A patient with an acute ST-elevation myocardial infarction (STEMI) is experiencing increasing shortness of breath, crackles in the lung bases, and jugular venous distention, indicative of acute heart failure. The patient's heart rate is 120 bpm, and there is a history of Type 2 Diabetes and hypertension. Which nursing intervention should be prioritized to address the patient's current symptoms?

B) Administer diuretics to reduce pulmonary congestion and fluid overload.

A) Increase the rate of intravenous fluids to improve cardiac output.

B) Administer diuretics to reduce pulmonary congestion and fluid overload.

C) Encourage deep breathing exercises to improve oxygenation.

D) Discontinue oxygen therapy to prevent oxygen toxicity.

A patient with a confirmed anterior STEMI is experiencing increasing shortness of breath and crackles upon lung auscultation. The nurse notes jugular venous distention and a heart rate of 120 bpm. Which intervention should the nurse prioritize to address the patient's current symptoms indicating acute heart failure?

C) Administer diuretics as prescribed

A) Administer additional oxygen therapy

B) Prepare for potential intubation

C) Administer diuretics as prescribed

D) Increase the rate of intravenous fluids

A patient with acute heart failure is experiencing increasing respiratory distress and hypotension, suggestive of worsening pulmonary edema and potential cardiogenic shock. After administering intravenous furosemide and repositioning the patient, which nursing action is most critical to perform next to prevent further complications?

A) Increase the supplemental oxygen flow rate to 10 L/min.

B) Prepare for immediate endotracheal intubation.

D) Administer additional doses of intravenous furosemide.

A patient with acute heart failure is experiencing increased respiratory distress, hypotension, and signs of confusion after receiving IV furosemide. Which nursing intervention should be prioritized to stabilize the patient?

C) Initiate non-invasive positive pressure ventilation to improve oxygenation

A) Increase the oxygen flow rate to maintain saturation above 95%

B) Reassess the patient's fluid status and consider withholding the next dose of furosemide

C) Initiate non-invasive positive pressure ventilation to improve oxygenation

D) Prepare for immediate intubation and mechanical ventilation due to worsening respiratory status

A patient with an acute anterior myocardial infarction and worsening heart failure presents with elevated serum creatinine levels and respiratory acidosis. Which nursing intervention is most appropriate to prioritize at this time?

C) Initiate non-invasive positive pressure ventilation to correct respiratory acidosis.

A) Administer supplemental oxygen via nasal cannula to improve oxygenation.

B) Increase the dose of diuretics to reduce fluid overload and improve cardiac output.

C) Initiate non-invasive positive pressure ventilation to correct respiratory acidosis.

D) Restrict fluid intake to prevent further renal impairment.

A patient with acute kidney injury is receiving continuous renal replacement therapy (CRRT) due to fluid overload and worsening renal function. Which of the following nursing interventions is most critical to ensure the effectiveness of CRRT?

A) Monitoring and adjusting the ultrafiltration rate as prescribed

B) Administering diuretics to increase urine output

C) Encouraging oral fluid intake to prevent dehydration

D) Discontinuing all antihypertensive medications to prevent hypotension

A patient with acute kidney injury (AKI) and fluid overload is being evaluated for continuous renal replacement therapy (CRRT). What is the primary nursing consideration when preparing to initiate CRRT for this patient?

B) Verifying patency and functionality of the vascular access

A) Ensuring the patient is NPO for 8 hours prior to the procedure

B) Verifying patency and functionality of the vascular access

C) Administering a diuretic to promote urine output before starting CRRT

D) Withholding all antihypertensive medications prior to CRRT initiation

A patient who underwent PCI 24 hours ago is experiencing frequent premature ventricular contractions (PVCs) due to hypokalemia. The healthcare team administers intravenous potassium to correct the electrolyte imbalance. What is the most important nursing intervention to prioritize during this treatment?

D) Evaluate serum potassium levels regularly.

A) Monitor the patient's urine output closely.

B) Check the ECG for resolution of PVCs every 6 hours.

C) Assess the patient's blood pressure every 15 minutes.

D) Evaluate serum potassium levels regularly.

A patient who underwent a PCI is exhibiting frequent premature ventricular contractions (PVCs) due to hypokalemia. Which nursing intervention should be prioritized to prevent progression to more severe arrhythmias?

C) Initiate intravenous potassium supplementation and monitor cardiac rhythm

A) Administer oral potassium supplements as prescribed

B) Encourage the patient to increase dietary potassium intake

C) Initiate intravenous potassium supplementation and monitor cardiac rhythm

D) Withhold diuretics until potassium levels normalize

Myocardial infarction - Nursing Case Study

Pathophysiology

• Primary mechanism: Myocardial infarction primarily results from the rupture of an atherosclerotic plaque in a coronary artery, leading to thrombus (blood clot) formation. This occlusion restricts blood flow, depriving the heart muscle of oxygen (ischemia).

• Secondary mechanism: Ischemia triggers a cascade of cellular events, including anaerobic metabolism and accumulation of lactic acid, which compromise cardiac muscle cell function and viability. Prolonged ischemia causes irreversible damage or necrosis of myocardial tissue.

• Key complication: The loss of viable heart muscle impairs cardiac contractility, potentially leading to heart failure and arrhythmias. Early reperfusion through medical intervention can limit damage and improve outcomes.

Patient Profile

Demographics:

62-year-old male, retired construction worker

History:

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

• Current medications: Metformin, Lisinopril, Atorvastatin, Aspirin

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Chest pain

• Key symptoms: Radiating chest pain to left arm, shortness of breath, nausea, diaphoresis

• Vital signs: Blood pressure 150/95 mmHg, heart rate 110 bpm, respiratory rate 24 breaths per minute, temperature 37.2°C, oxygen saturation 92% on room air

Section 1

As the emergency team initiates treatment for the suspected myocardial infarction, the patient undergoes a series of diagnostic tests to confirm the diagnosis and assess the extent of the cardiac injury. The 12-lead electrocardiogram (ECG) reveals ST-segment elevation in the anterior leads, indicating an acute ST-elevation myocardial infarction (STEMI). Blood tests are performed, showing elevated cardiac biomarkers, with troponin levels significantly higher than the normal range, further confirming myocardial damage. The patient is immediately started on oxygen therapy to improve oxygen saturation, which rises to 95%. Intravenous nitroglycerin is administered to alleviate chest pain and reduce myocardial oxygen demand.

Despite these interventions, the patient's clinical status begins to deteriorate. He exhibits increasing shortness of breath, and auscultation of the lungs reveals crackles at the bases, suggestive of pulmonary congestion. This finding, along with a rising heart rate now at 120 bpm, suggests the development of acute heart failure, a common complication of myocardial infarction due to impaired cardiac contractility. The patient is also noted to have jugular venous distention, further supporting the diagnosis of acute heart failure.

Given these developments, the healthcare team must quickly adjust the treatment plan. Diuretics are considered to reduce fluid overload, while careful monitoring of renal function and electrolytes is necessary due to the patient's history of Type 2 Diabetes and hypertension. The need for additional interventions, such as a possible percutaneous coronary intervention (PCI), is evaluated to restore coronary blood flow and prevent further myocardial damage. The team discusses these options while closely monitoring the patient's vital signs and clinical status, anticipating potential complications such as arrhythmias or worsening heart failure.

Section 2

As the team continues to manage the patient's acute heart failure, they observe a change in his clinical status. The patient begins to exhibit signs of increasing respiratory distress, with a respiratory rate climbing to 28 breaths per minute and oxygen saturation dropping to 90% on supplemental oxygen. Auscultation of the lungs now reveals more pronounced crackles extending to the mid-lung fields, indicating worsening pulmonary edema. The patient's blood pressure, previously stable, has decreased to 90/60 mmHg, raising concerns about potential cardiogenic shock.

In response to these alarming developments, the healthcare team administers a diuretic, specifically intravenous furosemide, to address the fluid overload contributing to the pulmonary congestion. The patient is positioned upright to improve respiratory effort and enhance lung expansion. Concurrently, the team closely monitors his renal function, with serum creatinine levels drawn to assess the impact of diuretic therapy on kidney function, particularly given his underlying Type 2 Diabetes and hypertension. Despite these interventions, the patient begins to exhibit signs of confusion and lethargy, prompting a reassessment of his neurological status and consideration of additional oxygenation strategies, such as non-invasive positive pressure ventilation, to stabilize him.

Recognizing the need for immediate coronary reperfusion, the cardiology team prepares for an urgent percutaneous coronary intervention (PCI). The goal is to restore coronary blood flow and limit further myocardial damage, which could exacerbate the heart failure. Meanwhile, the nursing team continues to monitor the patient's vital signs, fluid balance, and mental status closely, ready to address potential complications such as arrhythmias or further deterioration in cardiac output. This moment is critical, requiring coordinated efforts to stabilize the patient and prevent further decline, while also considering long-term management strategies post-intervention.

Section 3

As the healthcare team continues their vigilant monitoring, new diagnostic results bring critical insights into the patient's evolving condition. The latest electrocardiogram (ECG) reveals ST-segment elevations in the anterior leads, confirming an acute anterior myocardial infarction. This correlates with elevated cardiac biomarkers, including a significant rise in troponin levels, indicating ongoing myocardial injury. The echocardiogram shows reduced left ventricular ejection fraction, now measured at 35%, consistent with the patient's worsening heart failure status. These findings emphasize the urgency of the planned percutaneous coronary intervention (PCI) to alleviate the ischemic burden on the heart.

Simultaneously, laboratory assessments disclose a concerning increase in serum creatinine, now at 2.2 mg/dL, raising alarms about the patient's renal function amid aggressive diuretic therapy. This elevation suggests acute kidney injury, likely exacerbated by both the diuretics and the decreased cardiac output resulting from the infarction. The team considers the delicate balance between managing fluid overload and preserving renal function, highlighting the complexity of care in this scenario. The patient's blood gas analysis shows a respiratory acidosis with a pH of 7.32 and a partial pressure of carbon dioxide (pCO2) at 50 mmHg, indicating the need for more advanced respiratory support.

In light of these developments, the team reassesses the patient's management plan. The decision is made to initiate non-invasive positive pressure ventilation to address the respiratory acidosis and improve oxygenation. The renal team is consulted to explore options for renal support, possibly including the adjustment of diuretic dosing or the consideration of renal replacement therapy if the kidney function continues to decline. The cardiology team proceeds with the PCI, aiming to re-establish coronary perfusion swiftly. The coordinated efforts are a testament to the multidisciplinary approach required in managing such a complex case, as the patient's journey through this critical phase continues to unfold.

Section 4

As the healthcare team implements the revised management plan, they closely monitor the patient's response to interventions. Within hours of initiating non-invasive positive pressure ventilation, there is a noticeable improvement in the patient's respiratory status. Arterial blood gas analysis reveals a pH increase to 7.37 and a reduction in pCO2 to 45 mmHg, indicating a partial resolution of the respiratory acidosis and improved ventilation. The patient's oxygen saturation stabilizes at 94%, suggesting enhanced oxygenation and a positive response to the respiratory support.

However, the renal function continues to be a concern. Despite adjustments in diuretic therapy, the patient's serum creatinine rises to 2.5 mg/dL, and urine output remains below 30 mL/hour, signaling worsening acute kidney injury. The renal team suggests implementing continuous renal replacement therapy (CRRT) to manage fluid overload and support renal function. This decision is carefully weighed against the patient's hemodynamic stability, and the multidisciplinary team agrees that CRRT is the most appropriate step to prevent further renal deterioration while maintaining fluid balance.

Meanwhile, the cardiology team successfully performs the PCI, resulting in improved coronary perfusion. Post-procedure, the patient's hemodynamics show modest improvement, with a heart rate of 78 beats per minute, blood pressure of 110/70 mmHg, and a reduction in chest pain. Despite these positive developments, the team remains vigilant for potential complications, such as arrhythmias or further cardiac decompensation, necessitating continuous ECG monitoring and frequent reassessment. The patient's journey highlights the intricate interplay of organ systems in critical illness and underscores the importance of dynamic and coordinated care.

Section 5

As the multidisciplinary team continues to monitor the patient, a new complication arises. Approximately 24 hours after the PCI, the patient begins to exhibit signs of arrhythmia, manifesting as frequent premature ventricular contractions (PVCs) on the ECG monitor. Despite the initial stability in heart rate and rhythm, the frequency of PVCs increases, raising concerns about potential progression to more severe arrhythmias. The telemetry readings show a sporadic pattern of ectopic beats, and the team considers the possibility of electrolyte imbalances or myocardial irritability as underlying causes. The patient's potassium level is measured at 3.2 mEq/L, indicating hypokalemia, which is a known risk factor for arrhythmias.

In response to these findings, the healthcare team initiates a targeted intervention to correct the electrolyte imbalance. Intravenous potassium supplementation is promptly administered, with careful monitoring to avoid overcorrection. Concurrently, the patient's telemetry is closely observed for any signs of rhythm stabilization. The medical team also reviews the patient's medication regimen to identify and adjust any contributing factors to the hypokalemia, such as the use of diuretics. As the potassium levels gradually improve, the frequency of PVCs diminishes, suggesting a positive response to the intervention.

This development serves as a reminder of the delicate balance required in managing a patient with multiple comorbidities and the need for vigilance in monitoring potential complications. The team discusses the importance of maintaining optimal electrolyte levels and continues to emphasize a collaborative approach to care. The resolution of the arrhythmia highlights the dynamic nature of the patient's condition and sets the stage for ongoing observation and adjustment of the management plan, ensuring that the patient remains on a steady path to recovery.