Discharge Planning
This patient is a 41 year old, African American male who presented to the ED with
shortness of breath and chest pain, on 10/23/2013. He said he was at work and began
feeling lightheaded, short of breath and felt a crushing pain in his chest. He told his boss
that he needed to go to the emergency room and left work immediately. The patient has
had no previous symptoms similar to this before. The patient also has type 1 diabetes, and
hypertension. In the ED, his cardiac enzymes were checked and his troponin was
elevated, indicating an MI. An EKG was also placed on him at this time and he has had
continuous cardiac monitoring. Patient is being discharged because he is ready to go
home, but the cardiologist is going to schedule a CABG for him in the near future.
Patient is stable, and is aware of the reason he was hospitalized. Patient teaching was
specific to a myocardial infarction.
Patient teaching:
Pathophysiology –. A heart attack happens if the flow of oxygen rich blood
becomes suddenly blocked to a section of the heart muscle. Most heart attacks occur as a
result of coronary heart disease, which is a condition in which plaque builds up inside of
the coronary arteries, causing atherosclerosis. Eventually, an area of plaque can rupture
and form a blood clot, which can block blood flow through a coronary artery. This will
cause part of the heart muscle to die, since it is not receiving oxygen. It is extremely
important to seek medical attention if you experience any of the signs/symptoms of a
heart attack.
Causes- It can be caused by plaque in an artery breaking off and forming a clot,
which blocks the regular blood flow to the heart, causing death of the muscle. It
can also be caused by an artery that is open but not delivering enough oxygen to
the heart.
Contributing Factors- male sex, older age, family history of heart disease, postmenopausal, race (African-Americans, American Indians and Mexican Americans
are more likely to have heart diseases than Caucasians), smoking, high LDL and
low HDL, uncontrolled hypertension, physical inactivity, obesity, uncontrolled
diabetes, high C-reactive protein, uncontrolled stress and anger, narrowing of
coronary artery
Symptoms – pressure, tightness, pain or a squeezing/aching sensation in your
chest or arms that may spread to your neck, jaw or back. A feeling of fullness,
nausea, indigestion, heartburn or abdominal pain, SOB, sweating or a cold sweat,
feelings of anxiety or an impending sense of doom, fatigue, trouble sleeping,
lightheadedness or dizziness.
Diagnosis – ECG, vital signs, echocardiogram, cardiac enzymes, chest x ray
Medications – Review of meds in next section.
Nutrition - Patient should be on a cardiac diet that is low in salt. Limit canned,
packaged and fast foods, do not add salt to diet, and season foods with herbs
instead of salt when cooking. Limit fatty foods, and check lipid levels regularly.
Do not drink alcohol for at least 2 weeks, and after that, consume it in moderation
(1-2 drinks a day for men, 1 a day for women).
Rehabilitation –. Plan to rest for at least 4-8 weeks while recovering, and only
return to normal activity after doctor says its okay.
Additional Treatments- Patient should learn to take own BP and pulse, and
report feelings of SOB.
Community Resources- There are heart rehabilitation programs that are open to
the public for patients that have experienced a heart attack.
Discharge Instruction – Patient will verbalize the importance of taking
medications exactly as directed, without skipping doses. Patient should understand that
they should plan to rest for at least 4-8 weeks while recovering, and wait for the doctor’s
okay to return to normal activity. They should ask doctor about joining a heart
rehabilitation program and tell the doctor if they are feeling depressed. They should
verbalize that if they are experiencing chest pain, they need to call 911 for an ambulance.
They should learn how to take their own BP and pulse, keep a record of the results, and
ask their doctor when they should seek medical attention. A handout was also provided
with this information on it.
Core measures- aspirin was given to patient upon arrival, a lipid panel was
completed within 24 hours, echocardiogram was done on the day of admission, and
patient will be discharged on a beta blocker and aspirin. Patient does not smoke so
smoking cessation teaching was not necessary.
Medications for discharge
Aspirin- antipyretic (inflammatory disorders, mild-moderate pain, fever, and
prophylaxis of TIA and MI)
Take after meals or with food or an antacid to minimize gastric irritation. Food
slows but does not ate the total amount absorbed. Do not crush or chew enteric
coated tablets. Do not take antacids within 1-2 hours of enteric coated tablets.
Chewable tablets may be chewed, dissolved in liquid, or swallowed whole. Take
with a full glass of water and remain in an upright position for 15-30 minutes after
administration.
-Advice patient to report tinnitus, unusual bleeding of gums, bruising, black, tarry
stools, or fever lasting longer than 3 days.
-Caution patient to avoid concurrent use of alcohol with this medication to minimize
possible gastric irritation. 3 or more drinks a day may increase risk of GI bleeding.
Caution patient to avoid taking concurrently with acetaminophen or NSAIDS for
more than a few days.
-Teach patients on a sodium restricted diet to avoid effervescent tablets or buffered
aspirin preparations.
-Tablets with an acetic (vinegar like) odor should be discarded
-Advise patients on long term therapy to inform health care professional of
medication regimen before surgery. Aspirin may need to be held for 1 week before
surgery.
Side effects: GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain,
anorexia, hepatotoxicity, vomiting, anemia, hemolysis, rash, uticaria, anaphylaxis,
laryngeal edema
Metoprolol- beta blocker (hypertension, angina pectoris, prevention of MI and
decreased mortality in patients with recent MI, management of stable, symptomatic
heart failure due to ischemic, hypertensive or cardiomyopathic origin.
Instruct patient to take medication as directed, at the same time each day, even if
feeling well; do not skip or double up on missed doses. Take missed doses as soon as
possible up to 8 hours before the next dos. Abrupt withdrawal may precipitate lifethreatening arrhythmias, hypertension, or myocardial ischemia.
- Teach patient and family how to check pulse daily and BP biweekly and to
report significant changes to health care professional
- May cause drowsiness. Caution patient to avoid driving or other activities
that require alertness until response to the drug is known.
- Advise patient to change positions slowly to minimize orthostatic
hypotension.
- Caution patient that this medication may increase sensitivity to cold.
- Instruct patient to notify health care professional or all medications or OTC
medications, vitamins, or herbal products being taken and to consult health
ccare professional before taking any medications, OTC or herbal products,
especially cold preparations, concurrently with this medication. Shold avoid
excess amounts of coffee, tea, and cola.
- Diabetics should closely monitor blood glucose, especially if weakness,
malaise, irritability or fatigue occurs. Medication does not block swearing as
a sign of hypoglycemia.
- Advise patient to notify health care professional if slow pulse, difficulty
breathing, wheezing, cold hands and feet, dizziness, light headedness,
confusion, depression, rash, fever, sore throat, unusual bleeding or bruising
occurs.
- Instruct patient to inform health care provider of medication regimen before
treatment or surgery.
- Advise patient to carry identification describing disease process and
medication regimen at all times.
Side effects: blurred vision, bronchospasm, wheezing, bradycardia, HF, pulmonary
edema, hypotension, periphereal vasoconstriction, constipation, diarrhea, dry
mouth, gastric pain, increased liver enzymes, nausea, vomiting, erectile dysfunction,
rashes, hyperglycemia, hypoglycemia, arthralgia, back pain, joint pain, drug induced
lupus syndrome
Lisinopril- ace inhibitor (alone or with other agents in management of hypertension,
management of heart failure, reduction of risk of death or development of heart
failure after MI)
Instruct patient to take medication as directed at the same time every day, even if
feeling well. Take missed doses as soon as remembered but not if almost time for
next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor
unless directed by health care professional
-Caution patient to change positions slowly to minimize orthostatic hypotension.
Use of alcohol, standing for long periods, and hot weather may increase orthostatic
hypotension.
-advise patient to consult health care professional before taking any OTC cough, cold
or allergy remedies, or other medications or herbal products.
-May cause dizziness. Caution patient to avoid driving and other activities requiring
alertness until response to medication is known.
-Advise patient to inform health care professional of medication regimen before
treatment or surgery.
-Instruct patient to notify health care professional if rash, mouth sores, sore throat,
fever, swelling of hands and feet, irregular heart beat, chest pain, dry cough,
hoarseness, swelling of face, eyes lips, or tongue, or if difficulty breathing or
swallowing occurs. Persistent dry cough may occur and may not subside until
medication is discontinued. Consult health care professional if cough becomes
bothersome. Also notify health care professional if nausea, vomiting, or diarrhea
occurs and continues.
-Emphasize importance of follow up examinations to evaluate effectiveness of
medication.
Side effects: dizziness, fatigue, headache, weakness, cough, hypotension, chest pain,
abdominal pain, diarrhea, nausea, vomiting, erectile dysfunction, impaired renal
function, rashes, and hyperkalemia.
Home assessment: Patient lives with wife and two sons in a one -story home. His
living situation is safe. He is able to care for himself and if he needs help his wife and
two sons are willing to assist him. He has a car, and is able to pay for his
prescriptions without financial assistance.
Follow up: Patient is going to follow up with cardiologist to schedule his CABG.
Dietary consult is needed to assist patient in eating a diet with less salt and fats.
Summary: Patient was hospitalized for 5 days for a myocardial infarction. Patient
education was given on diet, medications, and signs and symptoms of a MI. Patient
will follow up with cardiologist to schedule a CABG procedure. A diet plan is needed
to assist patient in eating a more appropriate diet that will help prevent further
readmissions.