Cаrdiаc Cаse Study (Questiоn 5) Mr. Jоnes, age 63, was admitted tо the emergency room at 0400 with substernal chest pain that woke him up from his sleep. He states the pain started at 0300 and thought it was heartburn from the stuffed calzone that he ate for dinner. He called 911 at 0315 because he stated the pain was worsening and he felt like he was going to vomit and pass out. 1 dose of sublingual Nitroglycerin was given in the ambulance. PMH/PSH: Hypertension, Diabetes Type II, COPD, dental surgery two weeks ago, 1 PPD smoker x 40+ years Medications: Hydrochlorothiazide 75 mg PO daily, Simvastatin 40mg PO HS, Metformin 1000mg PO daily Assessment: Time Vital Signs System Lab Results 0400 B/P= 84/48 Pulse= See 6 second tele. strip below Respirations= 21 breaths/min. SPO2= 92% on 3 liters nasal Cannula Pain= 6 (0-10 scale) Temp= 100.4 (38F) Weight= 278 lbs. Cardiac: 6 sec. tele strip below, diaphoretic Resp: Lungs faint crackles bi-lateral lower lobes Neuro: A & E X 4, feels weak and anxious GI: Hypoactive BS X 4 quad., nauseous, vomited X 3 in ambulance (1000 mL output) Renal: 20mL urine output since arrival WBC= 13,546 per mcL Platelets= 200,000 per mcL Na+= 147 mEq/L K+= 3.1 mEq/L Glucose= 181 mg/dL HgBA1C= 7.8% (Normal 4-5.6%) BUN= 26 mg/dL (Normal 6-24 mg/dL) Creatinine= 1.2 mg/dL (Normal 0.6-1.2 mg/dL) Troponin= 0.03 ng/mL (Normal 0-0.4 ng/mL) 0500 B/P= 90/50 Pulse= See 6 second tele. strip below Respirations= 22 breaths/min. SPO2= 93% on 3 liters nasal Cannula Pain= 4 (0-10 scale) Temp= 99.4F (37.5F) Weight= 278 lbs. Cardiac: 6 sec. tele strip below, new S3 noted, diaphoretic Resp: Lungs faint crackles bi-lateral lower lobes Neuro: A & E X 4, feels weak and anxious GI: Hypoactive BS X 4 quad., nauseous, vomited at 0445 for 250 mL emesis Renal: 30mL hour urine output ABG= 7.46, CO2 45, HCO3- 27 Time Medications Given Provider Orders 0445 Morphine 2mg IV Ondansetron 4mg IV Piperacillin-tazobactam 3.375/50mL 0500 Complete Metabolic Panel Urinalysis, culture & sensitivity Blood cultures X 2 Troponin levels Q8H Echocardiogram STAT 0.9%NS Bolus 500 mL IV over 45 minutes Phenylephrine 20 mcg/kg/min- Titrate to keep MAP >65 Prepare for Arterial line insertion Incentive spirometer Q hourly 0400 Telemetry Strip (6 seconds): 0500 Telemetry Strip (6 seconds) The nurse gave STAT medications at 0445 and now the provider has placed new orders in the chart at 0500. Place from the highest priority (1) to the lowest priority (6) the order in which the nurse will carry out the new 0500 orders.