1 / 15

CCU Case Studies

CCU Case Studies. The following is a series of case studies to review different patient types and how they are captured on the form. The information is provided in sequence to reflect the natural progression of a patient’s care.

rich
Télécharger la présentation

CCU Case Studies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CCU Case Studies The following is a series of case studies to review different patient types and how they are captured on the form. The information is provided in sequence to reflect the natural progression of a patient’s care. As the case is presented, mark off the required information in the appropriate fields on your Macstrak form. At the end of each case study, the form will be reviewed with the correct answers supplied. If you have any questions, please refer to your Macstrak manual or contact us at the Macstrak Project Office. The Macstrak Project

  2. CCU Case Study The Macstrak Project

  3. CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MI’s in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. The Macstrak Project

  4. CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MI’s in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. On 02/03/06 FR presented to the ER with dyspnea at rest and was admitted to the ward service with CHF. He received ASA, an ACE inhibitor and furosemide. The Macstrak Project

  5. CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MI’s in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. On 02/03/06 FR presented to the ER with dyspnea at rest and was admitted to the ward service with CHF. He received ASA, an ACE inhibitor and furosemide. The morning of 06/03/06 he becomes increasingly short of breath. He has severe chest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF. The Macstrak Project

  6. CCU Case Study FR arrives in the CCU at 10:30 a.m. He is intubated and ventilated and given dopamine IV. He has an arterial line placed and remains hypotensive despite increasing amounts of dopamine. He also receives furosemide IV. A PA line is placed and confirms an elevated wedge pressure at 28 mmHg and low cardiac output at 3.2 litres/min. At 13:30 he has a VT/VF arrest and is promptly defibrillated. He remains hypotensive and anuric and dies of progressive hypotension at 18:30. His discharge diagnosis is CHF. The Macstrak Project

  7. MACSTRAK CCU CCU Case Study Patient Initials: F M L Birth Date:19 Day Month Year Gender: Male Female Centre:CCU ICU Date:20 Day Month Year F R 23 01 20 X FR is an 86-year-old(DOB: 23/01/20) man with a past medical history of MI’s in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. The Macstrak Project

  8. MACSTRAK CCU CCU Case Study Patient Initials: F M L Birth Date:19 Day Month Year Gender: Male Female Centre:CCU ICU Date:20 Day Month Year F R 23 01 20 06 03 06 X The morning of 06/03/06 he becomes increasingly short of breath. He has chest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF. The Macstrak Project

  9. CCU Case Study Past Medical History:<30 days >30 days MI ……………………………. Angina ……………………….. CABG ……………………….. PCI …………………………… CHF ………………………….. TIA/CVA …………………….. Diabetes (oral agents/insulin) ... None of the Above……………. FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MI’s in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. X X X The Macstrak Project

  10. CCU Case Study Patient Origin: ER EMS Walk In Dr.’s Office/Clinic (Direct) Other Hospital Inpatient Medical Ward Surgical Ward Other ICU Other: ……………… On 02/03/06 FR presented to the ED with dyspnea at rest and was admitted to the ward service with CHF. He received ASA, an ACE inhibitor and furosemide. X X The Macstrak Project

  11. CCU Case Study The morning of 06/03/06 he becomes increasingly short of breath. He has severechest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF. VS at Presentation:(complete for all patients) Dyspnea/Rales:None Mild Mod/Severe Systolic BP: < 100 101-130 131-160 161-190 >190 Heart Rate:< 80 80-100 >100 X X X The Macstrak Project

  12. Admitting Diagnosis:(Check one only) Acute AMI (48 hrs) UA R/O MI UA RSCP NYD CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………… ACS CCU Case Study The morning of 06/03/06 he becomes increasingly short of breath. He has severe chest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF. X The Macstrak Project

  13. Diuretics……………………… Inotropes IV………………….. ETT/Vent…………………….. PA Line………………………. TTVP………………………… IABP…………………………. ACS: RSCP - Ischemia – Definite…. – Probable… CK (+ve)………………...…… Troponin (+ve)……………….. NTG IV………………………. Heparin – UFH……………..... – LMWH……………. Other Antithrombin………...… GP 2b/3a Inhibitor IV……...… Clopidogrel (or ticlopidine)..… Cardiac Cath……………….... PCI…………………………... Outcomes: VF/Sustained VT………….… Infarction (new/repeat)*(1) …... Thrombolysis (new/repeat)*(2).. Stroke*(3) ……………………. Major Bleed*(4) ……………… Transfusion………………….. Crs1: ……………………….... Crs2: ……………………..….. None of the Above……….….. RN Initials ………………..…. CCU Case Study Date: FR arrives in the CCU at 10:30. He is intubated andventilated and given dopamine IV. He has an arterial line placed and remains hypotensive despite increasing amounts of dopamine. He also receives furosemide IV. A PA line is placed and confirms an elevated wedge pressure at 28 mmHg and low cardiac output at 3.2 litres/min. At 13:30 he has a VT/VF arrest and is promptly defibrillated. 06 D N D N N D Acuity: Shift: X X X X X KD The Macstrak Project

  14. Discharge Diagnosis: Acute MI Unstable Angina Chest Pain NYD CHF Arrhythmia Other Cardiac Problem: ………….................. Non Cardiac Problem:…..….............………..... CCU Case Study At 13:30 he has a VT/VF arrest and is promptly defibrillated. He remains hypotensive and anuric and dies of progressive hypotension at 18:30. His discharge diagnosis is CHF. Time: Date: 20 06 03 06 1830 Day Month Year Peak CK: Trop: X The Macstrak Project

  15. CCU Case Study At 13:30 he has a VT/VF arrest and is promptly defibrillated. He remains hypotensive and anuric and dies of progressive hypotension at 18:30. His discharge diagnosis is CHF. Discharged To: Cardiac Ward Med/Surg Ward Step Down Unit CV Surgery Other ICU Other Hospital Home Death Other:.............. Discharge Meds: ASA Clopidogrel (or ticlop.) Heparin (UF or LMW) Nitrates (po/top) B Blocker ACEI A2 Blocker Statin None of Above X X The Macstrak Project

More Related