Category: Case 2: Joan

On completion of this case you should have an understanding of:

• The symptoms and signs associated with STEMI and how STEMI is diagnosed
• The psychological impact of ACS, especially in patients with no past medical history of coronary heart disease
• The common complications of STEMI that may affect the initial presentation and management
• The additional medications that may be required in addition to routine secondary prevention medicines

Let’s look at how Joan’s drug-eluting stent is deployed.

A stent is a short, wire-mesh tube that acts like a scaffold to help keep your artery open. There are two main types of stent:

• bare metal (uncoated) stent: the biggest drawback of using bare metal stents is that, in around 30% of cases, the arteries begin to narrow again. This is because the immune system sees the stent as a foreign body and attacks it, causing swelling and excessive tissue growth around the stent.
• drug-eluting stent, which is coated with medication that reduces the risk of the artery becoming blocked again and reduces the problems above, These are coated with medication that reduces the body’s abnormal response and tissue growth. Once the stent is in place, the medication is released over time into the area that is most likely to become blocked again.

Reference: NHS Inform – Health information you can trust

The use of drug-eluting stents has reduced the rate of arteries re-narrowing from around 30% to below 10%. However, as drug-eluting stents are still a relatively new technology, it is uncertain how effective or safe they are in the long term.

Before the procedure the cardiologist will consider the benefits and risks of each type of stent for that particular patient.

If the cardiologist is going to consider a stent, they will also require to consider certain anti-platelet drugs to help reduce the risk of blood clots forming around the stent.

Joan is reviewed by an interventional cardiologist who explains she’ll need a coronary angiogram, which is performed via right radial approach. This showed critical narrowing in the Left Anterior Descending (LAD) vessel. You may wish to review the anatomy of the coronary arteries in module 1.

A drug-eluting stent is deployed to the lesion within the coronary artery.

Joan is transferred to the CCU. Using tools such as the Scottish Early Warning Scoring (SEWS) charts can identify if patients are becoming less well so that interventions can occur early.

There are many models and tools that incorporate all the different aspects involved in acute nursing care. The patient is at the centre of that care and their needs must be the priority. When considering these needs it may be useful to think of this in terms of the following areas using the SBAR tool. This can be particularly useful when considering acute patients and the need for concise but detailed handovers.

Click on the plus points on the chart below for further explanation.

SBAR	Nursing care	Rationale
Situation	Joan’s condition. This will include all relevant issues that Joan is concerned with. What is the problem? When it happened? How critical is it? The questions reflect Joan’s relevant issues in that she has had a STEMI, had a delayed transfer but did receive evidence based intervention thrombolysis. It is a critical situation for this 42-year old lady.	These questions can highlight the issues that require attention. Like the mnemonic discussed previously, tools such as this can focus the situation to allow chunks of information to be obtained.
Background	From above, her care includes observations (P, BP, O2Sats, RR, Temperature). All other clinical information required is: Prescribed medications Skincare and Personal Hygiene Instructions regarding mobility-not on complete bed rest unless ongoing pain/symptoms Elimination needs/requirements i.e, urinary catheter in situ Venous access, intravenous medications, dietary needs Joan is encouraged to participate in her daily care, and report any episodes of chest pain.	All of these aspects require consideration in order to provide holistic and patient led care.
Assessment	Consideration of your findings will lead to further assessment or review.	Considering your findings and reviewing appropriately will promote holistic focussed care.
Recommendation	If review required this should be timely in response to above.	Care may require reviewed and changed many times in acute environment.