HESI Case Study Coronary Artery Disease

Therapeutic Communication: Noncompliance: The client is post-menopausal and smokes two packs of cigarettes a day. Her hypertension is uncontrolled even with the prescribed ACE inhibitor. The client took the clinic's online learning course on reducing the risk for heart disease. At the conclusion of the course, the client tells the nurse that she does not need classes because she knows she is going to be healed. 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.)

Percutaneous Transluminal Angioplasty: 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? (Enter numerical value only. If rounding is necessary, round to the whole number.)

33 500/900 = 0.5550.555(60) = 33.333.3 = 33

A Complication Occurs: On the client's second day post-MI, the nurse notes a change in the client's cardiac monitor. The client's rhythm strip changes from normal sinus rhythm to sinus rhythm with short runs of ventricular tachycardia (VT). The nurse assesses the client, whose blood pressure is now 100/54 mmHg. The client is lethargic, but she is able to be aroused. 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.)

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.)

When determining the highest priority need, the nurse should always intervene first for the client who is the most physiologically unstable, establishing priorities using the ABCs of emergency care: airway, breathing, and circulation. Previous Section Ethical-Legal Considerations: Client Rights While the nurse is assessing the client, a group of people dressed in street clothes and lab coats enters the client's room. They are carrying clipboards and pens, and they begin to ask the client questions related to her hospitalization. The client seems unsure how to respond. 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.)

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.)

Management Issues: Priorities The next day, the client is transferred to the Progressive Cardiac Unit. During report, the nurse is assigned four clients. 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.)

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.)

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 (aspirin) 160-325 mg PO that acts on the platelets, keeping them from clumping together at the site of the coronary blockage.)

Nursing Diagnoses and Interventions: The nurse assesses the client for changes in vital signs and for dysrhythmias. Other assessment findings related to MI include: Dyspnea; Pallor; Diaphoresis; Weakness; Fatigue; Nausea/Vomiting; Fever The client is transferred to the critical care unit for treatment and monitoring. She is still receiving oxygen at 2 L/min and IV nitroglycerin infusion. Her vital signs are stable. Her oxygen saturation is 94%, her breath sounds are clear, and she denies any pain at the present time. The client's nurse develops a plan of care based on the following nursing problems: Pain related to an imbalance between myocardial oxygen supply and demand. Alteration in tissue perfusion (cardiac) related to blood flow interruption. Activity intolerance related to imbalance between oxygen supply and demand.Anxiety related to pain and fear. 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.)

Clinical Manifestations: The nurse reviews the client's symptoms during the myocardial infarction. Her pain was first noted as a discomfort during the first presentation. She was weak and short of breath. The ECG revealed ST elevation. Later her chest pain increased and the ECG revealed ST elevation in the lower lateral leads which indicated a STEMI. Elevated cardiac specific laboratory findings, ECG findings, and physical assessment confirmed that the client was having an acute myocardial infarction. After 2 doses of sublingual nitroglycerin and 4 mg IV morphine sulfate, the client's pain is 1 out of 10. 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? (Select all that apply. One, some, or all options may be correct.)

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.) *NOT Hypertension controlled with an oral antihypertensive. bc -> High blood pressure is a modifiable risk factor. If controlled, then it is not an active risk.

After further discussion, the client agrees to go to their scheduled lab appointment, and considers making some modifications in their lifestyle. Client Teaching: Hyperlipidemia The client's lab results include:Serum cholesterol 280 mg/dL (7.25 mmol/L).Low-density lipoproteins (LDL) 180 mg/dL (4.66. mmol/L).High-density lipoproteins (HDL) 32 mg/dL (0.83 mmol/L).The client asks the nurse if these results are bad. 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.)

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 modifications include heart healthy diet, regular exercise, avoiding tobacco products, and maintaining a healthy weight.)

Acute Myocardial Infarction (AMI)The client's angina remains stable, and she undergoes a hysterectomy for dysmenorrhea related to uterine fibroids. The day after being discharged from the hospital, the client comes to the ED with crushing substernal chest pain radiating down her left arm. She is dyspneic, pale, and diaphoretic. 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.)

The client is scheduled for percutaneous transluminal coronary angioplasty (PTCA) via femoral insertion. PTCA involves the insertion of a balloon-tipped catheter into the diseased coronary artery. When the balloon is inflated, it compresses the plaque against the vessel wall, resulting in an increase in the inner diameter of the blood vessel so blood can flow more easily. 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 client is started on a continuous IV infusion of lidocaine at 2 mg/min. The ventricular tachycardia is controlled, and her cardiac monitor strip shows a sinus rhythm with occasional PVCs. The nurse monitors the client for adverse effects of the infusion, including hypotension, drowsiness, seizures, bradycardia, and confusion. What steps should the nurse take to minimize the development of these adverse effects? (Select all that apply. One, some, or all options may be correct.)

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? (Select all that apply. One, some, or all options may be correct.)

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.)

In addition to teaching the client about antihyperlipidemic medication, the nurse provides information about a low-fat/low-cholesterol diet, an exercise regimen, a smoking cessation plan, and stress management skills. The client agrees to attend a series of "healthy heart" classes at the clinic. Several months later, the client visits the clinic for routine lab work. After walking into the clinic on a very hot day, she reports to the nurse that she is experiencing chest pain. After resting for five minutes, the pain is relieved. Following assessment and ECG evaluation, the client is diagnosed with stable angina and receives two prescriptions:Nitroglycerin 0.2 mg/hour transdermal patch. Apply every morning and remove at bedtime daily. Nitroglycerin 0.3 mg SL as needed for chest pain. 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.)

Diagnostic Tests: With the client's presenting symptoms, physical examination, electrocardiogram (ECG) findings, and elevated cardiac markers, the healthcare provider (HCP) confirms the diagnosis of myocardial infarction (MI). 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.)

Discharge Preparation: The nurse determines that these individuals are beginning nursing students who are learning to interview clients and the nurse asks the group to leave the client's room. The nurse reviews the importance of promoting client rights and ways to achieve this. Upon learning the students' goals, the client welcomes the opportunity to visit with the nursing students. She talks with them at length about her impending discharge, the concerns she has, and her plans to engage in a healthier lifestyle. The nurse completes the client's discharge teaching and schedules the client to begin therapy at the cardiac rehabilitation unit the following week. Which expected outcomes indicate that the nurse's discharge teaching was effective? (Select all that apply. One, some, or all options may be correct.)

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.)