A 57-year-old man named A.T. has been admitted to the telemetry unit for continuous cardiac monitoring. He has a past medical history of nonischemic cardiomyopathy, hypertension, chronic heart failure (HF) with an ejection fraction (EF) of 10%, implantable cardioverter-defibrillator (ICD) placement 1 month ago, alcohol abuse, and a past smoker (quit 3 years ago). He was admitted after reporting chest pain and his ICD firing 3 times at home, before admission. During his morning assessment, A.T. suddenly reports chest pain and feels like he was just kicked in the chest. There is no witnessed loss of consciousness.
- The nurse suspects that what just occurred?
- What is an ICD?
- How does the ICD get power to work?
- What cardiac rhythm would the nurse expect to see during the review of his continuous telemetry strip?
- What conditions are indications for placement of an ICD?
CASE STUDY PROGRESS
The nurse receives a call from the telemetry monitor technician, who reports a 5-second episode of this dysrhythmia.
- IDENTIFY THIS RHYTHM:
- The nurse will assess and monitor for what other signs or symptoms?
The nurse calls the cardiologist to report the change in A.T.’s condition and receives orders for lab work.
- What lab studies does the nurse expect to be ordered?
CASE STUDY PROGRESS
The nurse notes that the results from A.T.’s blood work are ready for review.
- Considering A.T.’s condition, what lab results would require further management? (Select all that apply)
- BTNP 435 pg/mL
- Calcium 9.4 mg/dL (2.35 mmol/L)
- Sodium 130 mEq/L (130 mmol/L)
- Glucose 107 mg/dL (5.9 mmol/L)
- Potassium 3.0 mEq/L (3.0 mmol/L)
- Hemoglobin 12.6 g/dL (126 g/L)
- Magnesium 1.3 mEq/L (0.5 mmol/L
Home Medications
| Mexiletine hydrochloride 150 mg PO every 12hours |
| Carvedilol 25 mg PO twice daily |
| Furosemide 80 mg PO twice daily at 8 a.m. and 2 p.m. |
| Lisinopril 10 mg PO once daily |
| Spironolactone 25 mg PO once daily |
| Isosorbide mononitrate 20 mg PO once daily |
| Aspirin EC 81 mg PO once daily |
| Rosuvastin 20 mg PO every evening |
- For each drug listed, state its drug classification and specific use for A.T.
- Which of A.T.’s medications would have a possible effect on his potassium level?
- The hospitalist following A.T. ordered magnetic resonance imaging (MRI) because A.T. reported pain over his right middle quadrant. The patient escort has arrived to take him to the MRI room. Will you intervene? Explain your answer
CASE STUDY PROGRESS
A.T. reports to the nurse that he feels overwhelmed at home managing his heart failure. He is saddened that he cannot play in his softball league but instead walks 1 mile every day in his neighborhood. He is proud that has quit smoking. He tells the nurse that he is “terrified” whenever his ICD “kicks him down.” He also tells you that he doesn’t really know what to do if his ICD goes off.
- The nurse provides instructions about the ICD. Which statement by A.T. indicates a need for further instruction?
- “I will wear a medical alert bracelet at all times.”
- “I will carry a list of my current medications with me.”
- “If my ICD goes off, I need to call my doctor right away.”
- “If my ICD goes off more than once, or if I feel sick, I will drive to the Emergency Room.”
CASE STUDY OUTCOME
A.T. spends 3 days on the telemetry unit. His continuous telemetry monitoring now shows a normal sinus rhythm with a heart rate of 82. His BP is 116/72. A 2D Echo was performed that showed an EF of 25%. His ICD was interrogated without adverse reports. A CT scan of the abdomen showed no abnormalities. His most recent potassium level is 3.5 mEq/L (3.5 mmol/L). The cardiologist has agreed to discharge A.T. with a follow-up appointment 1 week from discharge. A.T. joins an ICD support group that meets monthly and enjoys talking with others who have the same concerns.
