The time is 1900. You are working in a small, rural hospital. It has been snowing heavily all day, and the medical helicopters at the large regional medical center, 4 hours away by car (in good weather), have been grounded by the weather until morning

Question

The roads are barely passable. W.R., a 48-year-old plumber
with a 36–pack-year smoking history, is admitted to your floor with a diagnosis of rule out myocardial
infarction (R/O MI). He has significant male-pattern obesity ("beer belly," large waist circumference) and a
barrel chest and reports a dietary history of high-fat food. His wife brought him to the emergency department
after he complained of unrelieved "indigestion." His admission vital signs (VS) were blood pressure
(BP) 202/124 mm Hg, pulse (P) 106 beats/min, respirations 18 breaths/min, and oral temperature 98.2 °
F (36.8 ° C). W.R. was put on oxygen (O2) by nasal cannula (NC) titrated to maintain Spo2 over 92% and
started on an IV nitroglycerin (NTG) infusion. He was given aspirin 325 mg to chew and swallow and was
admitted to Dr. A.'s service. There are plans to transfer him by helicopter to the regional medical center
for a cardiac catheterization in the morning when the weather clears. Meanwhile, you have to deal with
limited laboratory and pharmacy resources. The minute W.R. comes through the door of your unit, he
announces he's "just fine" in a loud and angry voice and demands a cigarette. He also says he has no time
to fool around with hospitals.

What is the first priority in his care?

Are these VS reasonable for a man of his age? If not, which one(s) concern(s) you? Explain
why or why not.

Identify five priority problems associated with the care of a patient such as W.R.

Answer 1

The first priority is his safety. That means maintaining cardiac tissue perfusion and, if he has had an
MI, keeping him alive and limiting cardiac damage.

His blood pressure (BP is dangerously high, and his pulse (P is rapid for a 48-year-old man who is at
rest. Both of these can contribute to myocardial ischemia.

BP control: Monitor for efficacy of medication and side effects.
Myocardial ischemia: This results from (1) increased oxygen demand because of increased cardiac
output (high BP and P); (2) probable decreased oxygen availability related to coronary artery
disease (CAD) and/or chronic obstructive pulmonary disease (COPD); and (3) possible decreased
diffusion of gases across the alveolar-capillary membrane. The last two issues are directly related
to his smoking history as well as a possibly obstructed coronary artery.
Cigarette smoking: He is going to want to smoke. Smoking negatively affects the heart because of
the increased stress on the lungs and the vasoconstriction that restricts oxygenation. You need
to caution him about not smoking during his stay in the hospital, and ask his wife to take his
cigarettes and lighter or matches home with her.
Teaching needs: Teach him to report any chest pain or discomfort or difficult breathing.
Pain control: Pain will increase his anxiety and the heart rate, which increases the workload of the
heart and myocardial tissue perfusion.
Cardiac dysrhythmias: These increase the possibility of sudden death.
Constipation: His high-fat, low-fiber dietary preferences and decreased activity during
hospitalization increase his risk for constipation; the pattern of breath-holding during a bowel
movement is termed the Valsalva maneuver. In cardiac patients who are constipated, it can
precipitate an MI or sudden death.
Hostility: His anger is probably masking fear of death and fear of loss of control, which can contribute
to more stress on his heart and would be dangerous at this time. Consider an antianxiety agent at
this time.
Denial: His denial is a coping mechanism related to his fear. Although denial sometimes serves a
positive purpose, in this situation it is contributing to behaviors that increase W.R.'s risk for cardiac
damage.