The patient with worsening chest pain and shortness of breath has been started on intravenous nitroglycerin for angina control. Which nursing intervention is most important to prioritize given the current treatment plan and the patient's symptoms?

A) Monitor the patient's blood pressure closely for hypotension due to nitroglycerin administration.

B) Encourage the patient to ambulate frequently to prevent deep vein thrombosis.

C) Restrict the patient's fluid intake to prevent fluid overload and edema.

D) Educate the patient about the need for lifestyle modifications to manage coronary artery disease.

A patient with myocardial ischemia, evidenced by ST-segment depression and elevated troponin levels, is experiencing increased chest pain, dyspnea, and arrhythmias. The nurse is planning interventions to stabilize the patient's condition. Which intervention should the nurse prioritize to address the current clinical manifestations?

B) Initiate intravenous nitroglycerin to alleviate chest pain

A) Administer oral aspirin to reduce thrombus formation

B) Initiate intravenous nitroglycerin to alleviate chest pain

C) Prepare the patient for an emergent coronary angiography

D) Apply a transcutaneous pacemaker to manage arrhythmias

A patient with multi-vessel coronary artery disease is experiencing hypotension, tachycardia, and elevated lactate levels, suggesting cardiogenic shock. Which nursing intervention is most critical to prioritize in this situation to stabilize the patient?

B) Initiating inotropic support to improve cardiac output

A) Administering a fluid bolus to increase blood pressure

B) Initiating inotropic support to improve cardiac output

C) Increasing supplemental oxygen to enhance oxygenation

D) Preparing the patient for an immediate coronary artery bypass grafting (CABG) procedure

A patient with multi-vessel coronary artery disease is experiencing hypotension and elevated lactate levels despite initial symptom improvement after intravenous nitroglycerin administration. Which nursing intervention is most appropriate to prioritize at this moment?

B) Administer inotropic medication as prescribed to enhance cardiac output.

A) Encourage oral fluids to improve hydration status.

B) Administer inotropic medication as prescribed to enhance cardiac output.

C) Prepare the patient for immediate thrombolytic therapy.

D) Place the patient in a high Fowler's position to promote oxygenation.

A patient with severe left ventricular systolic dysfunction and multi-vessel coronary artery disease is experiencing cardiogenic shock. Which nursing intervention is most appropriate to prioritize for this patient to enhance cardiac output and tissue perfusion?

C) Monitor and titrate inotropic medication to optimize cardiac contractility.

A) Administer a diuretic to reduce fluid overload.

B) Position the patient in a high Fowler's position to decrease preload.

C) Monitor and titrate inotropic medication to optimize cardiac contractility.

D) Encourage early ambulation to improve circulation.

A patient with severe left ventricular systolic dysfunction and elevated troponin levels is being managed with inotropic support and vasopressors. Despite these interventions, the patient is at risk for further complications. Which nursing intervention is most critical to monitor for signs of improved end-organ perfusion?

A) Measure daily weight to assess fluid status

C) Check peripheral pulses every shift

D) Assess skin turgor periodically

A patient with severe left ventricular dysfunction and acute pulmonary edema is being managed with diuretics and CPAP. Which nursing intervention is most appropriate to monitor for the effectiveness of these treatments?

A) Measuring daily weight and monitoring urine output

B) Administering supplemental oxygen to maintain SpO2 above 90%

C) Encouraging the patient to perform incentive spirometry hourly

D) Monitoring blood glucose levels every four hours

A patient with severe left ventricular dysfunction and acute pulmonary edema is experiencing metabolic acidosis and decreased urine output. Which of the following nursing interventions is most critical to prioritize at this time?

C) Implement diuretic therapy to reduce fluid overload and pulmonary congestion.

A) Increase intravenous fluid administration to improve renal perfusion.

B) Administer a higher dose of inotropic medication to enhance cardiac output.

C) Implement diuretic therapy to reduce fluid overload and pulmonary congestion.

D) Initiate a higher setting of continuous positive airway pressure (CPAP) to improve oxygenation.

A patient with heart failure is experiencing persistent respiratory distress and worsening renal function despite treatment. Which nursing intervention is most appropriate to address the patient's current condition and prevent further deterioration?

C) Collaborate with the healthcare team to prepare for intra-aortic balloon pump insertion.

A) Increase the dose of diuretics to manage pulmonary congestion.

B) Initiate continuous renal replacement therapy (CRRT) to support renal function.

C) Collaborate with the healthcare team to prepare for intra-aortic balloon pump insertion.

D) Encourage the patient to perform deep breathing exercises to improve oxygenation.

A patient with heart failure and acute kidney injury is experiencing worsening respiratory distress despite diuretic therapy and CPAP. Which nursing intervention is most appropriate to address the patient's immediate respiratory needs?

C) Prepare the patient for potential intubation and mechanical ventilation.

A) Increase the flow rate of supplemental oxygen to 10 L/min via non-rebreather mask.

B) Administer a bronchodilator to improve airway patency and reduce respiratory rate.

C) Prepare the patient for potential intubation and mechanical ventilation.

D) Instruct the patient to perform pursed-lip breathing to enhance oxygenation.

chd - Nursing Case Study

Pathophysiology

• Primary mechanism: Coronary artery disease (CAD) is the primary cause of coronary heart disease (CHD). It involves the buildup of atherosclerotic plaques in the coronary arteries, leading to narrowed and hardened vessels, reducing blood flow to the heart muscle.

• Secondary mechanism: Endothelial dysfunction plays a crucial role, where the inner lining of the arteries fails to regulate vascular tone and blood flow properly, exacerbating plaque formation and increasing the risk of thrombosis.

• Key complication: Reduced blood flow from narrowed arteries can result in myocardial ischemia, potentially leading to angina, myocardial infarction, or heart failure if left untreated.

Patient Profile

Demographics:

58-year-old male, construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes Mellitus, Smoker for 30 years

• Current medications: Metformin, Lisinopril, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Chest pain and shortness of breath

• Key symptoms: Fatigue, dizziness, intermittent palpitations, occasional leg swelling

• Vital signs: Blood Pressure 150/95 mmHg, Heart Rate 105 bpm, Respiratory Rate 22 breaths per minute, Temperature 98.6°F, Oxygen Saturation 92% on room air

Section 1

Following his presentation with chest pain and shortness of breath, the patient underwent a series of diagnostic tests, including an electrocardiogram (ECG) and laboratory evaluations. The initial ECG results showed ST-segment depression, suggestive of myocardial ischemia. Troponin levels were slightly elevated at 0.8 ng/mL (normal <0.04 ng/mL), indicating possible myocardial injury. A stress test was scheduled to assess the extent of coronary artery disease, but the patient was unable to complete it due to severe fatigue and dyspnea at low levels of exertion.

Within 24 hours, the patient's condition worsened, with increased episodes of chest pain and more pronounced shortness of breath. His oxygen saturation dropped to 88% on room air, necessitating supplemental oxygen. Repeat vital signs showed a blood pressure of 160/100 mmHg and a heart rate of 115 bpm. He was placed on continuous cardiac monitoring, revealing frequent premature ventricular contractions (PVCs) and episodes of non-sustained ventricular tachycardia, raising concerns about potential arrhythmic complications.

Given the progression of symptoms and new findings, the healthcare team initiated treatment intensification, focusing on optimizing heart function and reducing cardiac workload. Intravenous nitroglycerin was administered for angina control, and beta-blockers were considered to manage arrhythmias and lower heart rate. The need for a coronary angiography was discussed to evaluate the severity of coronary blockages and guide further management. The unfolding clinical picture prompts careful consideration of potential interventions to prevent further deterioration, including the possibility of revascularization procedures or adjustments in the medical management plan.

Section 2

Following the administration of intravenous nitroglycerin and the consideration of beta-blockers, the patient's immediate symptoms showed partial improvement. His chest pain reduced in intensity, and his oxygen saturation improved to 92% with supplemental oxygen. However, during the ongoing monitoring, the frequency of premature ventricular contractions (PVCs) persisted, and there were intermittent episodes of non-sustained ventricular tachycardia. This suggested an ongoing risk of arrhythmias that warranted closer observation and further intervention.

A coronary angiography was performed, revealing significant stenosis in the left anterior descending artery, confirming a diagnosis of multi-vessel coronary artery disease. Given these findings, the cardiology team discussed the possibility of revascularization, such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), depending on the patient's overall condition and surgical risk. The decision-making process involved evaluating the potential benefits of revascularization against the risk of surgical complications, considering the patient's current unstable state.

Despite the initial improvement in symptoms, the patient's condition began to deteriorate again. He developed hypotension, with blood pressure dropping to 85/55 mmHg, and his heart rate increased to 130 bpm. Lactate levels were elevated at 4.5 mmol/L, indicating possible tissue hypoperfusion and the onset of cardiogenic shock. This prompted the healthcare team to escalate the management strategy, including the initiation of inotropic support to enhance cardiac output and further stabilize hemodynamics. The patient's journey now hinges on the effectiveness of these interventions and the urgent need for a definitive resolution of the underlying coronary artery obstructions to prevent further deterioration.

Section 3

As the healthcare team continued to manage the patient's deteriorating condition, a series of new diagnostic tests were conducted to gain further insights into his cardiac function and overall status. An echocardiogram revealed a significantly reduced ejection fraction of 30%, indicating severe left ventricular systolic dysfunction. This finding confirmed the suspicion of worsening heart failure, likely exacerbated by the myocardial ischemia from the multi-vessel coronary artery disease. Additionally, blood tests showed a rising troponin level, now at 0.8 ng/mL, which suggested ongoing myocardial injury despite initial treatment efforts. The patient's renal function also showed signs of compromise, with creatinine levels increasing to 2.1 mg/dL, hinting at possible acute kidney injury secondary to reduced cardiac output and perfusion.

In response to these concerning diagnostic results, the healthcare team intensified the patient's management plan. The inotropic support was optimized, and a vasopressor was added to maintain adequate blood pressure and organ perfusion. An intra-aortic balloon pump (IABP) was considered to provide mechanical circulatory support, aiming to decrease myocardial oxygen demand and improve coronary perfusion during this critical period. The cardiology team re-evaluated the timing and approach for revascularization, with CABG emerging as a potentially more comprehensive solution given the extent of coronary artery disease and the patient's current hemodynamic instability. However, the risks associated with surgery in the face of ongoing cardiogenic shock and potential multi-organ dysfunction required careful deliberation and risk stratification.

As the patient's journey continued, the focus remained on stabilizing his condition while preparing for a potential surgical intervention. The team closely monitored his response to the augmented pharmacological and mechanical support, looking for signs of improved cardiac function and end-organ perfusion. Any further changes in his clinical status, such as improvement in blood pressure or urine output, would provide valuable insights into the effectiveness of the current management strategy and guide the next steps in his complex care pathway.

Section 4

As the healthcare team continued to monitor the patient, a new set of diagnostic results highlighted further complications. A follow-up echocardiogram revealed no significant improvement in ejection fraction, which remained at 30%, indicating persistent severe left ventricular dysfunction. Additionally, the patient's B-type natriuretic peptide (BNP) level had risen to 1,200 pg/mL, further confirming the severity of heart failure. Blood gas analysis showed metabolic acidosis, with a pH of 7.32 and a bicarbonate level of 18 mEq/L, suggesting inadequate tissue perfusion and oxygenation.

Clinically, the patient began to exhibit signs of worsening respiratory distress, with an increased respiratory rate of 28 breaths per minute and the onset of bilateral crackles upon auscultation. Despite optimization of inotropic support and the introduction of vasopressors, his blood pressure remained marginal at 85/55 mmHg, and urine output had declined to less than 20 mL/hr, raising significant concerns about renal perfusion and function. The patient's clinical picture was now complicated by acute pulmonary edema, likely due to fluid overload and worsening heart failure, necessitating immediate adjustments to the management plan.

In response to these developments, the healthcare team faced the challenge of balancing fluid management to alleviate pulmonary congestion while ensuring sufficient perfusion to vital organs. Diuretic therapy was cautiously introduced, and continuous positive airway pressure (CPAP) was initiated to improve oxygenation and ease the work of breathing. The team remained vigilant, knowing that these interventions were critical in stabilizing the patient and potentially averting further deterioration, all while preparing him for possible surgical revascularization. The delicate interplay between cardiac, renal, and respiratory functions required careful coordination and ongoing assessment to optimize outcomes in this complex case.

Section 5

As the healthcare team continued to manage the patient's complex condition, a change in the patient's status became increasingly apparent. Over the next 12 hours, despite the initiation of diuretic therapy and CPAP, the patient's respiratory status showed minimal improvement. His respiratory rate remained elevated at 30 breaths per minute, and oxygen saturation hovered around 88% on supplemental oxygen. Bilateral crackles persisted, indicating ongoing pulmonary congestion. Clinically, the patient appeared increasingly fatigued, with shallow breathing and accessory muscle use, suggesting that his respiratory effort was unsustainable without further intervention.

Concurrently, the patient's renal function exhibited further decline. Repeat laboratory tests revealed a blood urea nitrogen (BUN) level of 45 mg/dL and creatinine of 2.5 mg/dL, pointing towards acute kidney injury likely exacerbated by both low cardiac output and the diuretic therapy. Electrolyte imbalances emerged, with serum potassium decreasing to 3.0 mEq/L, necessitating cautious replacement while avoiding exacerbation of fluid overload. The patient's mental status also subtly shifted, revealing mild confusion and lethargy, hinting at possible cerebral hypoperfusion or early signs of toxin buildup due to renal impairment.

In response to these developments, the healthcare team recognized the need for a multi-pronged approach that balanced aggressive management of heart failure symptoms with supportive care for emerging complications. Consideration was given to the potential need for renal replacement therapy should the patient's condition continue to deteriorate. Additionally, discussions regarding advanced cardiac support, such as intra-aortic balloon pump insertion, were initiated to improve coronary perfusion and cardiac output. The evolving clinical picture underscored the critical importance of timely intervention and ongoing reassessment to prevent further decline and to prepare the patient for potential surgical intervention.