WBC 11.83^9 cells/L AGAP 5
* (H) [5.0-10.0^9 Bun 19
Monocytes 7
cells/L]] Calcium 8.7
Eosinophils 1
RBC 4.37 Chloride 109mmol/L *(H) [98-106mmol/L]
Basophils 0
HgB 13.1 CO2 26
Immature Granulocytes 0.6 [0-0.5%]*(H)
Hct 38.9% * (L) GFRE 85
Creatinine 0.9
[41.5-50.4%] Glucose 119mg/dL *(H) [70-110mg/dL]
Platelet 175 Potassium 3.9
MCV 89.0 Sodium 140
MCH 30.0 Estimated Creatinine 72.0
MCHC 33.7 Hemoglobin A1C = 5.7% * [under 5.7%]
RDW 12.8 - Note: 5.7%-6.4% = prediabetes
MPV 9.8
Segs [Segmented Analysis:
Neutrophils] 77% * WBC and its differential are out of range, which may indicate that patient is under
stressful conditions from underlying cardiovascular conditions. Stress impacts the
(H) [50-70%] functioning of the immune system. Electrolytes are within normal parameters besides
Lymphs 14% * (L) chloride, which could indicate dehydration. Patient is considered prediabetic from A1C
reading. This is concerning since improper glucose management exacerbates
[20%-40%] cardiovascular conditions.

Note: patient is on mometasone, a corticosteroid. An adverse effect is lowered

immunity. Patient is on anticoagulants/antiplatelets, which thins blood and increases risk
of bleeding. This could explain the low hematocrit levels.
 Diagnostic Test Results - 2/27/23
CT Scan of Brain & MRI & CT Angiogram of Head & Neck:
These were Negative.This test was done for a suspected CVA
due to right facial numbness that patient was complaining of)

Chest X-Ray was conducted to rule out any respiratory issues

due to SOB, as patient has history of COPD. The results were
normal and lungs were clear.
ECG-12 Lead was done due to cardiac symptoms of
palpitations, weakness, dizziness, SOB. Patient went into
Atrial Fibrillation (A-Fib). It was found that he had a new onset
of paroxysmal A-Fib with rapid ventricular response (RVR).
A-Fib is a dysrhythmia where the atrium gets overly excited with electrical activity and
generates an uncoordinated beat 350-600 times/minute (Ignatavicius et al., 2021).
Basically, the atria loses control and the ventricles attempt to compensate by increasing
it rate. However, this decreases CO due to reduced ventricular filling (Ignatavicius et al.,
2021).

More specifically, Paroxysmal AFib occurs when heart rate returns back in less than 7
days of when it started or when treatment starts.

As mentioned, RVR is likely occurring to attempt to

compensate for A-Fib
General Survey

Patient appears calm and cooperative. He is not in any acute distress or

discomfort. His speech is normal appropriate for his age, and he responds
appropriately to questions. He is oriented x3. His short and long-term memory are
intact. Behavior is appropriate. He does not have any assistive devices. He has
bradycardia, and systolic BP is high, while diastolic BP is low. Other vital signs are
within normal limits.
 Head-to-Toe Assessment
Musculoskeletal/Neuro: Patient is Awake, Alert, and Oriented
X3. Spine and posture is adequate for age. There are no
spinal curvatures. Gait and balance is sufficient. Patient is able Psychiatric: cooperative, appropriate
to sit up and stand up, and ambulate w/o assistance. Shoulder mood and affect; appropriate judgement
strength is sufficient. No current signs of weakness or fatigue

Nose/Sinuses: Sense of smell is

Head/Face: Normocephalic. No lesions or skin breakdown in
intact. Nose is positioned midline to
scalp. Hair is thin, dirty blonde and gray, and distributed
face. No deviated septum. No
evenly. Patient has facial hair. Face is symmetrical. Facial
drainage. No pain or numbness with
Nerve (CN VII) is functioning. No deformities in skull. Temporal
palpation of frontal and maxillary
arteries were palpated and were a 2+ bilaterally
sinuses
Eyes: Structure is intact. There is no drainage. Conjunctiva is Mouth/Throat: Lips are light pink in color.
blue. Sclera is white. Pupils are equal and rounded bilaterally Bottom left Lip is blue from permanent
and react appropriately to light. EOMs are intact. Patient is bruise. There are no sores. No teeth are
wearing glasses present. Patient wears dentures but do
not currently have them in. Hard and Soft
Ears: Hearing is intact. Size and location is appropriate for Palettes are light pink and have no
age. No drainage or skin breakdown. lesions. Uvula is intact.
Head-Toe-Assessment Heart: precordium area is intact.
Bradycardia. Sinus rhythm. No
Neck: trachea is centered midline. No pain or tenderness of trachea. No
murmurs or gallops present.
bulging in neck. No JVD. ROM of neck is intact. Right Carotid Artery is
2+. Left Carotid artery is unable to be palpated. No presence of lymph
nodes. No pain or discomfort while swallowing; thyroid is intact; no
presence of a bruit. Abdomen: no lesions present. Bowel sounds
are normoactive in all 4 quadrants (RLQ,
Skin: skin turgor is less than 3 seconds; skin is warm and dry; color is RUQ, LUQ, LLQ). Abdomen is soft and
pink; no rash; no focal lesions non-tendered. Distension is present. No pain
during palpation. Denies difficulty with bowel
Upper Extremities: No signs of skin breakdown. No lesions or
movements or changes in elimination
deformities. Bruising is Present in Right Brachial due to Past IV Site. No
patterns.
edema. Skin temperature is warm. Brachial pulses are present bilaterally
at a +2. Left radial pulse was a 2+. Right radial pulse was unable to be Genitourinary (GU): No discomfort in genital
palpated. Nail beds are pink/white in color. No clubbing in nails. capillary area. Patient is fully continent and mobile.
refill is less than 3 seconds. Hand grasps are strong for the patient, but Patient denies any issues r/t to urination.
left arm is a bit more stronger and mobile than right arm. Hand grasps
are appropriate. Lower Extremities: No signs of skin breakdown. No
Thorax/Lungs: No deformities or lesions in the thorax. no barrel chest; lesions or deformities. ROM in hips, legs, and feet
temperature of thorax is warm, no pain/tenderness in thorax, normal are intact. Skin temperature of legs is warm. No
observation of inhalation/exhalation; no adventitious breath sounds bruising.No edema in legs or feet .Toe nails are
present anteriorly and posteriorly. No shortness of breath. Rate and pink/white in color. Capillary refill is under 3 sec.
rhythm of respirations are normal. Lungs are clear to auscultation Hips, leg, and feet are intact. Pedal pushes and
bilaterally. Equal breath and non-labored sounds. Equal symmetrical pulls are strong for the patient bilaterally. Pedal
expansion. Little cough when inhaling (probably COPD related) pulses are 2+ bilaterally. Bruise 2nd digit of right foot
Focused Assessment

Denies chest pain, palpitations, dizziness, lightheadedness; occasional SOB

sitting on bed
No chest pain is present during assessment. However, in general terms, patient
noted that chest pain seems to occur more when sitting or staying still over
exertion. The pain alternates between right and left side; The quality is
sharp-stabbing; When angina occurs, he rates it as a 4-6.
 Allergies: Shellfish (anaphylaxis/generalized anaphylaxis),
Medications Iodine (anaphylaxis/generalized anaphylaxis)

Active Inpatient Medications: Active PRN Medications:

- Apixaban (Eliquis) 5mg/1tab Oral BID - acetaminophen-oxyCODONE (Percoce
- Aspirin (Ecotrin) 81mg/1tab Oral D- Discontinue March 5/325 oral tablet); oral every 4 hours
25th - Albuterol 2.5mg/3mL NEB q6hr(0.083%
- Atorvastatin 80mg/1tab Oral D inhalation
- Mometasone (Asmanex Twisthaler 220mcg/inh
inhalation aerosol powder) 220mcg = 1 puff INH Daily
- Pantoprazole 40mg/1tab Oral D
- Sotalol 40mg/0.5tab Oral TID
- Ticagrelor 90mg/1tab Oral BID
- Umeclidinium-vilanterol (Anoro Ellipta) 1 Puff INH Daily
Note: The Beta-Blocker Sotalol was replaced with Long-Acting
Metoprolol due to Consistent Bradycardia.

Analysis: Patient is predominantly on Anticoagulants and Antiplatelets for

prophylaxis of blood clots and stroke following AFib. Patient is on the Beta-Blocker
to lower BP and regulate heart rate. He is on bronchodilators/corticosteroid for
COPD. He is on a PPI for GERD. Analgesics are used for pain relief for chronic
back pain.
 PRIORITY PROBLEMS

1. HEMODYNAMICS (Actual)
2. BLOOD GLUCOSE REGULATION (Potential)
3. PATIENT EDUCATION (Actual)
 1. Hemodynamics (Actual):

It is concerning that the patient is remaining in a bradycardic state

while being prescribed a beta-blocker. It helps that Metoprolol (long-acting
beta blocker) replaced Sotalol. Metoprolol is usually held if heart-rate is
under 50 BPM, and patient has been maintaining in the mid 50s. However, it
is still an experiment how heart is going to react while taking the medication.
Thus, cardiac consultation would be necessary for further evaluation. Low
heart rate can decrease perfusion and conductivity of heart and CO. In
addition, it is that balance of ensuring that patient does not get into A-Fib and
is super tachycardia. AFib increases risk for DVT, PE, and CVA due to blood
pooling.
2. Glucose Regulation (Potential/Precautionary)

Even though one glucose reading was available within the

recent dates, A1C levels were tested and were 5.7%, which is the
minimum level for prediabetes. Patient should take precautions to
regulate glucose levels since prediabetes can eventually lead to
diabetes. Also, glucose levels can exacerbate cardiovascular
issues since glucose can make blood vessel walls sticky, which
can narrow and clog vessels ahead of time. This can complicate
perfusion. In addition, patient has (+) family history for DM, so he is
predisposed and should be cautious. Patient should be taught
about the risk and appropriate lifestyle changes.
3. PATIENT EDUCATION & UNDERSTANDING (ACTUAL)
Patient was getting discharged 03/02/2023. It is important that he is educated about his low heart
rate and his Afib so that he increases his rate of compliance. Patient has a history of smoking and
drinking alcohol. Patient should frequently monitor his BP and HR at Home. Even though he “rarely
smokes or drinks,” it would be helpful to remind him to fully stop due to the consequences on his
heart and blood flow. Diet is important, so he could even be referred to a registered dietician (RD).
Discharge Instructions:
Due to HR being low within the 50s, Patient is discontinued with
Sotalol, a beta-blocker prescribed to be taken 25 mg 2x Day.
As an alternative, Patient is placed on Metoprolol, a long-acting
beta-blocker Patient prescribed 25mg Daily. Patient is
instructed to not take if pulse is less than 40 BPM

Come to Hospital if Symptomatic:

- Palpitations
- Dizziness
- High HR (Above 120 BPM)
(All indicative of AFIB!)
Resources

Ignatavicius, D, D., Workman, M. L., Rebar, C. R., & Heimgartner, N. D. (2021).

Medical-Surgical Nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.