What is the primary purpose of administering nitroglycerin to this patient with suspected NSTEMI?

C) To decrease blood pressure significantly

What is the primary reason supplemental oxygen is administered to the patient in this scenario?

C) To maintain optimal oxygen saturation

A) To decrease the workload on the heart

B) To prevent respiratory failure

C) To maintain optimal oxygen saturation

D) To treat pulmonary congestion

What is the primary purpose of administering sublingual nitroglycerin to a patient experiencing chest discomfort?

B) To reduce chest pain by dilating coronary arteries

C) To lower blood pressure rapidly

D) To stabilize blood glucose levels

Which of the following interventions was most effective in alleviating the patient's chest discomfort?

D) Lifestyle modification education

Which nursing intervention is most appropriate for a patient diagnosed with NSTEMI who is stable and awaiting a coronary angiogram?

B) Encouraging active participation in care decisions

A) Administering high-dose aspirin

B) Encouraging active participation in care decisions

C) Withholding all medications except for emergency drugs

D) Restricting the patient to bed rest with no activity

Which diagnostic test result in the case study provides reassurance about the patient's current cardiac status?

C) Basic metabolic panel showing normal electrolyte levels

D) Clear lung fields upon auscultation

What is the primary reason for monitoring troponin levels in a patient experiencing myocardial stress?

B) To evaluate the degree of myocardial injury

A) To assess the patient's fluid balance

B) To evaluate the degree of myocardial injury

C) To monitor electrolyte imbalances

D) To determine the patient's oxygen saturation levels

A patient on nitroglycerin reports mild headaches, a known side effect of the medication. Which non-pharmacological intervention could the nurse offer to help alleviate the headache?

B) Apply a cool compress to the forehead

A) Encourage deep breathing exercises

B) Apply a cool compress to the forehead

D) Administer caffeinated beverages

nstemi - Nursing Case Study

Pathophysiology

• Primary mechanism: NSTEMI, or Non-ST Elevation Myocardial Infarction, occurs due to partial blockage of a coronary artery, reducing blood flow and oxygen to the heart muscle, leading to tissue damage without full-thickness heart muscle involvement.

• Secondary mechanism: Plaque rupture or erosion within the coronary artery often causes this partial blockage, triggering platelet aggregation and clot formation, further narrowing the vessel.

• Key complication: Reduced oxygen delivery can lead to myocardial cell injury and necrosis, causing chest pain and potential heart muscle dysfunction if not promptly managed.

Patient Profile

Demographics:

55-year-old male, accountant

History:

• Key past medical history: Hypertension, hyperlipidemia

• Current medications: Lisinopril, atorvastatin, daily low-dose aspirin

• Allergies: None

Current Presentation:

• Chief complaint: Mild chest discomfort

• Key symptoms: Chest discomfort lasting 15 minutes, radiating to the left arm, mild shortness of breath

• Vital signs: Blood pressure 135/85 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F, oxygen saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon initial assessment in the emergency department, the patient is alert and oriented, with a slight pallor noted on examination. He is experiencing mild chest discomfort, which he describes as a pressure-like sensation, radiating to the left arm. The discomfort subsided after resting but there is occasional recurrence. The patient's cardiovascular assessment reveals regular heart sounds with no murmurs, gallops, or rubs. Breath sounds are clear bilaterally with no evidence of crackles or wheezing, indicating no immediate signs of heart failure or pulmonary congestion. Peripheral pulses are palpable and equal bilaterally, and capillary refill is less than 2 seconds, suggesting adequate peripheral perfusion at this time.

Given his history of hypertension and hyperlipidemia, along with the current presentation, a 12-lead ECG is performed showing no significant ST-segment elevation or depression, consistent with NSTEMI. Initial laboratory results reveal a mildly elevated troponin level at 0.07 ng/mL (normal <0.04 ng/mL), confirming myocardial injury. A complete blood count and basic metabolic panel are within normal limits, except for slightly elevated LDL cholesterol at 145 mg/dL (normal <100 mg/dL). The patient's vital signs remain stable, with blood pressure at 135/85 mmHg and heart rate at 78 bpm, although continuous monitoring is initiated to detect any changes.

Based on these findings, the nursing team prioritizes interventions to improve coronary perfusion and prevent further myocardial damage. The patient is placed on a cardiac monitor, and supplemental oxygen is administered at 2 liters per minute via nasal cannula to maintain optimal oxygen saturation. Aspirin therapy is continued, and nitroglycerin is administered sublingually to alleviate chest discomfort and dilate coronary vessels. The patient is also educated on the importance of medication adherence and lifestyle modifications to manage risk factors and prevent future cardiac events. The team prepares to collaborate with the cardiology department for further evaluation and management, including the consideration of a coronary angiogram to assess the extent of coronary artery disease.

Section 2

Response to Interventions:

Following the initial interventions, the patient's condition remains stable over the next few hours. The supplemental oxygen has successfully maintained his oxygen saturation at 98%, and the sublingual nitroglycerin has effectively alleviated his chest discomfort, with the patient reporting only minimal residual pressure. The patient remains on the cardiac monitor, which continues to show normal sinus rhythm without any episodes of arrhythmia. Vital signs are consistently stable, with a blood pressure of 130/82 mmHg and a heart rate of 74 bpm.

The nursing team continues to educate the patient about the importance of lifestyle modifications, such as adhering to a heart-healthy diet and incorporating regular exercise into his routine, to manage his hypertension and hyperlipidemia effectively. The patient is receptive and expresses a willingness to make these changes. He is also informed about the potential need for a coronary angiogram to further evaluate his coronary artery status and is assured that the cardiology team will provide more information during their consultation.

As the patient prepares for the cardiology evaluation, he is encouraged to ask questions and voice any concerns about his condition and treatment plan. The nursing staff remains vigilant, monitoring for any signs of complications such as recurrent chest pain or changes in vital signs that might indicate an escalation in his condition. Overall, the patient's response to the initial interventions is positive, setting a foundation for further management and recovery.

Section 3

As the patient's condition remains stable, the cardiology team conducts a thorough assessment and orders a series of diagnostic tests, including a 12-lead ECG, cardiac biomarkers, and a basic metabolic panel. The ECG continues to show normal sinus rhythm with no ST-segment changes, which is reassuring. The initial cardiac biomarker results reveal slightly elevated troponin levels, consistent with NSTEMI, but they do not suggest significant myocardial damage. These findings confirm the early-stage nature of the patient's condition, supporting the current management plan. The basic metabolic panel returns with normal electrolyte levels, indicating no disturbances that might complicate cardiac function.

In conjunction with these diagnostic results, the nursing team conducts a comprehensive head-to-toe assessment. The patient is alert and oriented, with no signs of distress. Heart sounds are regular without murmurs, and lung fields are clear upon auscultation. Peripheral pulses are palpable and strong, with no edema noted in the extremities. The patient reports no new symptoms and continues to describe only minimal residual chest pressure, which remains well-managed with the prescribed nitroglycerin.

Given the stable diagnostic and assessment findings, the care team decides to proceed with a conservative management approach while awaiting the coronary angiogram. The patient is encouraged to continue participating in discussions about his treatment options and lifestyle changes, emphasizing his active role in the recovery process. The nursing staff remains attentive, reinforcing education about medication adherence and dietary adjustments to further reduce cardiovascular risk. This approach aims to empower the patient, ensuring he feels supported as he navigates the initial stages of his recovery journey.

Section 4

As the patient continues to receive care, the nursing team focuses on monitoring his response to the prescribed interventions. Over the next 24 hours, the patient remains in a stable condition, with vital signs consistently within normal ranges: blood pressure at 125/80 mmHg, heart rate at 72 beats per minute, respiratory rate at 18 breaths per minute, and an oxygen saturation of 98% on room air. The patient's chest pressure has decreased significantly, and he reports feeling more comfortable, attributing relief to the regular administration of nitroglycerin. Despite this improvement, the nursing staff remains vigilant, frequently reassessing the patient's condition to identify any subtle changes.

The nursing team also pays close attention to the patient's adherence to recommended lifestyle modifications. During interactions, the patient expresses a willingness to make dietary changes, and the nursing staff provides additional education on reducing sodium and saturated fat intake. They also introduce the concept of cardiac rehabilitation, explaining its role in enhancing cardiovascular health and recovery. The patient is receptive and expresses interest in participating in a structured program after discharge.

To ensure comprehensive care, the nursing team collaborates closely with the cardiology team, sharing observations and discussing potential next steps. They emphasize the importance of the upcoming coronary angiogram in tailoring the patient's treatment plan. In the meantime, they continue to support the patient emotionally, addressing any concerns he may have about his condition and recovery process. This collaborative approach helps reinforce the patient's confidence in his care team, fostering a sense of security as he progresses through this early stage of recovery.

Section 5

As the patient continues under observation, the nursing team conducts frequent assessments to ensure his condition remains stable. During a routine check, the nurse notes a slight increase in the patient's heart rate, now at 78 beats per minute, while other vital signs remain stable. The patient mentions experiencing mild headaches, which he attributes to the nitroglycerin. The nurse reassures him that this is a common side effect and ensures that he is comfortable, offering non-pharmacological measures such as a cool compress and a quiet environment to alleviate his symptoms.

Later that day, the cardiology team reviews new diagnostic results, including a repeat electrocardiogram (ECG) and blood work. The ECG shows no significant changes from previous tracings, indicating stable cardiac function. However, the patient's latest blood tests reveal a slight elevation in his troponin levels, suggesting ongoing myocardial stress. The nursing staff discusses these findings with the cardiology team, who determine that the patient should continue to be monitored closely but that there is no immediate cause for alarm. They recommend continuing the current treatment regimen and emphasize the importance of the upcoming coronary angiogram to further evaluate the patient's coronary arteries.

Throughout his stay, the patient remains engaged in his care, asking questions about his test results and what they mean for his recovery. The nursing staff takes this opportunity to educate him on the significance of monitoring cardiac biomarkers like troponin and how they relate to heart health. They also reinforce the importance of adhering to his medication regimen and lifestyle modifications to prevent future cardiac events. This ongoing education and support help maintain the patient's motivation and confidence in managing his condition, laying a strong foundation for his eventual discharge and participation in cardiac rehabilitation.