NSTEMI Case Study for Nursing Students: Clinical Reasoning Cycle (Steps 1 and 2) Explained
Coursework Summative Assessment
Case Study – Non-ST Elevation Myocardial Infarction (NSTEMI)
Steps 1 & 2: Consider the patient situation and collect cues/information
You are the nurse taking over the care of TA, a 58-year-old self
employed taxi driver admitted to the Coronary Care Unit (CCU) following an episode of
chest pain earlier today.
Background Information
TA lives in South London with his wife, SW, who is currently at the bedside.
He has three adult children living nearby. His past medical history includes hypertension
(diagnosed 8 years ago) and hyperlipidaemia, but he admits to inconsistent medication use
due to irregular work hours. His current prescriptions are ramipril 5 mg once daily and
atorvastatin 20 mg at night. He is a current smoker (10 cigarettes per day) and drinks alcohol
socially (2–3 units per week). He has no known drug allergies.
David describes his work as “non-stop,” often driving long hours without regular meals. He
expresses worry about taking time off work, saying, “If I don’t drive, I don’t get paid.” His
wife reports that he’s been “under a lot of stress lately” due to financial pressures. Family
history is significant for ischaemic heart disease — his father died of a heart attack at 62.
Presenting situation
Earlier this morning, while loading luggage for a passenger, David experienced a tight,
central chest pain radiating to his left arm and jaw, accompanied by mild shortness of breath
and nausea. The pain persisted for about 25 minutes before paramedics arrived. David rated
his pain 9/10 on the numerical rating scale. En route to the hospital, he was given 300 mg of
aspirin orally and a sublingual GTN spray (400 micrograms), which provided partial relief.
On arrival at the Emergency Department, the ECG showed ST-segment depression in leads II,
III, and aVF, and high-sensitivity troponin I was elevated. He was diagnosed and treated as a
Non-ST Elevation Myocardial Infarction (NSTEMI) and transferred to the CCU for further
management.
The medical team have documented the confirmed medical diagnosis as Non-ST
Elevation Myocardial Infarction.
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Adult Nursing 2 [5KNIA011] – Coursework Summative Assessment
Current Observations
Parameter
Respiratory rate
Reading
20 breaths/min
Oxygen saturation (2L nasal cannula oxygen) 94 %
Heart rate
Blood pressure
98 beats/min
146/88 mmHg
Temperature
36.8 °C
Pain score
3/10 (after GTN)
ECG
Troponin I (0 h)
ST depression in II, III, aVF
0.48 ng/mL (↑)
Troponin I (3 h)
Total cholesterol
1.20 ng/mL (↑↑)
6.9 mmol/L
LDL cholesterol
HDL cholesterol
4.2 mmol/L
0.9 mmol/L
Triglycerides
2.3 mmol/L
Glucose
8.1 mmol/L
Urea
5.9 mmol/L
Creatinine
92 µmol/L
Current Status
TA is currently stable but anxious. He reports mild chest heaviness (3/10) and feels “on
edge” about what happens next. He has been started on oxygen at 2 L/min via nasal cannula,
aspirin 75 mg daily, ticagrelor 180 mg STAT and 90 mg BD, and fondaparinux 2.5 mg
subcutaneously daily. His medication has been adjusted to atorvastatin 80 mg nocte and
bisoprolol 2.5 mg once daily with ramipril 2.5 mg daily continuing. Intravenous access is
patent; fluids are not running.
He is on continuous cardiac monitoring. The medical registrar plans a coronary angiogram
within the next 24–48 hours, subject to bed availability at the tertiary centre.
Amina sits quietly beside him, visibly worried. She asks, “Is he going to need surgery? He
never listens when I tell him to take his tablets.” David sighs, saying, “I just want to go home
soon; my customers depend on me.”
Psychosocial Context
TA feels fear and uncertainty regarding his prognosis and the financial impact of his
hospitalisation. He shows guilt for neglecting his health and frustration at being unable to
work. His wife is anxious but cooperative, seeking reassurance. Both seem open to education
about cardiac risk factors and lifestyle changes.