Janet Saroyan, age 72, is recovering uneventfully on her third day after femoral-popliteal bypass surgery. She’s receiving medication to manage her surgical pain.
History and assessment hints
As you compare assessment data from the previous shift to your more recent findings, you note that the electrocardiographic (ECG) strip from the patient’s telemetry monitor shows a progressive change over a 14-hour period (see strips below). Although Mrs. Saroyan denies chest pain (“I’m just tired”), your concern over the ECG changes leads you to assess her further.
The patient seems slightly short of breath, but continues to deny chest discomfort. You note that her skin has become paler. Her vital signs are blood pressure 160/90 mm Hg, pulse 80 beats/minute, and respirations 28 breaths/minute with slight dyspnea; her oxygen saturation (SaO2) is 90% on room air.
At a recent workshop, you learned that women, diabetics, and the elderly may present atypically for acute coronary syndrome, including myocardial infarction (MI). You also learned that the following interventions offer a safety net: (1) Give O2 to reduce cardiac demand and increase supply. (2) Obtain I.V. access. (3) Implement cardiac monitoring to capture changes that could indicate myocardial ischemia, injury, and necrosis.
Call for help
You begin O2 administration, establish an I.V. line, and obtain a STAT 12-lead ECG. Then you page the physician and rapid response team (RRT) team. The RRT nurse quickly sees from the 12-lead ECG that the patient is having an acute MI.
On the scene
Mrs. Saroyan is taken immediately to the cardiac catheterization lab, where she undergoes percutaneous coronary intervention for a blocked coronary artery.
Blood flow is restored to the patient’s myocardium and her remaining hospitalization is uneventful.
Education and follow-up
In most units with cardiac monitoring, the ECG can be monitored in at least two leads. Commonly, the ability to perform a 12-lead ECG is incorporated into the system. Evidence-based guidelines recommend using leads II and V1 for two-lead continuous monitoring for arrhythmias and heart rate, with a 12-lead ECG to be done immediately as needed. Besides using the leads for this purpose, med-surg nurses can monitor subtle trends over time to recognize the evolution of such conditions as acute MI.
But you don’t need to be an expert in 12-lead ECG to know a patient’s condition has changed. In this case, your clinical judgment enabled you to correlate suspicious ECG changes with clinical findings. ECG strips that appeared normal at first glance showed progressive changes when placed side by side. Your knowledge of how to create a safety net helped save your patient’s life.
Pam Hamilton is a clinical nurse specialist and educator at DCH Regional Medical Center in Tuscaloosa, Alabama.