A patient presents with persistent chest pain radiating to the left arm, shortness of breath, and elevated cardiac enzymes. The healthcare team suspects a non-ST-segment elevation myocardial infarction (NSTEMI). Which nursing intervention is most appropriate to prioritize for this patient to prevent further cardiac injury?

A) Administer a loading dose of clopidogrel to prevent platelet aggregation.

B) Initiate supplemental oxygen to improve tissue perfusion.

C) Administer sublingual nitroglycerin to relieve chest pain.

D) Monitor blood pressure closely to prevent hypotensive episodes.

A patient with a suspected NSTEMI is experiencing worsening chest pain despite initial administration of sublingual nitroglycerin and supplemental oxygen. The healthcare team plans to initiate a continuous infusion of nitroglycerin. Which nursing action is most critical in monitoring this patient's response to the continuous nitroglycerin infusion?

A) Monitoring blood pressure every 15 minutes to assess for hypotension

B) Reassessing the patient's pain level every hour to evaluate pain management

C) Checking oxygen saturation every 30 minutes to ensure adequate oxygenation

D) Observing for signs of headache as a common side effect of nitroglycerin

A patient with a worsening NSTEMI is being treated with a continuous infusion of nitroglycerin and is scheduled for urgent coronary angiography. The nurse notes the patient's heart rate is 115 bpm, blood pressure is 145/85 mmHg, and respiratory rate is 24 breaths per minute. Which nursing intervention is most appropriate to address the patient's current clinical status?

B) Administer a beta-blocker as ordered to help control the heart rate.

A) Increase the rate of nitroglycerin infusion to further reduce chest pain.

B) Administer a beta-blocker as ordered to help control the heart rate.

C) Discontinue supplemental oxygen since saturation is stable at 94%.

D) Obtain a stat EKG to reassess for any changes indicating a STEMI.

A patient receiving continuous nitroglycerin infusion and beta-blocker therapy for chest pain and myocardial ischemia is being prepared for a percutaneous coronary intervention (PCI). Which nursing action is most important to perform prior to the procedure to ensure patient safety and effective care?

B) Monitor the patient's respiratory status and oxygen saturation closely.

A) Increase the rate of nitroglycerin infusion to manage chest pain effectively.

B) Monitor the patient's respiratory status and oxygen saturation closely.

C) Administer additional diuretics to prevent fluid overload.

D) Educate the patient about the benefits and risks of PCI.

A patient receiving treatment for myocardial ischemia is on a continuous nitroglycerin infusion and beta-blocker therapy. Despite a reduction in heart rate, the patient remains diaphoretic and anxious with an elevated respiratory rate. Given the current situation, what is the nurse's priority action?

B) Prepare the patient for immediate percutaneous coronary intervention (PCI)

A) Increase the dose of beta-blocker to further reduce heart rate

B) Prepare the patient for immediate percutaneous coronary intervention (PCI)

C) Administer additional oxygen to improve oxygen saturation levels

D) Notify the physician about the drop in oxygen saturation and elevated BNP

A patient undergoing preparation for percutaneous coronary intervention (PCI) shows signs of respiratory distress with a respiratory rate of 28 breaths per minute and oxygen saturation of 89%. Given the findings of decreased left ventricular ejection fraction (LVEF) and elevated BNP, which nursing intervention is the priority to address the patient's condition?

B) Increase diuretic therapy to reduce fluid overload.

A) Administer additional IV fluids to improve cardiac output.

B) Increase diuretic therapy to reduce fluid overload.

C) Initiate high-flow oxygen therapy to improve oxygenation.

D) Prepare the patient for immediate intubation to secure the airway.

A patient undergoing preparation for PCI exhibits respiratory distress, elevated respiratory rate, and declining oxygen saturation. Echocardiogram findings indicate decreased LVEF, and BNP levels are elevated. Which nursing intervention is most appropriate to address the patient's current respiratory status?

B) Administer intravenous furosemide as prescribed

A) Increase supplemental oxygen to 100%

B) Administer intravenous furosemide as prescribed

C) Initiate non-invasive positive pressure ventilation (NIPPV)

D) Position the patient in a high Fowler's position

A patient with acute heart failure exacerbation is experiencing worsening respiratory distress and decreased oxygen saturation despite supplemental oxygen. Which nursing intervention would be most appropriate to prioritize for this patient to improve oxygenation and hemodynamic stability?

C) Initiate a low-dose infusion of nitroglycerin to reduce cardiac preload and afterload.

A) Increase the rate of the oxygen delivery system.

B) Administer a higher dose of morphine to reduce respiratory distress.

C) Initiate a low-dose infusion of nitroglycerin to reduce cardiac preload and afterload.

D) Encourage the patient to perform deep breathing exercises to increase lung expansion.

A patient with worsening heart failure is experiencing respiratory distress and decreased oxygen saturation. Despite increased oxygen delivery, the patient's condition has not improved significantly. The healthcare team has initiated a low-dose nitroglycerin infusion. Which nursing intervention is most appropriate to prioritize in this situation?

B) Monitor the patient's blood pressure closely to ensure it remains stable.

A) Increase the infusion rate of nitroglycerin to quickly alleviate symptoms.

B) Monitor the patient's blood pressure closely to ensure it remains stable.

C) Administer an additional dose of morphine to manage respiratory distress.

D) Prepare the patient for immediate intubation due to respiratory failure.

Hypertension with chest pain - Nursing Case Study

Pathophysiology

• Primary mechanism: Increased systemic vascular resistance - Hypertension arises when the blood vessels constrict, narrowing the arterial pathways. This resistance forces the heart to work harder to pump blood, raising blood pressure levels.

• Secondary mechanism: Endothelial dysfunction - Damage to the inner lining of blood vessels, often due to high blood pressure, reduces nitric oxide production, impairing the vessels' ability to dilate and further elevating blood pressure.

• Key complication: Myocardial ischemia - Persistent hypertension can lead to chest pain (angina) as the heart muscle receives insufficient blood flow, often due to narrowed coronary arteries, increasing the risk of heart attack.

Patient Profile

Demographics:

55-year-old male, construction worker

History:

• Key past medical history: Diagnosed with hypertension 5 years ago, borderline diabetes, smoker for 20 years, occasional alcohol use

• Current medications: Lisinopril 20 mg daily, Metformin 500 mg twice daily, Aspirin 81 mg daily

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Persistent chest pain for the past 3 days

• Key symptoms: Dull chest pain radiating to the left arm, shortness of breath, occasional dizziness, fatigue

• Vital signs: Blood pressure 165/95 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 93% on room air

Section 1

As the healthcare team conducts an initial assessment of the patient, several concerning findings emerge. The patient's chest pain, described as a persistent dull ache radiating to the left arm, coupled with shortness of breath and fatigue, raises suspicion of a cardiac event. His vital signs show a blood pressure of 165/95 mmHg and a heart rate of 105 bpm, both indicative of uncontrolled hypertension and possible cardiac stress. Oxygen saturation at 93% on room air suggests mild hypoxemia, likely due to impaired cardiac output and potential pulmonary congestion. A focused physical examination reveals jugular venous distention and mild peripheral edema, further suggesting fluid overload and potential heart failure exacerbation.

The primary care team orders an electrocardiogram (ECG) and a series of cardiac enzyme tests to further investigate the possibility of myocardial ischemia or infarction. The ECG shows ST-segment depression in the anterior leads, a classic sign of myocardial ischemia, while initial cardiac enzyme levels, including troponin, are slightly elevated, suggesting some degree of myocardial injury. The combination of these findings prompts the healthcare team to consider the presence of unstable angina or a non-ST-segment elevation myocardial infarction (NSTEMI), necessitating immediate intervention.

In response, the patient is started on supplemental oxygen to improve tissue oxygenation and is given a loading dose of clopidogrel, in addition to his regular aspirin, to prevent further platelet aggregation. Nitroglycerin is administered sublingually to relieve chest pain by dilating coronary vessels, although his blood pressure is closely monitored to prevent hypotension. These interventions aim to stabilize the patient's condition while preparing him for possible further diagnostic testing, such as coronary angiography, should his symptoms persist or worsen. The team remains vigilant, recognizing that his history of hypertension, smoking, and borderline diabetes places him at significant risk for further cardiovascular complications.

Section 2

As the healthcare team monitors the patient's response to the initial interventions, there is a notable change in his clinical status. Approximately two hours after administering the sublingual nitroglycerin and supplemental oxygen, the patient begins to experience an escalation in his chest pain, now reporting it as more intense and pressure-like. Despite the medication, his vital signs reveal a concerning trend: blood pressure has decreased to 145/85 mmHg, which is within a safer range, but his heart rate has increased to 115 bpm, indicating rising sympathetic drive and possible cardiac distress. Oxygen saturation remains stable at 94% with supplemental oxygen, but his respiratory rate has increased to 24 breaths per minute, signaling respiratory compensation and increased work of breathing.

Alarmingly, repeat cardiac enzyme tests show a further rise in troponin levels, confirming an ongoing myocardial injury. The clinical team is now faced with the challenge of managing what appears to be an advancing NSTEMI. This development prompts a reassessment of the patient's treatment plan, with a focus on optimizing cardiac perfusion and minimizing myocardial workload. Given his worsening symptoms and lab findings, the healthcare team prepares for urgent coronary angiography to identify and potentially address any significant coronary artery blockages.

In conjunction with these plans, the team considers the patient's risk profile, including his history of hypertension, smoking, and borderline diabetes, which underscores the importance of aggressive risk factor modification. The decision is made to initiate a continuous infusion of nitroglycerin to better manage his chest pain and myocardial oxygen demand while closely monitoring his hemodynamic status. Additionally, the patient's care plan is updated to include beta-blockers to help control his heart rate and reduce myocardial oxygen consumption. This strategic approach aims to stabilize the patient, prevent further cardiac damage, and pave the way for definitive diagnostic and therapeutic interventions.

Section 3

As the healthcare team implements the updated treatment plan, they maintain vigilant monitoring of the patient's response to the continuous nitroglycerin infusion and newly added beta-blocker therapy. Over the next hour, the patient's chest pain shows a mild reduction in intensity, though it remains persistent. His heart rate begins to decrease, settling at 100 bpm, indicating some initial response to the beta-blocker. However, the patient's respiratory rate continues to be elevated at 26 breaths per minute, and he appears slightly diaphoretic and anxious, suggesting ongoing cardiac and respiratory stress. Vital signs are reassessed, showing blood pressure stabilizing at 140/80 mmHg, but oxygen saturation has dropped slightly to 92% despite supplemental oxygen, raising concerns about adequate oxygen delivery to the myocardium.

New diagnostic results from the urgent coronary angiography reveal significant stenosis in the left anterior descending artery, confirming the presence of a critical blockage that is likely contributing to the myocardial injury. The interventional cardiology team discusses the urgent need for percutaneous coronary intervention (PCI) to restore blood flow and prevent further ischemic damage. Additionally, laboratory results indicate elevated B-type natriuretic peptide (BNP) levels, suggesting that the patient may be developing early signs of heart failure, likely exacerbated by the increased myocardial workload and decreased cardiac output.

These findings prompt the healthcare team to prioritize preparations for PCI while continuing to optimize medical management. The team considers further adjustments to the patient's medications, including increasing diuretic therapy to address potential fluid overload and providing more aggressive pain management. The patient's care plan is revised to include frequent reassessments of cardiac and respiratory status, with a focus on early detection of any deterioration. The evolving clinical picture underscores the importance of timely intervention and comprehensive management to stabilize the patient and prevent progression to more severe complications.

Section 4

As the healthcare team prepares the patient for percutaneous coronary intervention (PCI), they observe a change in his status that necessitates immediate attention. Despite the initial stabilization of blood pressure at 140/80 mmHg and the mild reduction in chest pain, the patient's respiratory status continues to signal distress. His respiratory rate remains elevated at 28 breaths per minute, and his oxygen saturation further declines to 89%, even with supplemental oxygen. The patient exhibits increased dyspnea and continues to appear diaphoretic, with an anxious expression, suggesting that his condition may be deteriorating.

Given these developments, the team suspects the onset of pulmonary congestion, likely due to fluid overload and impending heart failure. A rapid bedside echocardiogram is performed, revealing decreased left ventricular ejection fraction (LVEF) at 35%, confirming significant systolic dysfunction. The elevated BNP levels and echocardiogram findings reinforce the need for prompt intervention to prevent further cardiac decompensation. The team decides to increase diuretic therapy to alleviate the fluid overload and continues titration of the beta-blocker to optimize heart rate control and reduce myocardial oxygen demand.

Simultaneously, the patient's pain management is reassessed. Given the persistence of chest discomfort, the healthcare team administers an additional dose of intravenous morphine to achieve better analgesia and reduce anxiety, which may further help in managing the patient's respiratory rate. Continuous monitoring remains crucial, with the nursing staff closely observing for any signs of worsening heart failure or respiratory compromise. The decision to proceed swiftly with PCI is underscored by the critical need to restore coronary perfusion and prevent irreversible myocardial injury. This comprehensive approach reflects the team's commitment to stabilizing the patient and mitigating the risks of more severe complications.

Section 5

As the team continues to monitor the patient closely, they note a concerning change in his status. The patient's respiratory distress intensifies, with his respiratory rate climbing to 32 breaths per minute despite the administration of morphine and supplemental oxygen. His oxygen saturation has dropped further to 85%, prompting the team to increase oxygen delivery through a non-rebreather mask. Physical examination reveals bilateral crackles upon auscultation, extending to the mid-lung fields, and an S3 heart sound is audible, indicating worsening heart failure.

Concurrently, new diagnostic results provide additional insights. A repeat chest X-ray shows increasing pulmonary vascular congestion and interstitial edema, consistent with acute heart failure exacerbation. Laboratory tests reveal worsening renal function, with creatinine levels rising from 1.2 mg/dL to 1.8 mg/dL, suggesting acute kidney injury likely secondary to the decreased cardiac output and diuretic therapy. These findings necessitate a cautious balance between aggressive fluid removal and renal protection, requiring the team to adjust the diuretic regimen carefully.

In response to these developments, the healthcare team prioritizes interventions to address the fluid overload while preparing for the impending PCI. They decide to initiate a low-dose infusion of nitroglycerin to reduce preload and afterload, thus potentially improving cardiac output and relieving pulmonary congestion. The nursing staff remains vigilant in observing the patient's hemodynamic status, ensuring that blood pressure remains stable enough for PCI. This strategic approach aims to manage the patient's acute symptoms while facilitating definitive intervention, highlighting the importance of dynamic clinical reasoning as the patient's condition evolves.