A patient in the emergency department is experiencing worsening chest pain and respiratory distress, with a confirmed ST-elevation myocardial infarction (STEMI). Which immediate nursing intervention should be prioritized to stabilize the patient before transfer to the cardiac catheterization lab?

A) Administer a high-flow oxygen mask to improve oxygenation

B) Initiate an intravenous morphine drip to reduce cardiac workload

C) Obtain a 12-lead ECG to monitor the heart's electrical activity

D) Prepare for transfer by ensuring all consent forms are signed

A patient in the emergency department is experiencing a deterioration in condition with persistent chest pain, decreased oxygen saturation, and signs of respiratory distress. Despite initial treatments, the patient's condition suggests worsening cardiac ischemia. What is the priority nursing intervention to address this change in status?

A) Administer high-flow oxygen and prepare for immediate transfer to the cardiac catheterization lab

B) Increase the dose of sublingual nitroglycerin and monitor vital signs every hour

C) Initiate a fluid bolus to maintain blood pressure and prevent hypotension

D) Encourage deep breathing exercises to improve oxygenation and reduce anxiety

A nurse is caring for a patient in the cardiac intensive care unit who recently underwent a percutaneous coronary intervention (PCI) for a significant blockage in the left anterior descending artery. The patient is now exhibiting signs of a low-grade fever, increased respiratory rate, mild crackles upon lung auscultation, and a slightly elevated white blood cell count. Which nursing intervention is the priority at this time?

D) Administer diuretics as ordered to manage potential fluid overload.

A) Administer prescribed antibiotics to address potential infection.

B) Increase the patient's supplemental oxygen to improve oxygen saturation.

C) Prepare the patient for a repeat PCI to evaluate stent placement.

D) Administer diuretics as ordered to manage potential fluid overload.

A patient who recently underwent a percutaneous coronary intervention (PCI) is being monitored in the cardiac intensive care unit. The patient develops a low-grade fever, increased respiratory rate, mild crackles upon lung auscultation, and an elevated white blood cell count. What is the most appropriate initial nursing intervention?

A) Administer prescribed diuretics to manage potential fluid overload.

B) Initiate antibiotic therapy to address possible infection.

C) Encourage deep breathing and coughing exercises to improve lung expansion.

D) Increase the oxygen delivery to maintain adequate oxygenation.

A patient receiving intravenous furosemide has developed mild hypokalemia with a potassium level of 3.2 mmol/L, alongside complaints of new chest discomfort and occasional premature ventricular contractions (PVCs). What is the most appropriate nursing intervention to prioritize in this situation?

A) Administer supplemental potassium as ordered and monitor cardiac rhythm closely.

B) Increase the rate of diuretic infusion to enhance fluid removal.

C) Restrict fluid intake to prevent further fluid overload.

D) Discontinue the diuretic therapy immediately to prevent further electrolyte imbalance.

A patient receiving intravenous furosemide for pulmonary edema develops hypokalemia with a potassium level of 3.2 mmol/L. Which nursing intervention is most appropriate to prioritize in this situation?

B) Administer potassium supplements as ordered and monitor the patient's cardiac rhythm closely.

A) Restrict the patient's fluid intake to prevent further electrolyte imbalance.

B) Administer potassium supplements as ordered and monitor the patient's cardiac rhythm closely.

C) Increase the rate of diuretic administration to enhance fluid removal and reduce respiratory distress.

D) Encourage the patient to ambulate frequently to promote lung expansion and prevent atelectasis.

A patient with ischemic heart disease and recent diuretic therapy develops fatigue, mild confusion, and hypotension. Laboratory results indicate hypokalemia and mild hyponatremia. What is the most appropriate nursing intervention to prioritize for this patient?

B) Reduce furosemide dosage and start low-dose IV fluids

A) Administer potassium supplements immediately

B) Reduce furosemide dosage and start low-dose IV fluids

C) Increase dietary sodium intake

D) Initiate high-dose intravenous fluid resuscitation

A patient receiving diuretic therapy for heart failure begins to exhibit increased fatigue, mild confusion, hypotension, and frequent PVCs. Laboratory results reveal persistent hypokalemia and newly developed mild hyponatremia. What is the most appropriate nursing intervention to address the patient's current condition?

B) Administer potassium supplementation and adjust fluid management.

A) Increase the dose of diuretics to enhance fluid removal.

B) Administer potassium supplementation and adjust fluid management.

C) Restrict fluid intake to prevent further hyponatremia.

D) Encourage high-sodium foods to correct hyponatremia.

A patient with hemodynamic instability and worsening renal function is being managed with intravenous fluids, inotropic support, and electrolyte supplementation. Despite these interventions, the patient continues to exhibit low blood pressure and increased lethargy. What is the most appropriate nursing intervention to address the patient's current status?

C) Monitor urine output hourly and report any significant decrease to the healthcare provider.

A) Increase the rate of intravenous fluid administration to improve blood pressure.

B) Elevate the head of the bed to 30 degrees to promote venous return and reduce pulmonary congestion.

C) Monitor urine output hourly and report any significant decrease to the healthcare provider.

D) Administer a bolus of hypertonic saline to rapidly correct hyponatremia.

A patient with hemodynamic instability is showing signs of lethargy and decreased Glasgow Coma Scale (GCS) score, along with electrolyte imbalances and renal function deterioration. Which nursing intervention should be prioritized to address the patient's current condition?

D) Prepare for the administration of a low-dose inotropic agent to support cardiac output.

A) Administer intravenous fluids to improve blood pressure.

B) Monitor neurological status every 2 hours to detect changes.

C) Implement a fluid restriction to prevent pulmonary congestion.

D) Prepare for the administration of a low-dose inotropic agent to support cardiac output.

Ischemic heart disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Atherosclerosis - This is the buildup of fatty deposits and plaques within the coronary arteries, leading to narrowed or blocked vessels. Reduced blood flow limits oxygen supply to the heart muscle, causing ischemia and potentially leading to angina or myocardial infarction.

• Secondary mechanism: Endothelial dysfunction - Damage to the endothelial cells lining the coronary arteries impairs their ability to regulate blood flow and maintain vascular tone. This dysfunction promotes inflammation, thrombosis, and further plaque formation, exacerbating ischemia.

• Key complication: Myocardial infarction - Prolonged ischemia can lead to cell death within the heart muscle, resulting in a heart attack. This can cause permanent damage, reducing cardiac output and increasing the risk of heart failure.

Patient Profile

Demographics:

58-year-old male, construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes Mellitus, Hyperlipidemia

• Current medications: Metformin, Lisinopril, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Chest pain and shortness of breath

• Key symptoms: Chest tightness, fatigue, occasional dizziness, and nausea

• Vital signs: Blood pressure 160/95 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 92% on room air

Section 1

Change in Patient Status:

During his stay in the emergency department, the patient’s condition began to deteriorate. Despite initial administration of supplemental oxygen and sublingual nitroglycerin, his chest pain persisted, and his oxygen saturation dipped further to 88% on room air. He exhibited increasing respiratory distress, evidenced by the use of accessory muscles and labored breathing. The chest pain intensity escalated to 8/10 on the pain scale, and he appeared diaphoretic and anxious. His vital signs showed a slight increase in heart rate to 110 bpm, while blood pressure remained elevated at 165/100 mmHg. These changes suggested worsening cardiac ischemia and potential progression toward a myocardial infarction.

The medical team swiftly initiated further interventions, including administering a high-flow oxygen mask to improve oxygenation and an intravenous morphine drip to alleviate chest pain and reduce cardiac workload. Additionally, a 12-lead ECG was obtained, revealing ST-segment elevation in the anterolateral leads, indicative of an acute ST-elevation myocardial infarction (STEMI). Concurrently, laboratory results showed elevated cardiac biomarkers, with troponin I levels significantly elevated, further confirming myocardial injury. The interdisciplinary team, recognizing the urgency of the situation, promptly prepared the patient for transfer to the cardiac catheterization lab for urgent percutaneous coronary intervention (PCI) to restore coronary blood flow and minimize myocardial damage.

This critical change in the patient’s status underscores the importance of timely recognition and intervention in cases of ischemic heart disease. The progression to STEMI highlights the need for rapid response to prevent further complications such as heart failure or arrhythmias. As the patient is stabilized and prepared for PCI, clinical reasoning must focus on evaluating potential risk factors for future cardiac events and developing a comprehensive post-procedural care plan to optimize recovery and manage underlying conditions such as hypertension and diabetes.

Section 2

Following the urgent transfer and successful completion of percutaneous coronary intervention (PCI), the patient was moved to the cardiac intensive care unit for close monitoring. Initially, he showed signs of stabilization with his chest pain subsiding and his oxygen saturation improving to 95% on supplemental oxygen via nasal cannula. The PCI revealed a significant blockage in the left anterior descending artery, which was effectively stented, restoring adequate blood flow. Post-procedure, the patient's heart rate normalized to 85 bpm, and his blood pressure decreased to 130/85 mmHg, indicating a positive response to the intervention.

However, during the subsequent hours, the patient began to exhibit signs of potential complications. He developed a low-grade fever of 100.3°F, and his respiratory rate increased to 22 breaths per minute, accompanied by mild crackles upon lung auscultation. These findings raised concerns for potential post-procedural pneumonia or pulmonary edema, possibly due to fluid overload or heart failure. Additionally, repeat blood work revealed a slightly elevated white blood cell count of 12,500/mm³, suggesting an inflammatory response or infection.

The medical team initiated a comprehensive assessment to delineate the cause of these new symptoms. A chest X-ray was ordered to evaluate pulmonary status, and blood cultures were drawn to rule out any infectious process. Diuretics were considered to manage potential fluid overload, and antibiotic therapy was debated pending further diagnostic results. This shift in the patient's clinical picture necessitated the reevaluation of his care plan, emphasizing the importance of vigilance in monitoring for and addressing complications following acute coronary events. The team remained focused on stabilizing the patient while planning for long-term management strategies to prevent recurrence and optimize cardiovascular health.

Section 3

Following the initial assessment and diagnostic efforts, the chest X-ray revealed mild bilateral infiltrates, raising the suspicion of early pulmonary edema rather than pneumonia. Consequently, the medical team initiated diuretic therapy with intravenous furosemide to address possible fluid overload. Meanwhile, the patient's temperature remained elevated, and his heart rate increased to 98 bpm, indicating a persistent inflammatory process. Blood cultures were still pending, but the elevated white blood cell count and the patient's febrile state prompted the team to start empiric antibiotic therapy with broad-spectrum coverage as a precautionary measure against potential infection.

As the diuretic took effect, the patient experienced a noticeable diuresis, leading to a reduction in respiratory distress and a slight improvement in oxygenation, with saturation rising to 97% on the same flow of supplemental oxygen. However, the patient began to complain of new chest discomfort, characterized by a dull, persistent ache rather than the sharp pain associated with his initial presentation. An electrocardiogram was promptly conducted, revealing no new ischemic changes but showing occasional premature ventricular contractions (PVCs), suggesting potential electrolyte imbalances secondary to diuretic use.

The clinical team ordered serum electrolyte panels, which showed a mild hypokalemia with a potassium level of 3.2 mmol/L. This finding necessitated the cautious supplementation of potassium to prevent further arrhythmias. The patient's care plan was adjusted to include close monitoring of electrolytes and cardiac rhythm, alongside ongoing evaluation of his respiratory and infectious status. This comprehensive approach aimed to stabilize the patient while addressing both the immediate complications and long-term risk factors for further cardiac events. The team remained vigilant, recognizing that the integration of these clinical findings was crucial in guiding the next steps in the patient's recovery and future management.

Section 4

As the medical team continued to monitor the patient closely, a change in his status became apparent. Despite initial improvement with diuretic therapy, the patient began to exhibit signs of increased fatigue and mild confusion. His blood pressure showed a downward trend, measuring 100/60 mmHg, while his heart rate climbed further to 112 bpm. The nurse noted that the patient appeared pale and slightly diaphoretic, raising concerns about potential hemodynamic instability. Given these symptoms, a repeat electrocardiogram was ordered, which still showed no significant ischemic changes but continued to demonstrate frequent PVCs.

Recognizing the potential for systemic effects of diuretic therapy, the team re-evaluated the latest laboratory results. The serum electrolytes showed not only persistent hypokalemia despite supplementation but also a newly developed mild hyponatremia with a sodium level of 133 mmol/L. The patient's kidney function tests revealed a slight elevation in creatinine, suggesting potential prerenal azotemia due to aggressive diuresis. These findings prompted the adjustment of the diuretic regimen, reducing the furosemide dose and emphasizing the importance of balanced fluid management.

In light of the new complications, the clinical team intensified their focus on maintaining electrolyte balance and hemodynamic stability. They decided to initiate low-dose intravenous fluid administration to cautiously address the patient's hypotension and electrolyte disturbances. Furthermore, the team planned for continuous cardiac monitoring to detect any progression of arrhythmias. The integration of clinical reasoning was pivotal at this stage, as the team aimed to prevent further complications while managing the underlying ischemic heart disease and associated risks. This strategy would be critical in guiding the patient towards stabilization and recovery.

Section 5

As the clinical team implemented the adjusted interventions, the patient's condition was closely monitored for response. Despite the cautious administration of intravenous fluids, the patient continued to exhibit signs of hemodynamic instability. Over the next few hours, his blood pressure remained low at 95/58 mmHg, and his heart rate increased to 118 bpm. The nursing staff noted that the patient appeared increasingly lethargic, with a Glasgow Coma Scale (GCS) score decreasing to 13 from a previous score of 15. This change in mental status, along with persistent fatigue, necessitated further evaluation.

Repeat laboratory tests were conducted to assess the effectiveness of the interventions. Electrolyte analysis showed slight improvement in potassium levels, now at 3.4 mmol/L, but sodium had decreased further to 130 mmol/L. The patient's creatinine level had risen to 1.6 mg/dL, indicating worsening renal function. Additionally, a chest X-ray was performed, revealing mild pulmonary congestion, suggesting volume overload despite earlier diuretic therapy. These findings prompted the team to reconsider the fluid management strategy, emphasizing the delicate balance required between adequate perfusion and avoiding fluid overload.

In response to these developments, the clinical team convened to refine the management plan. They decided to introduce a low-dose inotropic agent to support cardiac output and stabilize the patient's hemodynamics. Concurrently, the electrolyte replenishment regimen was adjusted, with more aggressive potassium and sodium supplementation. The team also initiated a consultation with a nephrologist to address the renal complications and to guide further fluid management. Through careful clinical reasoning and collaborative decision-making, the team aimed to stabilize the patient, prevent further deterioration, and facilitate a path toward recovery.