A patient with unstable angina and elevated Troponin I levels is experiencing worsening chest pain and pulmonary congestion. Which nursing intervention is most appropriate to prioritize to prevent further cardiac compromise?

D) Administer intravenous nitroglycerin as ordered to alleviate ischemic pain.

A) Administer a stat dose of oral aspirin as prescribed.

B) Increase the supplemental oxygen flow rate to 6 L/min via nasal cannula.

C) Prepare the patient for immediate transfer to the coronary care unit (CCU).

D) Administer intravenous nitroglycerin as ordered to alleviate ischemic pain.

A patient with unstable angina is being closely monitored in the emergency department. The patient's vital signs show fluctuating blood pressure, increased heart rate, and decreased oxygen saturation. Despite administration of sublingual nitroglycerin, the patient reports worsening chest pain. What is the nurse's priority action to address the patient's condition?

A) Administer intravenous nitroglycerin as ordered.

B) Increase the oxygen flow rate to maintain saturation above 94%.

C) Initiate a rapid response team intervention for potential myocardial infarction.

D) Prepare the patient for immediate transfer to the coronary care unit.

A patient with worsening chest pain and elevated Troponin I levels has been transferred to the coronary care unit. The patient is receiving intravenous nitroglycerin, but his chest pain persists and vital signs are unstable. Which of the following nursing interventions is the most appropriate to prioritize initially in this situation?

B) Prepare the patient for immediate coronary angiography.

A) Increase the nitroglycerin infusion rate.

B) Prepare the patient for immediate coronary angiography.

C) Administer a beta-blocker to control heart rate.

D) Initiate diuretic therapy to manage fluid overload.

A patient with suspected acute coronary syndrome is transferred to the coronary care unit with worsening symptoms. The patient's recent laboratory tests show elevated Troponin I levels, and an ECG reveals new T-wave inversions. Despite intravenous nitroglycerin, the patient reports persistent chest pain and shows signs of fluid overload. Which nursing action is most critical to prioritize for this patient at this time?

B) Prepare the patient for immediate coronary angiography

A) Increase the rate of intravenous nitroglycerin to manage chest pain

B) Prepare the patient for immediate coronary angiography

C) Administer diuretics to manage peripheral edema

D) Initiate beta-blocker therapy to control heart rate

A patient in the coronary care unit is being prepared for percutaneous coronary intervention (PCI) due to significant stenosis in the left anterior descending artery. What is the nurse's priority assessment prior to the procedure?

C) Evaluating the patient's allergy history, particularly to contrast dye.

A) Monitoring the patient's neurological status.

B) Assessing the insertion site for signs of infection.

C) Evaluating the patient's allergy history, particularly to contrast dye.

D) Checking for pedal pulses to assess peripheral circulation.

A patient in the coronary care unit is experiencing intermittent chest pain, labile blood pressure, and signs of heart failure despite medical management. Coronary angiography shows significant stenosis in the left anterior descending artery. The team plans for percutaneous coronary intervention (PCI). What is the primary nursing consideration before the procedure?

C) Assess and ensure the patient has adequate renal function before the administration of contrast dye.

A) Ensure the patient is NPO (nothing by mouth) for at least 8 hours before the procedure.

B) Educate the patient and family about the importance of lifestyle changes post-procedure.

C) Assess and ensure the patient has adequate renal function before the administration of contrast dye.

D) Administer a loading dose of aspirin to prevent thrombus formation during the procedure.

A patient recently underwent percutaneous coronary intervention (PCI) with the placement of a drug-eluting stent and is now exhibiting signs of acute heart failure, including dyspnea, jugular venous distention, and pulmonary congestion. The healthcare provider has initiated diuretics and an ACE inhibitor. Which nursing intervention is most critical in the immediate post-procedure period to monitor the effectiveness of these treatments?

A) Monitor the patient's urine output and daily weights

B) Assess for relief of chest pain and document pain levels

C) Evaluate the patient's peripheral pulses and capillary refill time

D) Check the patient's blood glucose levels regularly

A patient who recently underwent a percutaneous coronary intervention (PCI) with drug-eluting stent placement in the left anterior descending artery now presents with dyspnea, jugular venous distention, crackles at the lung bases, and an increased BNP level. An echocardiogram reveals a reduction in left ventricular ejection fraction to 35%. Which nursing intervention is the most appropriate to prioritize for this patient?

D) Restrict fluid intake to manage volume overload.

A) Administer supplemental oxygen to improve oxygenation.

B) Encourage ambulation to prevent deep vein thrombosis.

C) Educate the patient on smoking cessation to improve long-term outcomes.

D) Restrict fluid intake to manage volume overload.

A patient with heart failure and moderate mitral regurgitation is experiencing persistent dyspnea and a slight decrease in urine output despite increased diuretic therapy. The patient also presents with fatigue, dizziness, and a rising serum creatinine level. Which nursing intervention is most appropriate to address the patient's current condition?

C) Collaborate with the healthcare provider to adjust the diuretic regimen and consider the addition of a potassium-sparing diuretic.

A) Increase the dose of the current diuretic to enhance fluid removal.

B) Administer a potassium supplement to correct the low potassium level.

C) Collaborate with the healthcare provider to adjust the diuretic regimen and consider the addition of a potassium-sparing diuretic.

D) Encourage the patient to increase oral fluid intake to improve renal perfusion.

A patient with heart failure and recent coronary intervention is experiencing persistent dyspnea, fatigue, and dizziness despite adjusted diuretic therapy. The echocardiogram reveals moderate mitral regurgitation and a rising serum creatinine level. Which nursing intervention is most appropriate to address the patient's current condition?

C) Administer potassium supplements to correct hypokalemia.

A) Increase the diuretic dose to reduce fluid overload.

B) Initiate a fluid restriction to manage pulmonary congestion.

C) Administer potassium supplements to correct hypokalemia.

D) Recommend a beta-blocker to enhance cardiac output.

Chest pain - Nursing Case Study

Pathophysiology

• Primary mechanism: Myocardial ischemia occurs when coronary blood flow is reduced, often due to atherosclerosis, leading to decreased oxygen supply to heart muscle, causing chest pain known as angina.

• Secondary mechanism: Gastroesophageal reflux disease (GERD) can cause chest pain when stomach acid irritates the esophagus, leading to a burning sensation that can mimic cardiac-related pain.

• Key complication: Persistent ischemia can progress to myocardial infarction, where prolonged lack of oxygen results in heart muscle damage, significantly increasing morbidity and mortality if not promptly managed.

Patient Profile

Demographics:

52-year-old male, construction worker

History:

• Key past medical history: Hypertension, hyperlipidemia, smoking history (20 pack-years)

• Current medications: Lisinopril 20 mg daily, Atorvastatin 40 mg daily, Aspirin 81 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Chest pain

• Key symptoms: Pressure-like chest pain radiating to the left arm, shortness of breath, nausea, diaphoresis

• 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

As the healthcare team continues to assess the patient, further initial findings reveal elevated cardiac biomarkers, with Troponin I levels at 1.2 ng/mL, indicating myocardial injury. An electrocardiogram (ECG) shows ST-segment depression in the anterior leads, suggestive of subendocardial ischemia. The patient's overall presentation and diagnostic results align with unstable angina, a precursor to myocardial infarction if not stabilized effectively. Auscultation of the lungs also reveals bilateral crackles, indicating possible pulmonary congestion, which raises concerns for the development of acute heart failure secondary to decreased cardiac output.

While the patient remains under continuous cardiac monitoring, his vital signs begin to fluctuate. His blood pressure shows variability, dropping to 140/90 mmHg and then rising back to 165/100 mmHg, reflecting possible autonomic instability. The heart rate increases to 112 bpm, and the oxygen saturation decreases to 89% on room air, necessitating supplemental oxygen via nasal cannula to maintain adequate oxygenation. The patient reports worsening chest pain despite initial administration of sublingual nitroglycerin, prompting consideration for additional pharmacologic interventions, such as intravenous nitroglycerin, to improve coronary blood flow and alleviate ischemic pain.

These developments highlight the need for escalated care, including potential transfer to a higher acuity setting such as the coronary care unit (CCU) for more intensive monitoring and management. The clinical team's reasoning now focuses on preventing progression to myocardial infarction by optimizing hemodynamics, ensuring adequate myocardial oxygen supply, and managing associated complications like pulmonary congestion. Further decisions may involve adjustments to medication regimens and consideration of advanced diagnostic testing or interventional procedures, such as coronary angiography, to assess the extent of coronary artery disease.

Section 2

In response to the escalation of symptoms and the need for intensified care, the healthcare team decides to transfer the patient to the coronary care unit (CCU) for closer monitoring and management. Upon arrival, a repeat set of laboratory tests, including cardiac biomarkers, reveals a further increase in Troponin I levels to 2.5 ng/mL, suggesting worsening myocardial injury. The clinical team orders a follow-up ECG, which now shows new T-wave inversions in the anterior leads, indicative of ongoing ischemia and potential progression towards myocardial infarction. These changes necessitate a reevaluation of the current management plan, with an emphasis on aggressive intervention to prevent further cardiac damage.

The patient's clinical status continues to evolve with the administration of intravenous nitroglycerin, aimed at relieving ischemic pain and improving coronary perfusion. Despite this, the patient's chest pain persists and his blood pressure remains unstable, fluctuating between 135/85 mmHg and 170/105 mmHg, with the heart rate peaking at 120 bpm. In addition to these concerns, new assessment findings reveal the development of mild peripheral edema and an increase in jugular venous distention, raising suspicion for exacerbated heart failure. The team considers the addition of diuretics to manage fluid overload and alleviate pulmonary congestion, while also deliberating on the potential need for beta-blockers to address the tachycardia and improve cardiac workload.

These findings and the patient's lack of adequate response to initial interventions underscore the necessity for immediate coronary angiography to evaluate the extent of coronary artery disease and determine any possible revascularization strategies. The clinical team discusses the risks and benefits of this procedure with the patient and his family, emphasizing its critical role in guiding further therapeutic decisions. As the patient's journey continues, the focus remains on timely intervention to stabilize his condition and prevent the transition from unstable angina to a full-blown myocardial infarction.

Section 3

As the healthcare team continues to manage the patient's condition in the coronary care unit, a new set of diagnostic results provides further insight into the patient's evolving clinical status. The coronary angiography reveals significant stenosis in the left anterior descending (LAD) artery, with 80% occlusion, corroborating the earlier ECG findings of anterior ischemia. Additionally, there is moderate disease noted in the right coronary artery (RCA) and the circumflex artery, suggesting widespread coronary artery disease. These findings underscore the urgency of addressing the LAD stenosis to prevent further myocardial damage.

Despite aggressive medical management, including intravenous nitroglycerin and the initiation of diuretics, the patient's clinical condition shows only partial improvement. The chest pain persists intermittently, and the blood pressure remains labile, fluctuating between 140/90 mmHg and 165/100 mmHg. The heart rate has decreased slightly to 110 bpm, but the jugular venous distention and mild peripheral edema persist, indicating ongoing cardiac strain and volume overload. Laboratory tests reveal a slight increase in B-type natriuretic peptide (BNP) levels, now at 650 pg/mL, which supports the clinical picture of heart failure exacerbation.

In light of these developments, the medical team decides to prioritize revascularization through percutaneous coronary intervention (PCI) to address the critical LAD lesion. The patient and his family are informed about the potential benefits and risks of the procedure, including the possibility of stent placement to restore adequate blood flow and prevent further ischemic episodes. The decision hinges on the necessity to stabilize the patient's condition and avert progression to a myocardial infarction. The team prepares for the intervention, aiming to optimize the patient's hemodynamic status and ensure close monitoring throughout the procedure.

Section 4

As the medical team proceeds with the percutaneous coronary intervention (PCI) for the patient, the intervention is initially successful, with the placement of a drug-eluting stent in the left anterior descending (LAD) artery. Post-procedure, the patient's chest pain significantly diminishes, and there is a notable improvement in the patient's overall hemodynamic status. The blood pressure stabilizes around 130/85 mmHg, and heart rate decreases further to 95 bpm. These changes suggest effective relief of the ischemic burden on the heart. However, during the post-procedure monitoring period, the patient begins to exhibit new symptoms of concern.

Approximately two hours after the PCI, the patient experiences an abrupt onset of dyspnea and a return of jugular venous distention, coupled with increasing peripheral edema. Auscultation reveals crackles at the lung bases, indicating pulmonary congestion. A repeat BNP test shows a further increase to 750 pg/mL, highlighting worsening heart failure. An urgent echocardiogram is performed, revealing a moderate reduction in left ventricular ejection fraction (LVEF) to 35%, suggesting new or worsening systolic dysfunction. These findings prompt the team to suspect acute left ventricular dysfunction possibly exacerbated by reperfusion injury.

In response to this new complication, the healthcare team adjusts the therapeutic approach. Diuretics are escalated to manage the volume overload, and an ACE inhibitor is initiated to improve cardiac output and reverse remodeling. Close monitoring is instituted to assess the patient's response to these interventions. The team discusses the potential need for advanced heart failure therapies if the patient's condition does not stabilize. This turn in the patient's condition underscores the complexity of managing coronary artery disease with concomitant heart failure and demands vigilant re-evaluation of treatment strategies to optimize patient outcomes.

Section 5

As the healthcare team monitors the patient's response to the adjusted therapeutic regimen, they observe that the patient's dyspnea has not significantly improved despite the escalation of diuretics. Additionally, the patient's blood pressure starts trending downward, now measuring at 110/70 mmHg, raising concerns about potential over-diuresis or inadequate cardiac output. Heart rate stabilizes at 88 bpm; however, the patient reports persistent fatigue and occasional dizziness, suggesting possible hypotension-related symptoms. The patient's urine output has decreased slightly to 20 mL/hr, indicating a need to reassess fluid management and renal perfusion.

A follow-up echocardiogram is performed to evaluate the efficacy of the ACE inhibitor and the diuretic therapy. The imaging reveals a slight improvement in left ventricular ejection fraction to 40%, yet there is still evidence of moderate mitral regurgitation contributing to the pulmonary congestion. Laboratory results show a serum creatinine level rising to 2.2 mg/dL, which may reflect acute kidney injury secondary to both heart failure and aggressive diuresis. Electrolyte panels reveal a potassium level of 3.2 mEq/L, necessitating careful replacement to prevent arrhythmic complications.

Given these findings, the healthcare team decides to adjust the patient's diuretic to a lower dose and incorporate a potassium-sparing agent to stabilize electrolyte imbalances. The ACE inhibitor dosage is titrated cautiously, and the team considers the possible introduction of beta-blocker therapy to further support cardiac function, provided the patient's blood pressure remains stable. This nuanced approach highlights the need for ongoing clinical reasoning and individualized care, as the team balances the complexities of managing heart failure, renal function, and the recent coronary intervention to optimize the patient's recovery trajectory.