A patient with a confirmed anterior STEMI is receiving dual antiplatelet therapy and a diuretic. Which of the following assessments should the nurse prioritize to identify potential complications associated with the treatment plan?

A) Monitoring for signs of bleeding and electrolyte imbalances

B) Assessing for chest pain and changes in EKG

C) Observing for signs of infection and allergic reaction

D) Evaluating for increased urine output and weight loss

A patient with a confirmed STEMI and mild pulmonary congestion is being managed with oxygen, dual antiplatelet therapy, and a diuretic. Which nursing intervention is most critical to perform first to ensure the patient's safety and effective treatment?

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

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

C) Prepare the patient for potential percutaneous coronary intervention (PCI).

D) Place the patient in a semi-Fowler's position to facilitate breathing.

A patient receiving dual antiplatelet therapy and diuretics for coronary artery disease presents with increased heart rate, hypotension, and frequent premature ventricular contractions. The medical team suspects cardiogenic shock. Which nursing intervention is most appropriate to prioritize at this time?

C) Prepare the patient for immediate percutaneous coronary intervention (PCI)

A) Administer a bolus of intravenous fluids to increase blood pressure

B) Increase the supplemental oxygen flow to improve oxygen saturation

C) Prepare the patient for immediate percutaneous coronary intervention (PCI)

D) Initiate antiarrhythmic medication to manage ventricular tachycardia

A patient with suspected cardiogenic shock is being prepared for PCI after developing frequent premature ventricular contractions and runs of ventricular tachycardia. The nurse is responsible for monitoring the patient's hemodynamic status. Which nursing intervention is most appropriate to prioritize while awaiting transfer to the catheterization lab?

B) Initiate continuous cardiac monitoring and alert the team of any further arrhythmias

A) Administer a bolus of intravenous fluids to increase blood pressure

B) Initiate continuous cardiac monitoring and alert the team of any further arrhythmias

C) Increase the supplemental oxygen to 100% via non-rebreather mask

D) Prepare to administer a diuretic to manage pulmonary congestion

A patient with suspected cardiogenic shock is showing signs of decreased perfusion and worsening metabolic acidosis. Which nursing intervention should be prioritized to address the patient's condition effectively?

C) Optimize oxygen delivery by adjusting the oxygen delivery system.

A) Increase the rate of norepinephrine infusion to rapidly improve blood pressure.

B) Administer a rapid IV bolus of normal saline to improve renal perfusion.

C) Optimize oxygen delivery by adjusting the oxygen delivery system.

D) Initiate continuous renal replacement therapy to manage elevated creatinine levels.

A nurse is caring for a patient who is showing signs of cardiogenic shock, including hypotension, tachycardia, and metabolic acidosis. The patient is receiving a low-dose norepinephrine infusion. Which nursing intervention should the nurse prioritize to optimize the patient's condition?

B) Continuously monitor the patient's respiratory status and adjust oxygen delivery as needed.

A) Administer a rapid fluid bolus to increase blood pressure.

B) Continuously monitor the patient's respiratory status and adjust oxygen delivery as needed.

C) Increase the dose of norepinephrine to achieve a blood pressure above 100 mmHg systolic.

D) Prepare for immediate intubation and mechanical ventilation.

A patient in the catheterization lab is diagnosed with cardiogenic shock due to an acute myocardial infarction with a significant occlusion in the left anterior descending artery. The nurse observes that the patient's blood pressure has stabilized at 90/55 mmHg with norepinephrine infusion. Which nursing intervention is most critical to optimize the patient's hemodynamic status before proceeding with percutaneous coronary intervention (PCI)?

D) Adjust high-flow oxygen therapy to maintain oxygen saturation above 94%.

A) Administer a fluid bolus to address potential hypovolemia.

B) Continue monitoring urine output to assess renal perfusion.

C) Titrate norepinephrine infusion to maintain systolic blood pressure above 100 mmHg.

D) Adjust high-flow oxygen therapy to maintain oxygen saturation above 94%.

A patient in the catheterization lab is experiencing cardiogenic shock with a significant occlusion in the left anterior descending artery and a severely reduced ejection fraction. Which nursing intervention is most critical in preparing the patient for percutaneous coronary intervention (PCI) to optimize outcomes?

B) Ensure continuous ECG monitoring to detect any new dysrhythmias during the procedure.

A) Discontinue all vasopressor support before PCI to reduce myocardial workload.

B) Ensure continuous ECG monitoring to detect any new dysrhythmias during the procedure.

C) Administer a diuretic to reduce pulmonary congestion before the procedure.

D) Instruct the patient to perform deep breathing exercises to reduce anxiety.

A patient undergoing PCI is experiencing tachycardia with a heart rate of 120 bpm, persistent low blood pressure, and signs of respiratory distress including increased work of breathing and respiratory acidosis. Which nursing intervention is most appropriate to prioritize in this situation?

C) Initiate non-invasive ventilation support to address respiratory distress and acidosis.

A) Administer additional doses of norepinephrine to stabilize blood pressure.

B) Prepare for the insertion of an intra-aortic balloon pump (IABP) to reduce cardiac workload.

C) Initiate non-invasive ventilation support to address respiratory distress and acidosis.

D) Increase diuretic dosage to manage pulmonary edema.

A patient undergoing a PCI procedure is showing signs of tachycardia, persistent low blood pressure, increased work of breathing, and respiratory acidosis. Which nursing intervention should take priority to address the patient's current condition?

C) Initiate non-invasive ventilation support to improve ventilation and oxygenation.

A) Administer additional norepinephrine to stabilize the patient's blood pressure.

B) Prepare the patient for potential intubation to manage respiratory failure.

C) Initiate non-invasive ventilation support to improve ventilation and oxygenation.

D) Notify the cardiologist immediately to discuss the insertion of an intra-aortic balloon pump (IABP).

Myocardial infarction - Nursing Case Study

Pathophysiology

• Primary mechanism: Coronary artery occlusion due to atherosclerotic plaque rupture, leading to reduced blood flow and oxygen supply to cardiac tissue, causing myocardial ischemia and necrosis.

• Secondary mechanism: Inflammatory response and release of enzymes such as troponin from necrotic myocardial cells further exacerbate tissue damage and can lead to impaired cardiac function.

• Key complication: Left ventricular dysfunction may occur due to the loss of contractile tissue, potentially resulting in heart failure or arrhythmias as the heart struggles to maintain effective circulation.

Patient Profile

Demographics:

58-year-old male, office manager

History:

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

• Current medications: Metoprolol, Metformin, Atorvastatin, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe chest pain radiating to the left arm

• Key symptoms: Dyspnea, diaphoresis, nausea, palpitations

• Vital signs: Blood pressure 160/95 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 91% on room air

Section 1

As the medical team initiates interventions, including administering oxygen and preparing for possible reperfusion therapy, new diagnostic results provide further insight into the patient's condition. An electrocardiogram (EKG) reveals ST-segment elevation in the anterior leads, confirming an acute ST-elevation myocardial infarction (STEMI). Concurrently, a blood test shows elevated cardiac biomarkers, with troponin levels significantly increased, indicating substantial myocardial damage. These results corroborate the initial clinical suspicion of a substantial coronary event requiring urgent intervention.

Meanwhile, a chest X-ray is performed to assess for any additional complications. It reveals mild pulmonary congestion, suggesting early signs of heart failure due to left ventricular dysfunction. This finding is consistent with the patient's symptoms of dyspnea and decreased oxygen saturation. Given the patient's history of hypertension and diabetes, the risk of heart failure exacerbation is heightened, necessitating close monitoring and adjustment of the treatment plan.

In response to these findings, the medical team advances the care plan to include the initiation of dual antiplatelet therapy and consideration for percutaneous coronary intervention (PCI) to restore coronary blood flow. The patient is also started on a diuretic to manage fluid overload and reduce pulmonary congestion. As these interventions are initiated, the clinical team remains vigilant for potential complications, such as arrhythmias or further hemodynamic instability, which may arise as the patient's condition evolves.

Section 2

As the medical team closely monitors the patient's response to the initiated interventions, a change in the patient's status becomes evident. Approximately one hour after the administration of dual antiplatelet therapy and diuretics, the patient's vital signs reveal a concerning trend. The heart rate has escalated to 110 beats per minute, blood pressure has dropped to 88/56 mmHg, and the patient reports increased chest discomfort. Additionally, the oxygen saturation remains stable but relatively low at 92% on supplemental oxygen, and the respiratory rate has increased to 24 breaths per minute. These findings prompt the clinical team to suspect potential hemodynamic instability or evolving complications such as cardiogenic shock or arrhythmias.

In light of these changes, a repeat electrocardiogram (EKG) is performed, which now shows frequent premature ventricular contractions and occasional runs of ventricular tachycardia. This new development raises the concern for electrical instability of the heart, necessitating immediate attention to prevent further deterioration. The medical team decides to initiate antiarrhythmic therapy while preparing for possible advanced cardiac life support interventions. Additionally, blood tests are repeated, showing a further increase in troponin levels and a drop in kidney function, with creatinine levels rising to 1.8 mg/dL, indicating potential acute kidney injury secondary to reduced perfusion.

The evolving clinical picture prompts the team to reconsider the current treatment strategy. A discussion is held regarding the urgency of performing percutaneous coronary intervention (PCI) to address the underlying coronary occlusion and restore myocardial perfusion. The plan is to proceed with PCI as soon as possible, while also providing supportive measures to stabilize the patient's hemodynamic status. This includes the cautious use of intravenous fluids to improve blood pressure without exacerbating pulmonary congestion, and continuous cardiac monitoring to detect and manage any further arrhythmias. As the patient is prepared for transfer to the catheterization lab, the clinical team remains vigilant, anticipating potential complications and adjusting the care plan dynamically to address the patient's rapidly changing condition.

Section 3

As the patient is being prepped for transfer to the catheterization lab, the medical team continues to monitor her closely. Within the next 30 minutes, a noticeable change in the patient's condition is observed. The patient becomes increasingly diaphoretic and anxious, complaining of severe shortness of breath. Vital signs reveal a further drop in blood pressure to 82/50 mmHg, a heart rate that has now climbed to 120 beats per minute, and a respiratory rate that has increased to 28 breaths per minute. Oxygen saturation has decreased to 89% despite supplemental oxygen. These changes suggest the patient is slipping towards cardiogenic shock, underscoring the urgency for definitive intervention.

In conjunction with these signs, new laboratory results present additional challenges. The patient's arterial blood gas analysis indicates worsening metabolic acidosis with a pH of 7.28, bicarbonate level of 18 mmol/L, and elevated lactate levels at 5 mmol/L. These findings confirm tissue hypoperfusion and inadequate oxygen delivery to vital organs. Furthermore, the elevated creatinine level suggests the kidneys are struggling to cope, possibly exacerbated by the progression of shock and reduced cardiac output. The clinical team, realizing the critical nature of these developments, intensifies their efforts to stabilize the patient through a delicate balance of pharmacological support and fluid management.

The team initiates a low-dose norepinephrine infusion to support the patient's blood pressure and improve organ perfusion while carefully monitoring for any signs of worsening pulmonary congestion. Simultaneously, they adjust the oxygen delivery system to optimize respiratory support. As the patient is transferred to the catheterization lab, the team remains vigilant, fully aware of the potential for rapid deterioration. They are prepared to implement advanced cardiac life support measures if necessary, ensuring that all interventions are promptly coordinated to mitigate the risk of further complications and to facilitate a successful revascularization procedure.

Section 4

As the patient arrives in the catheterization lab, the team undertakes a focused initial assessment to gather more critical information. They note that the patient is still profoundly diaphoretic and agitated, with a sense of impending doom. The patient's jugular venous pressure is elevated, hinting at increased central venous pressure and potential fluid overload. Lung auscultation reveals bilateral crackles, suggesting pulmonary congestion. The patient's extremities are cool to touch, consistent with poor peripheral perfusion, further confirming the severity of cardiogenic shock.

New diagnostic results from the catheterization lab provide crucial insights into the patient's deteriorating condition. Coronary angiography reveals a significant occlusion in the left anterior descending artery, correlating with the patient's acute myocardial infarction. Additionally, echocardiography performed on-site shows a severely reduced ejection fraction of 30%, indicating compromised left ventricular function. The wall motion abnormalities observed reinforce the urgency of revascularization to restore adequate cardiac output and improve systemic circulation.

Despite these alarming findings, the patient's response to the initiated interventions offers a glimmer of hope. The norepinephrine infusion has resulted in a slight improvement in blood pressure, now stabilizing at 90/55 mmHg, providing a critical window to proceed with percutaneous coronary intervention (PCI). Oxygen saturation has modestly increased to 92% with adjusted high-flow oxygen therapy. The team remains on high alert, meticulously coordinating the PCI procedure to swiftly address the underlying coronary blockage, fully aware that timely revascularization is pivotal in averting further complications such as irreversible myocardial damage or multi-organ failure.

Section 5

As the PCI procedure progresses, the team remains vigilant, closely monitoring the patient's vital signs and response to the intervention. Despite the initial stabilization of blood pressure with norepinephrine, the patient's heart rate begins to climb, reaching 120 beats per minute. This tachycardia, combined with the persistent low blood pressure, signals the potential onset of a new complication: arrhythmia, possibly due to the ischemic stress on the heart. The telemetry monitor reveals occasional premature ventricular contractions (PVCs), raising concerns about the risk of further arrhythmias such as ventricular tachycardia.

Simultaneously, the patient's respiratory status becomes a focal point of concern. Although oxygen saturation improved marginally, the patient is now exhibiting increased work of breathing, with the use of accessory muscles and a respiratory rate escalating to 28 breaths per minute. Arterial blood gas analysis indicates a developing respiratory acidosis, with a pH of 7.30 and a PaCO2 of 52 mmHg, suggesting inadequate ventilation and potential respiratory failure. The bilateral crackles auscultated earlier are now accompanied by wheezing, indicating worsening pulmonary edema despite aggressive diuretic therapy.

The interventional cardiology team must now weigh the risks and benefits of additional interventions. With the potential for arrhythmia and respiratory compromise, they consider the need for temporary mechanical circulatory support, such as an intra-aortic balloon pump (IABP), to stabilize hemodynamics and reduce cardiac workload. Meanwhile, respiratory therapy is consulted for possible non-invasive ventilation support to counteract the respiratory distress. These decisions are critical, as they aim to optimize the patient's stability post-PCI and prevent the cascade of further complications, ensuring a trajectory towards recovery rather than deterioration.