HESI Case Study - Coronary Artery Disease

Which nursing intervention best promotes effective communication?

"Do you feel that you do not need to be involved in your health care?" Clarification of the client's statement is a useful therapeutic technique that encourages further communication.

The primary healthcare provider (HCP) prescribes a continuous IV infusion of amiodarone 1 mg/min for the client. The available drug is amiodarone 900 mg in 500 mL of D5W. The nurse should set the IV pump at how many mL/hr?

33 mL/hr

Which client should the nurse assess first?

A client with unstable angina who is complaining of chest discomfort and who has been given one nitroglycerin tablet sublingually (SL). This is the least stable of the four clients. The nurse needs to assess for the effectiveness of the nitroglycerin and for other symptoms that may indicate the onset of an MI.

Which nursing intervention best promotes effective communication?

HDL less than 50 mg/dL (1.29 mmol/L) for women indicates an increased risk. HDL is considered the "good" cholesterol, which reduces the risk of heart disease. Current guidelines state that an HDL of less than 50 mg/dL (1.29 mmol/L) for women is too low to safeguard the arteries.

While taking the prescribed antihyperlipidemic, which serum laboratory value requires intervention?

ALT 60 U/L (1.0 mckat/L). Normal ALT is 4 - 36 U/L (0.07 - 0.60 mckat/L). Antihyperlipidemics can cause increased liver enzymes and should be monitored periodically during treatment.

Which intervention should the nurse initiate first?

Administer amiodarone IV. The treatment of choice for frequent premature ventricular contractions (PVCs) and ventricular tachycardia is an immediate IV bolus of amiodarone.

ECG findings reveal ST segment elevation in leads II and III, and a VF indicating that the client is having an inferior acute myocardial infarction (AMI). Which intervention should the nurse implement first?

Have the client chew four 81 mg chewable acetylsalicylic acid. The first intervention according to American Heart Association standard is to administer acetylsalicylic acid 160-325 mg PO that acts on the platelets, keeping them from clumping together at the site of the coronary blockage.

Which intervention is most important for the nurse to include in the client's plan of care?

Continuous cardiac monitoring of heart rate and rhythm. The heart rate and rhythm should be continuously monitored. Lethal arrhythmias are the most common immediate complication following an acute myocardial infarction that can be life threatening.

The nurse is monitoring the client for complications that are common after a myocardial infarction. Which focused assessment finding warrants immediate intervention by the nurse?

Dysrhythmias. The most common complication after an MI is dysrhythmias. Lethal dysrhythmia often occur within 4 hours from onset of chest pain. Premature ventricular contractions may precede the lethal dysrhythmias ventricular tachycardia and fibrillation.

Which information in the client's history indicates an increased risk for coronary artery disease (CAD) and requires the nurse to provide disease management education?

Family history of hyperlipidemia. Genetic predisposition is a significant factor in the development of CAD. Consumption of a high fat diet. Unhealthy habits, such as consuming fatty foods, are contributing risk factors to CAD. Smoking two packs of cigarettes per day. Smoking is a modifiable risk factor for coronary artery disease.

After discussing these test results with the healthcare provider (HCP) and the nurse, the client expresses interest in learning how to lower her cholesterol and lose weight. The HCP prescribes the antihyperlipidemic agent lovastatin 20 mg PO daily. Which intervention is most important for the nurse to include in the client's plan of care related to the use of an antihyperlipidemic?

Healthy lifestyle habits Lifestyle modifications should be used in conjunction with a cholesterol-lowering medication. Lifestyle modificatios include heart healthy diet, regular exercise, avoiding tobacco products, and maintaining a healthy weight.

Which nursing intervention should be implemented first?

IV access and administer morphine sulfate as ordered by the HCP. Acute chest pain related to myocardial infarction, ischemia, or reduced coronary artery blood flow is the most important nursing problem to address for the client with Acute Coronary Syndrome (ACS). Treating pain is critical, as pain activates the sympathetic nervous system and aggravates diaphoresis, weakness, light-headedness, and palpitations which, in turn, increases cardiac workload.

Which nursing intervention should be implemented first when the client returns to her room?

Immobilize the affected leg. The prevention of catheter dislodgement and of bleeding or oozing at the insertion site is a high priority in the immediate post-procedure period. The site should be immobilized and closely monitored for signs of hematoma formation (bleeding, inflammation, tenderness, or swelling). In addition, distal circulation should be monitored closely by assessment of pedal pulses, color, warmth, and capillary refill

The healthcare provider (HCP) orders IV nitroglycerin for the client. What changes in the client's cardiac function should the nurse tell the client to expect?

Improved perfusion of oxygenated blood to the heart muscle. Nitrates cause the coronary blood vessels to dilate, allowing improved oxygen delivery to cardiac muscle. In addition, nitrates cause systemic vasodilation, reducing the workload on the heart, which in turn reduces the myocardium's need for oxygen.

The HCP prescribes a stress echocardiogram. When preparing the client for the test, which instruction is most important for the nurse to provide?

Instruct the client not to smoke on the day of the test. The client smokes and should be specifically instructed not to smoke prior to test. Nicotine can interfere with the heart rate.

What steps should the nurse take to minimize the development of these adverse effects?

Monitor serum lidocaine levels. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/mL (6.4 to 21.34 mcmol/L). Monitor ECG, blood pressure, and respiratory status. Heart rhythm and VS, especially blood pressure and respirations, must be monitored closely. Monitor the client's anxiety level. Nervousness and excitation are adverse effects of lidocaine and the nurse should monitor the client closely for these developments.

The client continues to recover in the intensive care unit. Which interventions should the nurse implement for the client?

Provide pain medication with onset of pain. Providing optimal pain relief with prescribed analgesics is important because pain can exacerbate tachycardia and increases blood pressure. Administer anti-anxiety medication as needed. Identify when level of anxiety increases. Anxiety increases the need for oxygen. Assess the client's level of knowledge and ability to learn. Knowledge related to disease process and prognosis is important but should also be realistic. Realistic expectations promotes realistic decision making.

Which intervention is most important for the nurse to reinforce when assisting the client in achieving their goal to quit smoking?

Provide the client with a list of local smoking cessation programs. Prescribed and over-the-counter medications work best when taken in conjunction with a smoking cessation program.

Which intervention is most important for the nurse to include in the client's plan of care for the self-administration of sublingual nitroglycerin?

Put one tablet every 5 minutes under tongue up to 3 tablets. Nitroglycerin tablets should be placed under the tongue when chest pain occurs. They may be taken one tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets. If the pain is not relieved after three doses, the client should be instructed to go to the Emergency Department.

In addition to nitroglycerin, the HCP orders morphine sulfate 4mg IV. Which reaction requires immediate intervention by the nurse?

Respiratory rate slowing to 10 breaths/min. Profound respiratory depression is an adverse reaction of opioids such as morphine sulfate. Respiratory rate should remain 12 breaths/min or higher.

The client reports an increase in her chest pain as 8 out of 10. The nurse immediately obtains another ECG. Which ECG assessment finding warrants immediate intervention by the nurse?

ST segment elevation and the development of Q waves. ST segment elevation is indicative of acute myocardial injury leading to infarction and requires immediate intervention (STEMI versus non-STEMI - STEMI causes more deaths).

When providing education for the prescribed transdermal nitroglycerin, which intervention is most important for the nurse to include?

Tell the healthcare provider (HCP) of persistant dizziness when standing. Nitroglycerin is a nitrate, causing systemic vasodilation. This often leads to hypotension, which can cause the client to feel dizzy. She should be instructed to change positions slowly and to avoid prolonged standing. If the dizziness is persistant when standing, the client's blood pressure may be too low, requiring the HCP to adust the dosage or change the medication.

Which expected outcomes indicate that the nurse's discharge teaching was effective?

The client chooses walking as her initial form of exercise. Walking is the best initial activity/exercise for the post-MI client. The client should be instructed to establish a gradually progressive walking schedule and to assess pulse and tolerance when increasing activity. Activities such as heavy lifting that cause straining should be avoided for several weeks. The client chooses a diet low in saturated fat and cholesterol. A diet low in saturated fat and cholesterol will reduce the risk for the client developing another MI.

The nurse should immediately intervene to prevent violation of which client right?

The right to have information about the qualifications of caregivers. The individuals in the group should wear name tags that clearly identify their roles, they should introduce themselves, and they should explain to the client why they would like to ask her some questions. Clients have the right to privacy during examination and treatment, as well as the right to refuse observation by those not directly involved in their care.

In addition to the ECG, the nurse sent blood to the laboratory to evaluate the client's cardiac isoenzyme. Which serum laboratory values requires intervention by the nurse?

Troponin T 0.4 ng/mL (0.4 mcg/L). Troponin T 0 - 0.2 ng/mL (0.2 ug/L) (onset: 2-4 hrs, peak: 10-24 hrs, return to normal: 10-14 days). This indicates acute myocardial injury and requires immediate intervention.