A nurse is caring for Mr. Johnson, who is experiencing symptoms suggestive of acute coronary syndrome. Despite initial interventions, he begins to exhibit episodic hypotension and signs of potential cardiogenic shock. What is the most appropriate nursing action to prioritize at this time to address his condition?

B) Prepare Mr. Johnson for an immediate transfer to the cardiac catheterization lab

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

B) Prepare Mr. Johnson for an immediate transfer to the cardiac catheterization lab

C) Administer an additional dose of sublingual nitroglycerin to reduce chest pain

D) Encourage Mr. Johnson to perform deep breathing exercises to reduce anxiety

Based on Mr. Johnson's clinical presentation and the interventions already administered, which additional nursing action should be prioritized to address his current symptoms and prevent further deterioration?

C) Place Mr. Johnson in a semi-Fowler's position to enhance breathing

A) Administer a diuretic to manage pulmonary congestion

B) Increase the dose of intravenous heparin to prevent clot formation

C) Place Mr. Johnson in a semi-Fowler's position to enhance breathing

D) Administer an opioid analgesic to relieve chest pain

A nurse is caring for Mr. Johnson in the cardiac care unit following his percutaneous coronary intervention. Which of the following assessments is the priority to monitor for complications related to the procedure?

B) Assessing for signs of reperfusion arrhythmias

A) Monitoring for changes in blood pressure

B) Assessing for signs of reperfusion arrhythmias

C) Checking peripheral pulses for symmetry

D) Monitoring urine output for renal perfusion

A nurse is caring for Mr. Johnson post-percutaneous coronary intervention in the cardiac care unit. With his current clinical presentation, which nursing intervention is the priority to prevent complications and promote recovery?

B) Monitor for signs of reperfusion injury and arrhythmias through continuous ECG monitoring.

A) Administer prescribed beta-blockers to manage his elevated heart rate.

B) Monitor for signs of reperfusion injury and arrhythmias through continuous ECG monitoring.

C) Encourage early ambulation to prevent deep vein thrombosis.

D) Provide patient education on lifestyle modifications to reduce future cardiac events.

Mr. Johnson is experiencing frequent premature ventricular contractions (PVCs) and hypokalemia post-stent placement. Which of the following nursing interventions would be the most appropriate initial action to stabilize his cardiac rhythm?

C) Initiate intravenous potassium replacement as ordered.

A) Administer a prescribed oral potassium supplement immediately.

B) Prepare for emergency cardioversion to address the PVCs.

C) Initiate intravenous potassium replacement as ordered.

D) Increase the rate of the intravenous normal saline infusion.

A nurse is caring for Mr. Johnson, who is experiencing premature ventricular contractions (PVCs) and hypokalemia after a recent stent placement. Which of the following actions should the nurse prioritize to address Mr. Johnson's cardiac irritability?

A) Administer a potassium supplement as ordered to correct the hypokalemia.

B) Increase the beta-blocker dosage to control the heart rate.

C) Encourage deep breathing exercises to reduce anxiety.

D) Prepare the patient for an emergency cardioversion procedure.

Mr. Johnson, a patient with a mild decrease in left ventricular ejection fraction at 45%, is being managed with an ACE inhibitor and beta-blocker therapy. Given his current condition and treatment plan, which nursing intervention is most appropriate to prioritize at this time?

B) Monitor blood pressure closely to assess for potential hypotensive episodes.

A) Encourage increased sodium intake to prevent hypotension.

B) Monitor blood pressure closely to assess for potential hypotensive episodes.

C) Advise the patient to limit physical activity to prevent fatigue.

D) Administer a diuretic to manage potential fluid overload.

Mr. Johnson's recent echocardiogram showed a decrease in left ventricular ejection fraction to 45%. Which nursing intervention is most appropriate to prioritize in his care plan given his current cardiac status?

C) Administer diuretics as prescribed to manage fluid retention.

A) Encourage increased fluid intake to maintain hydration.

B) Elevate the head of the bed to reduce cardiac workload.

C) Administer diuretics as prescribed to manage fluid retention.

D) Encourage high-intensity exercise to strengthen cardiac function.

Mr. Johnson is experiencing new complications with symptoms of chest pain and fluctuating blood pressure. Based on the presented case, which nursing intervention should be prioritized to address these complications and stabilize his condition?

A) Administer oxygen therapy to improve myocardial oxygenation.

B) Encourage Mr. Johnson to perform deep breathing exercises to alleviate pain.

C) Increase intravenous fluid rate to counteract hypotension.

D) Position Mr. Johnson in a flat supine position to improve blood flow.

Mr. Johnson, a patient with new-onset chest discomfort and telemetry showing episodes of non-sustained ventricular tachycardia, has been initiated on nitrates and beta-blockers. His blood pressure occasionally drops to 88/60 mmHg. As his nurse, what is the most appropriate action to take to ensure his safety and optimize his care?

B) Monitor blood pressure closely and withhold beta-blockers if hypotension worsens.

A) Increase the dosage of beta-blockers to control heart rate.

B) Monitor blood pressure closely and withhold beta-blockers if hypotension worsens.

C) Administer additional doses of nitrates to relieve chest pain.

D) Encourage Mr. Johnson to ambulate to improve circulation.

cardiac artery disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Atherosclerosis is the main cause, where lipid deposits form plaques in the coronary arteries, narrowing them and reducing blood flow to the heart muscle. This process begins with endothelial damage, leading to the accumulation of lipids and inflammatory cells in the arterial wall.

• Secondary mechanism: Plaque rupture can occur, exposing the underlying materials to the bloodstream, which triggers platelet aggregation and thrombus formation, potentially leading to partial or complete blockage of the artery.

• Key complication: Reduced blood flow often results in myocardial ischemia, manifesting as chest pain (angina) or, if severe, leading to myocardial infarction (heart attack), resulting in heart muscle damage or necrosis.

Patient Profile

Demographics:

62-year-old male, retired construction worker

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Chest pain and shortness of breath

• Key symptoms: Fatigue, episodic dizziness, intermittent claudication

• Vital signs: Blood pressure 150/95 mmHg, Heart rate 95 bpm, Respiratory rate 22 breaths/min, Temperature 98.6°F

Section 1

During the initial assessment, the nursing team observed that the patient, Mr. Johnson, exhibited signs of increasing distress. His chest pain, initially described as a 5 out of 10, had intensified to an 8, despite rest and administration of sublingual nitroglycerin. His shortness of breath had worsened, evidenced by an increase in respiratory rate to 28 breaths/min and the use of accessory muscles to breathe. Auscultation revealed crackles at the lung bases, suggesting potential pulmonary congestion. Additionally, his skin appeared cool and clammy, and he reported a feeling of impending doom. These findings indicated a possible escalation of myocardial ischemia, requiring immediate intervention.

The healthcare team swiftly prioritized obtaining a 12-lead ECG, which showed ST-segment depression in the anterior leads, consistent with ischemia. Lab results revealed elevated cardiac biomarkers, with a troponin level of 0.8 ng/mL, suggestive of myocardial injury. Given these findings, the clinical team reasoned that Mr. Johnson might be experiencing an acute coronary syndrome, possibly unstable angina or a non-ST elevation myocardial infarction (NSTEMI). This prompted the initiation of a higher dose of aspirin, the administration of intravenous heparin, and the addition of a beta-blocker to further decrease myocardial oxygen demand.

Despite these interventions, Mr. Johnson's condition remained precarious, and he began to exhibit episodic hypotension, with blood pressures dropping to 90/60 mmHg. This raised concerns about the adequacy of coronary perfusion and potential progression to cardiogenic shock. The team recognized the need for urgent revascularization and coordinated his transfer to the cardiac catheterization lab for potential percutaneous coronary intervention. This next step was crucial to restore adequate blood flow to the heart, prevent further myocardial damage, and stabilize Mr. Johnson's condition.

Section 2

As Mr. Johnson was swiftly transferred to the cardiac catheterization lab, the medical team remained vigilant in monitoring his vital signs and clinical status. Upon arrival, his blood pressure showed slight improvement, registering at 95/65 mmHg, though his heart rate remained elevated at 110 beats per minute. The persistent tachycardia, along with the continued presence of crackles in the lung bases, highlighted ongoing concerns about cardiac function and potential fluid overload. The interventional cardiologist proceeded with the coronary angiography, which revealed significant stenosis in the left anterior descending artery, approximately 90%, and moderate stenosis in the right coronary artery.

In the catheterization lab, the decision was made to perform percutaneous coronary intervention with the placement of a drug-eluting stent in the left anterior descending artery. This intervention aimed to alleviate the obstruction and enhance myocardial perfusion. Following the procedure, Mr. Johnson experienced a gradual improvement in his symptoms. His chest pain reduced to a 3 out of 10, and his respiratory distress lessened as evidenced by a decrease in respiratory rate to 22 breaths/min, with less reliance on accessory muscles. The auscultation of lung sounds showed diminished crackles, suggesting a reduction in pulmonary congestion.

Despite the positive trend in symptoms, the clinical team remained cautious, closely monitoring for any new complications. They considered the risk of reperfusion injury or arrhythmias post-intervention, which could potentially arise. Continuous ECG monitoring was maintained to detect any arrhythmic events, and Mr. Johnson was kept under observation in the cardiac care unit. The nursing team prepared for ongoing assessment and support, focusing on ensuring stable hemodynamics and optimizing his recovery path. This phase of care emphasized the importance of vigilant monitoring and the need for potential adjustments in pharmacotherapy to prevent further complications and promote cardiac stability.

Section 3

As the hours progressed in the cardiac care unit, Mr. Johnson's condition took a concerning turn. While he initially showed signs of improvement following the stent placement, the nursing team noted a sudden change in his status. His heart rate spiked to 130 beats per minute, and he began to exhibit increased restlessness and anxiety. The telemetry monitor revealed frequent premature ventricular contractions (PVCs), suggesting heightened cardiac irritability. His blood pressure, previously stabilizing, had dropped to 88/60 mmHg, indicating potential hemodynamic instability.

In response to these developments, the medical team swiftly ordered a series of diagnostic tests, including repeat cardiac enzyme panels and electrolyte levels, to assess for any contributing factors such as ischemia or electrolyte imbalances. The laboratory results revealed a mild elevation in troponin levels, consistent with the possibility of reperfusion injury. Additionally, a notable finding was the presence of hypokalemia, with serum potassium measuring 3.2 mEq/L, which could be exacerbating the arrhythmic events. The team promptly initiated a potassium replacement protocol to address this imbalance, hoping to stabilize Mr. Johnson's cardiac rhythm.

While the immediate focus was on managing these new complications, the clinical team also revisited Mr. Johnson's pharmacotherapy regimen. They adjusted his medications to optimize cardiac output and prevent further arrhythmias. Beta-blocker therapy was cautiously titrated to help control the tachycardia while ensuring adequate myocardial perfusion. As they continued to monitor his response to these interventions, the team remained vigilant, recognizing the delicate balance required in managing Mr. Johnson's complex cardiac condition. This adaptive approach emphasized the dynamic nature of cardiac care and the critical role of ongoing assessment and timely intervention in preventing further deterioration.

Section 4

As the medical team closely monitored Mr. Johnson's response to the interventions, an initial improvement was observed in his cardiac rhythm. The potassium replacement protocol successfully elevated his serum potassium level to 4.0 mEq/L, contributing to a reduction in the frequency of premature ventricular contractions. His heart rate gradually decreased to a more manageable 100 beats per minute, and his blood pressure improved slightly to 95/65 mmHg. Despite these positive changes, Mr. Johnson continued to experience intermittent episodes of anxiety and restlessness, prompting the team to consider additional underlying factors that might be influencing his condition.

New diagnostic results were obtained from an echocardiogram, which provided insight into Mr. Johnson's cardiac function following the acute episode. The echocardiogram revealed a mild decrease in left ventricular ejection fraction, now at 45%, suggesting some degree of systolic dysfunction potentially exacerbated by the recent ischemic event. This finding prompted the clinical team to adjust their management strategy, integrating measures to support myocardial function and prevent further deterioration. The decision was made to initiate an ACE inhibitor to enhance cardiac output and reduce afterload, alongside continued beta-blocker therapy to maintain heart rate control.

In light of these developments, the team remained vigilant for any new complications that might arise. Continuous telemetry monitoring was maintained to detect any recurrent arrhythmias, while serial assessments of cardiac enzymes and electrolytes were planned to evaluate ongoing cardiac recovery. The integration of these clinical findings with Mr. Johnson's evolving condition highlighted the importance of a proactive and adaptive approach in managing cardiac patients. The team prepared for the next steps in Mr. Johnson's care, with a focus on stabilizing his cardiac function and preventing further ischemic events.

Section 5

New Complications

Despite the initial responsiveness to treatment, Mr. Johnson began to exhibit new symptoms suggestive of emerging complications. On the third day of hospitalization, he reported increased chest discomfort, described as a sharp, episodic pain radiating to his left arm. Concurrently, his telemetry readings showed occasional episodes of non-sustained ventricular tachycardia, raising concern for potential ischemic changes or further destabilization of his cardiac condition. His blood pressure fluctuated, occasionally dropping to 88/60 mmHg, which coupled with the chest pain, necessitated urgent reassessment.

In response, the clinical team expedited additional diagnostic evaluations, including a repeat electrocardiogram and cardiac enzyme panel. The ECG revealed new ST-segment depressions in the anterolateral leads, suggesting ongoing ischemia. Cardiac enzyme levels showed a mild elevation in troponin I, indicating possible myocardial injury. These findings prompted the team to enhance their therapeutic strategy, prioritizing the stabilization of Mr. Johnson's myocardial oxygen supply-demand balance. Nitrates were introduced to alleviate the ischemic burden, alongside a careful titration of the beta-blocker dosage to ensure adequate heart rate and blood pressure management.

The evolving situation highlighted the critical need for vigilant monitoring and swift intervention to prevent further deterioration. The team engaged in a multidisciplinary discussion to explore potential adjustments in Mr. Johnson’s management plan, including the possibility of coronary angiography to evaluate the need for revascularization. As the team considered these next steps, they remained focused on optimizing Mr. Johnson’s hemodyamic stability and addressing the underlying factors contributing to his recurrent ischemic episodes. The continuity of care and adaptive clinical reasoning were paramount in guiding Mr. Johnson through this challenging phase of his recovery.