A 58-year-old male patient with a suspected myocardial infarction is being prepared for transfer to the cardiac catheterization lab. During pre-transfer preparations, the nurse notes that the patient's oxygen saturation is 88% on room air, and he is experiencing increased fatigue and chest discomfort radiating to the arm and jaw. Which nursing intervention is the most appropriate to perform first?

A) Administer supplemental oxygen to maintain adequate saturation levels.

B) Initiate intravenous fluids to support blood pressure and perfusion.

C) Provide patient education about the cardiac catheterization procedure.

D) Reassess the patient's blood pressure and heart rate before transfer.

A 58-year-old male patient with a history of hypertension is admitted to the hospital with symptoms suggestive of an acute myocardial infarction. Which nursing intervention should be prioritized to address the patient's current symptoms and prevent further cardiac damage?

C) Initiate supplemental oxygen to maintain oxygen saturation above 94%.

A) Administer prescribed morphine sulfate to manage chest pain.

B) Monitor urinary output to assess renal function.

C) Initiate supplemental oxygen to maintain oxygen saturation above 94%.

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

A patient recently underwent a cardiac catheterization with stent placement for critical stenosis in the left anterior descending artery. Post-procedure, the patient develops shortness of breath, mild hypotension, jugular venous distention, and bilateral crackles. Which intervention should the nurse prioritize to address the underlying cause of these symptoms?

C) Administer prescribed diuretics

A) Administer a bolus of normal saline

B) Increase supplemental oxygen flow rate

C) Administer prescribed diuretics

D) Encourage the patient to engage in deep breathing exercises

A patient in the intensive care unit following a cardiac catheterization and stent placement is experiencing shortness of breath, mild hypotension, jugular venous distention, and bilateral crackles. Which nursing intervention is most appropriate to prioritize for this patient to manage these symptoms effectively?

B) Administer prescribed diuretics to reduce pulmonary congestion.

A) Increase the rate of intravenous fluids to improve blood pressure.

B) Administer prescribed diuretics to reduce pulmonary congestion.

C) Position the patient in a Trendelenburg position to enhance venous return.

D) Discontinue supplemental oxygen as the patient’s oxygen saturation is at 94%.

A patient with acute decompensated heart failure is experiencing worsening respiratory distress despite treatment with diuretics and vasodilators. His oxygen saturation is 88% on a non-rebreather mask, and a recent echocardiogram shows an ejection fraction of 30%. In considering the potential need for non-invasive positive pressure ventilation (NIPPV), what is the primary goal of using this intervention in this clinical scenario?

C) To enhance oxygenation and decrease work of breathing

A) To decrease myocardial oxygen demand

C) To enhance oxygenation and decrease work of breathing

A patient with acute decompensated heart failure is being treated with dobutamine for inotropic support. The nurse notes that the patient's serum creatinine levels are rising. Which nursing intervention is most appropriate to address this complication while managing the patient's condition?

B) Monitor urine output and notify the provider of significant changes.

A) Increase the frequency of diuretic administration.

B) Monitor urine output and notify the provider of significant changes.

C) Discontinue dobutamine to reduce renal strain.

D) Increase the infusion rate of dobutamine to improve cardiac output.

A patient with heart failure and renal impairment shows signs of hypoperfusion and hyperkalemia. Despite treatment with dobutamine, the patient's blood pressure remains low and mental status is altered. What is the most appropriate nursing intervention to prioritize at this time?

B) Administer calcium gluconate and insulin with glucose immediately

A) Increase the dose of dobutamine to improve cardiac output

B) Administer calcium gluconate and insulin with glucose immediately

C) Initiate renal replacement therapy to correct electrolyte imbalances

D) Hold diuretics and assess fluid status to prevent further renal damage

A patient with advanced heart failure presents with tachypnea, low oxygen saturation, and bilateral lung crackles. After administering increased doses of intravenous diuretics and initiating non-invasive positive pressure ventilation (NIPPV), which of the following is the most appropriate next step in managing this patient?

C) Evaluate the need for inotropic support

A) Initiate continuous renal replacement therapy (CRRT)

B) Administer a bolus of intravenous fluids

C) Evaluate the need for inotropic support

D) Start oral beta-blocker therapy

A patient with advanced heart failure presents with increased respiratory distress, tachypnea, and crackles at the lung bases. The healthcare team suspects acute decompensated heart failure with pulmonary edema. Which nursing intervention is most appropriate to address the patient's respiratory status?

B) Administer prescribed intravenous diuretics to reduce fluid overload.

A) Position the patient flat in bed to promote comfort.

B) Administer prescribed intravenous diuretics to reduce fluid overload.

C) Encourage the patient to perform deep breathing exercises.

D) Restrict oral fluid intake to 1000 mL per day.

cardiovascular - Nursing Case Study

Pathophysiology

• Primary mechanism: Atherosclerosis - The buildup of plaques within the arterial walls leads to narrowed and stiffened arteries, reducing blood flow and increasing blood pressure. This can result in ischemia and is the foundation for many cardiovascular diseases.

• Secondary mechanism: Hypertension - Elevated blood pressure exerts excess force against arterial walls, causing damage and further atherosclerotic plaque formation. Over time, this can lead to heart hypertrophy and heart failure due to the increased workload on the heart.

• Key complication: Myocardial infarction - Reduced or blocked blood flow to the heart muscle, often due to atherosclerotic plaques, results in tissue death. This compromises heart function, leading to possible heart failure or arrhythmias.

Patient Profile

Demographics:

58-year-old male, construction worker

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath on exertion

• Key symptoms: Chest pain, fatigue, occasional dizziness, swelling in legs

• Vital signs: Blood pressure 150/95 mmHg, heart rate 98 bpm, respiratory rate 22 breaths/min, temperature 98.6°F, oxygen saturation 92% on room air

Section 1

As the healthcare team continued to monitor the 58-year-old male patient, they observed a notable change in his status. Despite initial management of his symptoms with oxygen therapy and adjustments in his hypertensive regimen, the patient began to exhibit increased fatigue and persistent chest discomfort, now radiating to his left arm and jaw. Concurrently, his oxygen saturation dropped to 88% on room air, necessitating supplemental oxygen. His blood pressure remained elevated at 160/100 mmHg, and his heart rate increased to 110 bpm, indicating a possible deterioration in his cardiovascular status.

Further diagnostic testing was promptly initiated to assess the situation more comprehensively. An electrocardiogram (ECG) revealed ST-segment elevations in the anterior leads, suggestive of an evolving myocardial infarction. Laboratory results showed elevated cardiac biomarkers, with troponin levels significantly above the normal range, confirming myocardial injury. Additionally, a chest X-ray indicated pulmonary congestion, raising concerns of developing heart failure due to the impaired cardiac output.

This change in the patient's condition underscored the urgency of escalating care. The clinical team initiated treatment protocols for acute coronary syndrome, including dual antiplatelet therapy and intravenous nitroglycerin to relieve ischemic pain and reduce myocardial workload. Plans were also made for immediate transfer to the cardiac catheterization lab for possible revascularization. These critical interventions were aimed at restoring coronary perfusion and preventing further cardiac damage, highlighting the importance of timely clinical reasoning and intervention in managing cardiovascular complications.

Section 2

As the patient was transferred to the cardiac catheterization lab, the healthcare team remained vigilant for any new developments. During the procedure, the interventional cardiologist discovered a critical stenosis in the left anterior descending artery, commonly referred to as the "widowmaker" due to its potential for catastrophic outcomes. A drug-eluting stent was successfully placed, restoring adequate blood flow to the compromised myocardial region. Post-procedure, the patient was monitored in the intensive care unit for signs of reperfusion injury and other potential complications.

In the hours following the intervention, the patient's condition initially appeared stable. His chest pain subsided, and his oxygen saturation improved to 94% with supplemental oxygen. However, a subsequent assessment revealed a concerning development: the patient began experiencing shortness of breath and mild hypotension, with his blood pressure dropping to 100/60 mmHg. Jugular venous distention was noted, and auscultation of the lungs revealed bilateral crackles, suggesting a worsening of pulmonary congestion. Blood tests indicated a rising B-type natriuretic peptide (BNP) level, confirming the suspicion of acute decompensated heart failure as a complication post-revascularization.

This new complication prompted the clinical team to initiate tailored heart failure management, including diuretics to alleviate fluid overload and vasodilators to optimize cardiac output. The patient's response to these interventions would need careful monitoring to ensure stabilization, requiring the healthcare team to continually reassess and adjust the treatment plan based on evolving clinical indicators. This scenario emphasized the dynamic nature of cardiovascular care, where comprehensive clinical reasoning and timely adaptation of therapeutic strategies are crucial for patient recovery.

Section 3

As the team continued to manage the patient's acute decompensated heart failure, a change in his status warranted immediate attention. Despite the administration of diuretics and vasodilators, the patient's respiratory distress worsened. His oxygen saturation dropped to 88% on a non-rebreather mask, and his respiratory rate increased to 28 breaths per minute. The healthcare team performed a repeat chest X-ray, which showed increasing pulmonary edema. Furthermore, an echocardiogram revealed a reduced ejection fraction of 30%, suggesting significant left ventricular systolic dysfunction.

In light of these findings, the clinical team decided to escalate the patient's treatment to include inotropic support, administering dobutamine to improve myocardial contractility and support cardiac output. They also considered the potential need for non-invasive positive pressure ventilation (NIPPV) to aid in oxygenation and reduce the work of breathing. Concurrently, laboratory tests revealed an increase in serum creatinine, indicating possible renal impairment secondary to the acute heart failure exacerbation and diuretic therapy. The team recognized the delicate balance required in managing fluid status to avoid further renal compromise while addressing the heart failure.

This progression highlighted the complexity of managing cardiovascular patients with multiple interacting pathophysiological processes. The team remained vigilant for further complications such as arrhythmias, electrolyte imbalances, or worsening renal function, all of which could arise from or exacerbate the current situation. Close monitoring and frequent reassessment were paramount to ensure timely interventions, underscoring the importance of a cohesive, multidisciplinary approach to optimize the patient's outcomes and guide the next steps in his care journey.

Section 4

As the team focused on monitoring the patient's response to the interventions, they observed a change in his status that required immediate attention. Despite the administration of dobutamine, his blood pressure began to fluctuate, with readings dropping to 85/55 mmHg, suggesting potential hypoperfusion. The patient's mental status also altered; he appeared more lethargic and disoriented, raising concerns about cerebral perfusion. The team quickly performed a bedside assessment, noting cool extremities and delayed capillary refill, indicative of poor peripheral circulation.

In response to these alarming signs, the healthcare team ordered additional laboratory tests. The results revealed a further increase in serum creatinine to 2.5 mg/dL, confirming worsening renal function. Additionally, the serum potassium level had risen to 5.8 mEq/L, indicating hyperkalemia, a potentially dangerous electrolyte imbalance. Recognizing the risk of arrhythmias associated with elevated potassium levels, the team prepared to administer calcium gluconate and insulin with glucose to stabilize the cardiac membrane and drive potassium back into the cells.

This development underscored the intricate balance required in managing the patient's heart failure while addressing the complications of renal impairment and electrolyte disturbances. The team deliberated on the necessity of adjusting the diuretic regimen and considered initiating renal replacement therapy if the renal function continued to decline. This situation emphasized the ongoing need for a coordinated, multidisciplinary approach, with input from cardiology, nephrology, and critical care to navigate the complexities of the patient's condition and pave the way for subsequent management strategies.

Section 5

As the team continued to manage the patient's complex condition, they noted a sudden change in his respiratory status. The patient developed tachypnea, with a respiratory rate of 32 breaths per minute, and his oxygen saturation dropped to 88% on room air. Upon auscultation, crackles were heard bilaterally at the lung bases, suggesting pulmonary congestion. Given these findings, the team suspected that the patient was experiencing acute decompensated heart failure, leading to pulmonary edema. This situation necessitated an adjustment in his treatment plan, particularly concerning his fluid status and diuretic therapy.

In light of the patient's fluid overload and deteriorating respiratory condition, the team decided to increase the dose of intravenous diuretics and considered initiating non-invasive positive pressure ventilation (NIPPV) to improve oxygenation and reduce the work of breathing. Additionally, they ordered an urgent chest X-ray, which confirmed the presence of bilateral pulmonary infiltrates consistent with fluid overload. The patient's B-type natriuretic peptide (BNP) levels were also elevated at 1200 pg/mL, further supporting the diagnosis of heart failure exacerbation.

This sequence of events highlighted the dynamic and often unpredictable nature of managing patients with advanced heart failure, where respiratory complications can quickly arise. The healthcare team recognized the importance of continuous monitoring and the need to reassess their therapeutic approach frequently. They planned to re-evaluate the patient's response to the intensified diuretic therapy and NIPPV, while also considering the possibility of initiating inotropic support or advanced therapies if his condition continued to decline. This approach would require careful coordination among the multidisciplinary team to ensure all aspects of the patient's care were addressed promptly and effectively.