intermittent substernal chest pressure



John Thomas is a 64-year-old Caucasian male who presents to the emergency room with a two-day history of intermittent substernal chest pressure associated with shortness of breath and diaphoresis.  The pain had originally awoken Mr. Thomas from sleep 2 nights ago and has been intermittently relieved with some sublingual nitroglycerin tablets that he had received from his physician 3 years ago.  The pain increases with exertion, but now is constant.  He rates the pain a “7” on a scale of 1 to 10.

Past Medical History:  HTN, Type 2 DM

Home Medications:    Lopressor (metoprolol) 50 mg PO daily

                                    Lasix 40 mg PO daily

                                    ASA 325 mg PO daily

                                    Glucophage 50 mg PO BID

Vital Signs:  T-98.9 (O)          P= 110             R=28               BP= 90/60       SpO2=88% on RA

Physical Exam:

            Neuro:             Anxious, but alert and oriented x3

            Pulm:               Bilateral rales, labored

            CV:                 RRR; S1, S2, S3; tachycardic; PMI displaced laterally

            ABD:              Active bowel sounds; soft/non-tender; liver enlarged

            EXT:               2+ lower extremity edema; 1+ peripheral pulses

            INTEG:           Poor capillary refill; nail beds cyanotic; skin is diaphoretic

Lab Results:

Na= 133;         K=5.0;             C1=100;          CO2=22;          BUN=29;        Cr=1.8; Glucose=183            Hgb=9.2;         Hct=27.6;        WBC=11.2;     Plt=203

            CPK=2900;     CKMB=432%;                        LDH=972;      Troponin=6

Diagnostic Tests:

            12 lead ECG; Sinus tachycardia with left ventricular hypertrophy and

ST elevation in leads V1, V2, V3, & V4

            CXR:   Increased vascular markings in both lungs

Critical thinking exercises

  1. List your primary medical and nursing diagnoses for this patient.
  2. What area of the left ventricle is affected by this MI?
  3. What is your rationale for EACH of the abnormal physical assessment parameters, the abnormal laboratory results, and the abnormal diagnostic tests?
  4. What are your anticipated nursing interventions for this patient?



Mr. Thomas is admitted to the CCU with a diagnosis of Acute MI with congestive heart failure.  The following orders are obtained:

            Vital Signs q1h

            Continuous ECG monitor


            Foley catheter

            Nitroglycerin IV infusion @ 10 mcg/min

            Heparin IV infusion @ 1000 units/hr

            PTT q6h and call results if <60 or > 90

            CK isoenzymes q8h x3

            Troponin level q12h x2

            O2 at 2 1iters/min per NC—titrate for SpO2>91%

            Lopressor 25 mg PO BID

            Ambien 5 mg PO qHS PRN sleep


  1. What is your rationale for each of the admitting orders?


Mr. Thomas’ urine output decreases to 10 ml/hr and is unresponsive to a dose of IV Lasix.  He complains of increased SOB and physical exam reveals increasing rales bilaterally.  A pulmonary artery catheter is inserted with the following parameters obtained:

            CVP= 10         PCWP=22       PA pressure=38/20

            CO=  4.1         CI=1.9             SVR=1872


  1. What is the reason for each of the above parameters and what medication do you anticipate starting?


You had provided Mr. Thomas with some IV morphine sulfate for pain.  You check on him 30 minutes later and find that he is unresponsive with slow, shallow respirations.  He is diaphoretic.  An ABG on 2L/NC reveals:

            pH=7.22          pCO2=50         pO2=82            HCO3=26        SaO2=83%


  1. What does the ABG reveal?
  2. What is the probable cause?
  3. What are the anticipated medical and nursing interventions?

Calculate the price of your order

Simple Order Process

Fill in the Order Form

Share all the assignment information. Including the instructions, provided reading materials, grading rubric, number of pages, the required formatting, deadline, and your academic level. Provide any information and announcements shared by the professor. Choose your preferred writer if you have one.

Get Your Order Assigned

Once we receive your order form, we will select the best writer from our pool of experts to fit your assignment.

Share More Data if Needed

You will receive a confirmation email when a writer has been assigned your task. The writer may contact you if they need any additional information or clarifications regarding your task

Let Our Essay Writer Do Their Job

Once you entrust us with your academic task, our skilled writers embark on creating your paper entirely from the ground up. Through rigorous research and unwavering commitment to your guidelines, our experts meticulously craft every aspect of your paper. Our process ensures that your essay is not only original but also aligned with your specific requirements, making certain that the final piece surpasses your expectations.

Quality Checks and Proofreading

Upon the completion of your paper, it undergoes a meticulous review by our dedicated Quality and Proofreading department. This crucial step ensures not only the originality of the content but also its alignment with the highest academic standards. Our seasoned experts conduct thorough checks, meticulously examining every facet of your paper, including grammar, structure, coherence, and proper citation. This comprehensive review process guarantees that the final product you receive not only meets our stringent quality benchmarks but also reflects your dedication to academic excellence.

Review and Download the Final Draft

If you find that any part of the paper does not meet the initial instructions, send it back to us with your feedback, and we will make the necessary adjustments.