A patient with a suspected NSTEMI presents with elevated jugular venous pressure, bilateral crackles, and tachycardia. Which nursing intervention should be prioritized to prevent progression to acute decompensated heart failure?

A) Administer intravenous diuretics as prescribed to reduce fluid overload.

B) Increase the dosage of metoprolol to manage hypertension and tachycardia.

C) Apply supplemental oxygen to address low oxygen saturation levels.

D) Prepare the patient for coronary angiography to assess coronary artery disease.

A 68-year-old female patient with a history of type 2 diabetes and hypertension is admitted with chest pain and shortness of breath. The initial assessment reveals bilateral crackles, elevated jugular venous pressure, and ST-segment depression on ECG. Her troponin levels are elevated, indicating a non-ST elevation myocardial infarction (NSTEMI). Which of the following nursing interventions is the most appropriate to address her pulmonary congestion?

B) Administering intravenous diuretics to reduce fluid overload

A) Administering supplemental oxygen to improve oxygen saturation

B) Administering intravenous diuretics to reduce fluid overload

C) Increasing metoprolol dosage to control heart rate

D) Initiating nitroglycerin to alleviate chest pain

A patient with a history of coronary artery disease and diabetes presents with increased respiratory rate, chest discomfort, nausea, diaphoresis, and fluctuating oxygen saturation. The repeat ECG shows persistent ST-segment depression and troponin levels have risen. What is the priority nursing intervention to prevent further cardiac compromise in this patient?

A) Administer intravenous nitroglycerin as ordered

B) Increase the dose of diuretics to manage fluid overload

C) Initiate a low-sodium diet to manage hypertension

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

A patient with persistent chest discomfort and elevated troponin levels is being monitored closely. She is currently experiencing increased respiratory rate, nausea, diaphoresis, and fluctuating oxygen saturation levels. Her ECG shows persistent ST-segment depression, and the healthcare team decides to initiate intravenous nitroglycerin. Which nursing intervention is critical in managing this patient's condition during nitroglycerin administration?

A) Monitor the patient's blood pressure closely to prevent hypotension.

B) Encourage the patient to increase fluid intake to maintain hydration.

C) Position the patient flat to promote better coronary perfusion.

D) Limit the patient's activity to prevent exacerbation of symptoms.

A patient with multi-vessel coronary artery disease, diabetes, and heart failure is being prepared for a percutaneous coronary intervention (PCI). Considering her current condition and medication regimen, which nursing intervention is most critical in optimizing her cardiovascular risk factors prior to the procedure?

C) Monitoring the patient's renal function closely with the introduction of an ACE inhibitor

A) Initiating cardiac rehabilitation exercises to improve cardiac function

B) Educating the patient on the importance of adhering to a low-sodium diet

C) Monitoring the patient's renal function closely with the introduction of an ACE inhibitor

D) Administering an additional dose of intravenous nitroglycerin to manage chest pain

A patient with multi-vessel coronary artery disease and heart failure is being prepared for a percutaneous coronary intervention (PCI). The healthcare team has initiated an ACE inhibitor and adjusted her diuretic therapy. As the nurse, what is your priority action to ensure optimal care prior to the procedure?

C) Assess the patient's fluid status and adjust diuretics as needed.

A) Monitor the patient's blood pressure and adjust the ACE inhibitor dosage accordingly.

B) Educate the patient on the importance of medication adherence post-PCI.

C) Assess the patient's fluid status and adjust diuretics as needed.

D) Prepare the patient by explaining the PCI procedure and obtaining consent.

A patient with exacerbated heart failure is experiencing increased respiratory distress, as evidenced by an increased respiratory rate and decreased oxygen saturation despite supplemental oxygen. Which intervention should the nurse prioritize to address the patient's current condition?

D) Position the patient in a high Fowler's position to facilitate lung expansion.

A) Increase the supplemental oxygen flow rate to improve oxygen saturation.

B) Administer the prescribed low-dose aldosterone antagonist to enhance diuresis.

C) Contact the healthcare provider to discuss the addition of a beta-blocker.

D) Position the patient in a high Fowler's position to facilitate lung expansion.

A patient with heart failure is experiencing worsening pulmonary congestion, increased respiratory rate, and decreased oxygen saturation despite supplemental oxygen. Which nursing intervention is most appropriate to prioritize at this time?

C) Position the patient in high Fowler's position.

A) Increase the patient's supplemental oxygen flow rate.

B) Administer the prescribed low-dose aldosterone antagonist.

C) Position the patient in high Fowler's position.

D) Encourage the patient to perform incentive spirometry.

A patient with heart failure and declining renal function is being prepared for a percutaneous coronary intervention (PCI). The patient is currently on diuretics and a low-dose aldosterone antagonist. Which nursing intervention is most appropriate to address the patient's current clinical status?

B) Monitor the patient’s renal function and adjust medications accordingly.

A) Increase the dose of diuretics to manage fluid retention.

B) Monitor the patient’s renal function and adjust medications accordingly.

C) Encourage the patient to increase fluid intake to prevent dehydration.

D) Discontinue the aldosterone antagonist to protect renal function.

A patient with heart failure and declining renal function is being managed with diuretics and has been recently started on a low-dose aldosterone antagonist. Which nursing intervention is most appropriate to prioritize in this situation?

C) Assess for signs of electrolyte imbalances, particularly hyperkalemia.

A) Monitor blood pressure closely to assess for hypotension.

B) Encourage increased fluid intake to prevent dehydration.

C) Assess for signs of electrolyte imbalances, particularly hyperkalemia.

D) Increase the frequency of respiratory assessments to monitor lung function.

angina - Nursing Case Study

Pathophysiology

• Primary mechanism: Angina primarily results from myocardial ischemia, where there is an imbalance between oxygen supply and demand in the heart muscle. This is often due to atherosclerosis, where plaque buildup in coronary arteries reduces blood flow.

• Secondary mechanism: Vasospasm, or the sudden constriction of coronary arteries, can further decrease blood flow, even in the absence of significant atherosclerotic blockage, exacerbating ischemia and triggering angina episodes.

• Key complication: Prolonged or recurrent ischemia can lead to myocardial infarction if left unaddressed, resulting in permanent heart muscle damage and increased risk of heart failure.

Patient Profile

Demographics:

62-year-old female, retired school teacher

History:

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

• Current medications: Metoprolol, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Chest pain and shortness of breath

• Key symptoms: Radiating chest pain to the left arm, nausea, dizziness, intermittent palpitations

• Vital signs: Blood pressure 150/95 mmHg, Heart rate 110 bpm, Respiratory rate 24 breaths per minute, Temperature 98.6°F, Oxygen saturation 92% on room air

Section 1

As the medical team conducts an initial assessment, the patient's physical examination reveals bilateral crackles upon auscultation of the lungs, suggesting possible pulmonary congestion. Her jugular venous pressure appears elevated, indicating potential fluid overload or heart failure. An electrocardiogram (ECG) shows ST-segment depression in the anterior leads, consistent with subendocardial ischemia. The laboratory tests reveal elevated cardiac biomarkers, with troponin levels at 0.12 ng/mL, suggesting myocardial injury or a non-ST elevation myocardial infarction (NSTEMI). Her blood glucose is 220 mg/dL, reflecting suboptimal diabetes control, potentially exacerbating her condition by impairing endothelial function.

Given these findings, the healthcare team is concerned about the progression towards heart failure. They initiate treatment with nitroglycerin to alleviate angina by dilating coronary vessels and reducing myocardial oxygen demand. Supplemental oxygen is provided due to her low saturation, and intravenous diuretics are considered to manage pulmonary congestion. The patient's hypertension and tachycardia remain a concern, prompting an adjustment in her metoprolol dosage to better control her heart rate and blood pressure, aiming to reduce cardiac workload and prevent further ischemic episodes.

As interventions commence, the patient experiences a temporary improvement in chest pain, but her oxygen saturation remains marginally low, requiring close monitoring. Her symptoms and diagnostic findings prompt the team to consider further investigations, such as a coronary angiography, to assess the extent of coronary artery disease and guide potential revascularization strategies. The interplay of her chronic conditions, acute symptoms, and current management requires careful coordination to prevent further complications, such as acute decompensated heart failure, and to stabilize her cardiac status.

Section 2

As the healthcare team continues to monitor the patient closely, a change in her status becomes evident. Despite initial improvements, her respiratory rate begins to increase, and she reports a return of chest discomfort, now accompanied by mild nausea and diaphoresis. Her oxygen saturation has fluctuated, lingering around 88% on room air, necessitating a higher flow rate of supplemental oxygen to maintain adequate levels. Repeat vital signs reveal a blood pressure of 160/95 mmHg and a heart rate of 110 beats per minute, indicating persistent hypertension and tachycardia, which could exacerbate myocardial stress and contribute to ongoing ischemia.

In light of these developments, the medical team reassesses her treatment plan. A repeat ECG shows persistent ST-segment depression, raising concerns about ongoing ischemic episodes. Additionally, follow-up laboratory tests indicate a further rise in troponin levels to 0.18 ng/mL, confirming continued myocardial injury. This prompts the team to escalate her care by initiating intravenous nitroglycerin for more effective coronary vasodilation and to consider an urgent coronary angiography to elucidate the severity and nature of her coronary artery disease.

The patient’s fluid status is reassessed, revealing persistent jugular venous distension and crackles at the lung bases, suggesting that fluid overload is not fully under control. This necessitates an adjustment in her diuretic regimen, increasing the frequency and dose to enhance diuresis and alleviate pulmonary congestion. The team also explores the possibility of using an ACE inhibitor to address hypertension, improve cardiac function, and provide renal protection, especially given her diabetic status. The clinical picture underscores the need for a multidisciplinary approach to prevent further deterioration and to stabilize her condition while considering potential interventions such as percutaneous coronary intervention (PCI) based on angiographic findings.

Section 3

As the clinical team implements the revised care plan, they closely monitor the patient's response to the intravenous nitroglycerin infusion and increased diuretic therapy. Initial observations indicate a slight improvement in her chest discomfort, but her respiratory rate remains elevated at 24 breaths per minute. Repeat vital signs show a blood pressure of 145/90 mmHg and a heart rate of 105 beats per minute, suggesting some stabilization, yet not complete resolution of her symptoms. Her oxygen saturation improves to 92% with supplemental oxygen, but she continues to experience mild nausea and diaphoresis, prompting further evaluation of her therapeutic response.

The decision to perform an urgent coronary angiography yields significant findings. The angiogram reveals a critical stenosis of the left anterior descending artery, along with moderate blockages in the right coronary and circumflex arteries. This confirms the presence of multi-vessel coronary artery disease, explaining the persistence of her ischemic symptoms despite initial treatment. Given these findings, the cardiology team discusses the urgency of addressing the critical lesion through percutaneous coronary intervention (PCI) to restore adequate blood flow and mitigate the risk of further myocardial damage.

With the confirmation of significant coronary artery disease, the healthcare team reviews her medication regimen, emphasizing the importance of optimizing her cardiovascular risk factors. The introduction of an ACE inhibitor is prioritized to manage her hypertension effectively, enhance cardiac remodeling, and offer renal protection, particularly considering her diabetes. Additionally, the plan includes titrating her diuretics to balance fluid status, evidenced by ongoing jugular venous distension and crackles at the lung bases, indicating a need for continued vigilance in managing her heart failure symptoms. This comprehensive approach aims to stabilize her condition and prevent further complications, setting the stage for her potential PCI and long-term management strategy.

Section 4

As the care team proceeds with the revised plan, the patient's condition exhibits subtle yet concerning changes, necessitating heightened clinical attention. During routine monitoring, her respiratory status shows signs of deterioration; her respiratory rate increases to 28 breaths per minute, and her oxygen saturation drops to 88% despite the continued use of supplemental oxygen. Auscultation reveals worsening crackles in the lung bases, suggesting progressing pulmonary congestion. Her jugular venous pressure remains elevated, indicating persistent fluid overload. Despite these changes, her blood pressure remains at 140/88 mmHg, and her heart rate decreases slightly to 98 beats per minute, reflecting partial hemodynamic stability.

Laboratory results reveal a slight rise in her B-type natriuretic peptide (BNP), now at 620 pg/mL, consistent with exacerbated heart failure. Additionally, her renal function tests show a mild increase in creatinine to 1.4 mg/dL, raising concerns about renal perfusion in the context of aggressive diuretic therapy. These findings prompt the team to adjust her treatment plan, emphasizing the delicate balance between managing her ischemic symptoms and preventing renal compromise. An echocardiogram is scheduled to assess her cardiac function and guide further intervention.

In light of these developments, the healthcare team reevaluates her medication regimen, considering adjustments in her diuretic therapy to address her worsening pulmonary congestion. The introduction of a low-dose aldosterone antagonist is contemplated to enhance diuresis while providing additional cardioprotective benefits. These interventions aim to stabilize her respiratory status and optimize her fluid balance, setting the stage for her potential PCI. The team remains vigilant, recognizing the need for continued monitoring and timely intervention to prevent further decompensation, ensuring the patient is adequately prepared for the next phase of her treatment journey.

Section 5

As the healthcare team proceeds with the adjusted treatment plan, the patient's condition continues to evolve, warranting close observation. A follow-up echocardiogram reveals a decrease in left ventricular ejection fraction to 40%, confirming a decline in cardiac function. This finding underscores the need for enhanced cardiovascular support and prompts a discussion about optimizing her heart failure management. Concurrently, laboratory tests indicate further renal impairment, with creatinine levels rising slightly to 1.6 mg/dL, raising alarms about the risk of acute kidney injury in the context of diuretic therapy. These developments necessitate a careful reevaluation of her medication regimen, balancing the need to alleviate pulmonary congestion without exacerbating renal function decline.

Despite these challenges, the introduction of a low-dose aldosterone antagonist begins to yield positive outcomes. Over the next 48 hours, the patient's pulmonary status shows subtle improvement; her respiratory rate decreases to 24 breaths per minute, and oxygen saturation stabilizes at 91% with supplemental oxygen. Crackles in the lung bases, while still present, have diminished slightly. These changes suggest that fluid balance is gradually being restored. However, her jugular venous pressure remains elevated, indicating ongoing fluid retention and necessitating continued vigilance.

The care team remains focused on optimizing her condition for the planned percutaneous coronary intervention (PCI). With her cardiac function now more clearly defined and renal status monitored closely, discussions about potential adjustments to her heart failure management, including the use of advanced therapies, are underway. The team emphasizes the importance of maintaining a delicate equilibrium between aggressive treatment of her ischemic symptoms and cautious management of her renal function, ensuring she remains stable enough to undergo the next critical step in her care plan.