A patient with an anterior wall STEMI is receiving thrombolytic therapy and intravenous nitroglycerin. The nurse notes that the patient has elevated blood glucose levels and metabolic acidosis. What is the highest priority nursing intervention at this time?

C) Monitor for signs of bleeding and assess neurological status.

A) Increase the rate of intravenous fluids to improve renal perfusion.

B) Administer insulin to manage hyperglycemia and correct acidosis.

C) Monitor for signs of bleeding and assess neurological status.

D) Prepare the patient for percutaneous coronary intervention (PCI).

A patient with an anterior wall STEMI is receiving a thrombolytic agent. The nurse notes the patient has elevated blood glucose levels and metabolic acidosis. Which nursing intervention is most appropriate to address the metabolic acidosis while continuing to monitor cardiac status?

A) Administer insulin as prescribed to manage hyperglycemia and monitor for changes in ECG.

B) Increase the rate of IV fluids to flush out excess acid and improve perfusion.

C) Encourage the patient to take deep breaths and cough to improve oxygenation and correct pH.

D) Administer sodium bicarbonate to directly correct the metabolic acidosis.

A patient receiving thrombolytic therapy for acute myocardial infarction is now exhibiting signs of respiratory distress, hypotension, and pulmonary edema. Which nursing intervention should be prioritized to address the patient's current status?

B) Administer a diuretic to reduce pulmonary congestion and improve respiratory function.

A) Increase the nitroglycerin infusion rate to improve myocardial perfusion.

B) Administer a diuretic to reduce pulmonary congestion and improve respiratory function.

C) Increase supplemental oxygen to improve oxygen saturation levels.

D) Elevate the head of the bed to alleviate respiratory distress.

A patient who received thrombolytic therapy is now showing signs of increased respiratory distress, hypotension, and has developed a new S3 heart sound. Which of the following nursing interventions should be prioritized to stabilize the patient?

B) Administer a diuretic to reduce pulmonary congestion

A) Increase the rate of nitroglycerin infusion to improve coronary blood flow

B) Administer a diuretic to reduce pulmonary congestion

C) Increase supplemental oxygen to enhance oxygen saturation

D) Elevate the head of the bed to improve respiratory function

A patient with respiratory distress, pulmonary congestion, and suspected myocardial ischemia is being managed with IV furosemide and supplemental oxygen. Given the arterial blood gas analysis showing respiratory acidosis and hypoxemia, what is the priority nursing action?

B) Prepare for potential initiation of mechanical ventilation.

A) Increase the rate of oxygen delivery on the non-rebreather mask.

B) Prepare for potential initiation of mechanical ventilation.

C) Administer potassium supplements to address hypokalemia.

D) Initiate continuous positive airway pressure (CPAP) therapy.

A patient with acute pulmonary congestion and respiratory acidosis is being managed with a reduced nitroglycerin infusion and intravenous furosemide. Despite these interventions, the patient remains in respiratory distress with hypoxemia. Based on the current situation, what is the nurse's priority action?

B) Prepare the patient for possible intubation and mechanical ventilation.

A) Increase the dose of intravenous furosemide to enhance diuresis.

B) Prepare the patient for possible intubation and mechanical ventilation.

C) Administer supplemental potassium to correct hypokalemia.

D) Increase the nitroglycerin infusion to improve myocardial perfusion.

A patient with respiratory distress is placed on BiPAP, showing slight improvement in respiratory rate and oxygen saturation. However, the patient remains fatigued and exhibits labored breathing. The arterial blood gas analysis shows partial correction of respiratory acidosis and persistent hypoxemia. What should be the nurse's next priority action?

B) Prepare the patient for potential mechanical ventilation.

A) Increase the BiPAP pressure settings to improve oxygenation.

B) Prepare the patient for potential mechanical ventilation.

C) Administer a bronchodilator to alleviate labored breathing.

D) Re-evaluate the patient's electrolyte status to ensure correction of hypokalemia.

A patient with respiratory distress is initiated on BiPAP therapy. Despite improvements in respiratory rate and oxygen saturation, the patient remains fatigued with labored breathing. Arterial blood gas analysis reveals a pH of 7.34, PaCO2 of 46 mmHg, and PaO2 of 60 mmHg. Given these findings, what is the nurse's priority action?

B) Prepare for possible intubation due to persistent hypoxemia.

A) Increase the BiPAP inspiratory pressure to enhance ventilation.

B) Prepare for possible intubation due to persistent hypoxemia.

C) Administer supplemental oxygen to improve oxygenation.

D) Reassess the patient's electrolyte levels to address hypokalemia.

A patient with an acute anterior myocardial infarction is being prepared for percutaneous coronary intervention (PCI). The nurse notes the patient is on an intravenous nitroglycerin infusion and maintains continuous cardiac monitoring. Which of the following nursing interventions is most critical at this time?

A) Monitor for signs of hypotension and adjust the nitroglycerin infusion rate as needed.

B) Encourage the patient to deep breathe to reduce anxiety and improve oxygenation.

C) Prepare the patient for possible intubation by ensuring all equipment is ready.

D) Educate the patient about lifestyle changes to prevent future cardiac events.

A patient with a suspected acute anterior myocardial infarction is experiencing chest pain, hypotension, and pallor after initiating BiPAP. Which nursing intervention is most critical to perform immediately to stabilize the patient's condition?

B) Administer a bolus of intravenous normal saline to address hypotension

A) Increase the BiPAP pressure settings to improve oxygenation

B) Administer a bolus of intravenous normal saline to address hypotension

C) Prepare the patient for immediate transfer to the cardiac catheterization lab

D) Administer an additional dose of nitroglycerin to relieve chest pain

myocardial infarction - Nursing Case Study

Pathophysiology

• Primary mechanism: Coronary artery occlusion due to atherosclerotic plaque rupture leads to thrombus formation, severely restricting blood flow and oxygen supply to the myocardial tissue, causing ischemia and subsequent myocardial cell death.

• Secondary mechanism: Oxygen deprivation initiates anaerobic metabolism within myocardial cells, resulting in lactic acid accumulation, decreased ATP production, and cellular damage, further exacerbating necrosis and loss of cardiac function.

• Key complication: The necrotic myocardial tissue can lead to impaired contractility and electrical conduction, potentially resulting in heart failure, arrhythmias, or even cardiac arrest if not promptly managed.

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: Severe chest pain radiating to the left arm

• Key symptoms: Shortness of breath, nausea, diaphoresis, mild dizziness

• Vital signs: Blood pressure 150/95 mmHg, heart rate 105 bpm, respiratory rate 22 breaths/min, temperature 98.6°F, SpO2 92% on room air

Section 1

As the healthcare team continues to monitor the patient, new diagnostic results are obtained to further assess the extent of the myocardial infarction. An ECG reveals ST-segment elevation in the anterior leads, confirming an anterior wall ST-elevation myocardial infarction (STEMI). Blood tests show elevated cardiac biomarkers, with troponin levels significantly increased, indicating myocardial necrosis. A chest X-ray indicates mild pulmonary congestion, suggesting the beginning signs of heart failure. These findings align with the current clinical picture of myocardial ischemia and potential cardiac impairment.

The patient's status is closely monitored, and additional lab results indicate a worsening metabolic profile. Blood glucose levels are elevated at 240 mg/dL, and there is evidence of metabolic acidosis with an arterial blood gas analysis showing a pH of 7.31, HCO3- of 18 mEq/L, and pCO2 of 34 mmHg. The metabolic disturbances are likely exacerbated by the stress of the acute myocardial event and the patient's underlying Type 2 Diabetes Mellitus, necessitating careful adjustment of his metabolic management plan.

Given these developments, the clinical team initiates interventions aimed at reperfusion and stabilization. The patient is administered a thrombolytic agent to dissolve the occlusive thrombus and restore myocardial perfusion, alongside intravenous nitroglycerin to reduce cardiac workload and control blood pressure. Despite these efforts, the patient's oxygen saturation remains suboptimal, necessitating supplemental oxygen therapy. The evolving situation requires ongoing assessment to detect any further complications, such as arrhythmias or progression to heart failure, and to promptly adjust the treatment strategy to support the patient's recovery. The team prepares for potential escalation of care, including consideration of percutaneous coronary intervention (PCI) if thrombolytic therapy does not yield the desired outcomes.

Section 2

As the healthcare team continues their vigilant monitoring of the patient, they notice a change in his status indicating further complications. Approximately two hours after the administration of thrombolytic therapy, the patient begins to exhibit signs of increased respiratory distress. His respiratory rate has risen to 28 breaths per minute, and he is using accessory muscles to breathe. His oxygen saturation, despite supplemental oxygen, has dropped to 88%. Auscultation of the lungs reveals diffuse crackles, particularly at the bases, suggesting worsening pulmonary edema and progression towards acute heart failure.

Simultaneously, the patient's blood pressure has decreased to 90/60 mmHg, indicating hypotension that may be exacerbated by the intravenous nitroglycerin, which is aimed at reducing cardiac workload but may now be contributing to hemodynamic instability. Heart sounds reveal a new S3 gallop, further supporting the suspicion of heart failure. The patient also reports feeling lightheaded and has developed a cold, clammy skin, which are signs consistent with decreased perfusion.

In response to these alarming changes, the clinical team must quickly reassess the management plan. The nitroglycerin infusion rate is reduced to mitigate the hypotension, and a diuretic is considered to manage the pulmonary congestion. Additionally, continuous cardiac monitoring is essential to detect any arrhythmias, as the combination of myocardial ischemia and electrolyte imbalances from metabolic acidosis heightens the risk of life-threatening dysrhythmias. The team debates early initiation of PCI in light of the patient's deteriorating condition and suboptimal response to thrombolytic therapy, weighing the benefits of mechanical reperfusion to prevent further myocardial damage and stabilize the patient.

Section 3

In light of the patient's deteriorating condition and the team's decision to adjust the management plan, the focus shifts to the patient's response to these interventions. After reducing the nitroglycerin infusion, there is a slight improvement in blood pressure, now reading 95/65 mmHg, though it remains on the lower side. The team administers a dose of intravenous furosemide to address the pulmonary congestion. Within thirty minutes, the patient begins to produce a significant amount of urine, indicating a diuretic effect, and his respiratory rate decreases to 24 breaths per minute. Supplemental oxygen through a non-rebreather mask is maintained, and the oxygen saturation rises slightly to 90%, suggesting marginal improvement in gas exchange.

Despite these measures, the patient continues to experience significant respiratory distress and fatigue, with persistent crackles auscultated throughout the lung fields. An arterial blood gas analysis reveals a pH of 7.30, PaCO2 of 50 mmHg, and PaO2 of 55 mmHg, confirming the presence of respiratory acidosis and hypoxemia. Electrolyte panels show mild hypokalemia, with a potassium level of 3.2 mEq/L, potentially contributing to an elevated risk for arrhythmias. Continuous cardiac monitoring reveals occasional premature ventricular contractions, heightening concern for potential progression to more serious dysrhythmias.

The team discusses the possibility of mechanical ventilation support to alleviate the work of breathing and improve oxygenation, alongside considering urgent percutaneous coronary intervention (PCI) to address the underlying ischemic burden. The patient's overall condition underscores the urgency of addressing both respiratory compromise and myocardial perfusion. The priority remains stabilizing the patient to prevent further deterioration while preparing for possible escalation in care, including transfer to the cardiac catheterization lab if deemed necessary.

Section 4

As the medical team evaluates the patient's ongoing respiratory distress and declining oxygen levels, they decide to initiate non-invasive positive pressure ventilation (NIPPV) as a step before considering mechanical ventilation. The patient is placed on BiPAP, with settings adjusted to improve alveolar ventilation and decrease the work of breathing. Within the first 15 minutes of BiPAP initiation, the patient's respiratory rate decreases slightly to 22 breaths per minute, and his oxygen saturation improves to 92%. Despite these positive changes, the patient remains visibly fatigued and continues to exhibit labored breathing patterns.

A repeat arterial blood gas analysis is performed to assess the effectiveness of the intervention. The results show a pH of 7.34, PaCO2 of 46 mmHg, and PaO2 of 60 mmHg, indicating partial correction of the respiratory acidosis but persistent hypoxemia. Meanwhile, the electrolyte imbalance is addressed by administering intravenous potassium chloride to correct the hypokalemia, with a target to stabilize the potassium level above 4.0 mEq/L to reduce the risk of arrhythmias.

However, during continuous cardiac monitoring, the frequency of premature ventricular contractions increases, prompting the team to consider the potential need for antiarrhythmic therapy. The patient's condition remains precarious, with the next critical decision being whether to proceed with urgent PCI to restore myocardial perfusion, given the ongoing ischemic risk and its contribution to the patient's clinical picture. The team prepares for the possibility of rapid transfer to the cardiac catheterization lab, emphasizing the need for timely intervention to prevent further deterioration.

Section 5

As the medical team deliberates on the next steps, the patient's condition begins to exhibit new complications. Approximately 30 minutes after initiating BiPAP, the patient complains of increasing chest pain, which he rates as 8 out of 10, and there is a noticeable change in his skin color, with pallor and diaphoresis becoming more pronounced. His blood pressure drops to 90/60 mmHg, heart rate spikes to 110 beats per minute, and his respiratory rate, although slightly decreased, remains elevated at 22 breaths per minute with labored effort. These signs suggest worsening myocardial ischemia, likely due to insufficient coronary perfusion.

The decision is made to urgently proceed with percutaneous coronary intervention (PCI) to address the suspected coronary artery blockage. As preparations are underway for transfer to the cardiac catheterization lab, the patient's electrocardiogram shows ST-segment elevations in the anterior leads, corroborating the diagnosis of an acute anterior myocardial infarction. The presence of frequent premature ventricular contractions and the risk of ventricular tachycardia or fibrillation further underscore the critical need for intervention.

Throughout this period, the nursing team plays a crucial role in monitoring vital signs, ensuring the patient’s comfort, and providing reassurance. An intravenous nitroglycerin infusion is started to help alleviate the chest pain and improve coronary blood flow, while continuous cardiac monitoring is maintained. The clinical team remains vigilant for any signs of hemodynamic instability or arrhythmias, recognizing the precarious balance between maintaining adequate perfusion and preventing further cardiac compromise. The urgency of the situation demands coordinated efforts to stabilize the patient and facilitate the swift execution of PCI, aiming to restore myocardial perfusion and avert additional complications.