Questions and Answers
What is the primary nursing diagnosis for a patient with acute myocardial infarction?
Ineffective Tissue Perfusion Related to decreased compliance, contractility, & cardiac output
What are the goals and outcomes for a patient with ineffective tissue perfusion?
Patient will understand how to take medications & what symptoms to report. Patient will reduce activity as needed to maintain optimal tissue perfusion. Patient will describe emergency actions to take when experiencing chest pain.
What should a nurse implement regarding C.A.D. in a patient with acute myocardial infarction?
Assess & document vital signs. Assess for changes in level of consciousness, & manifestations of impaired tissue perfusion. Auscultate heart & lung sounds. Monitor ECG continuously. Monitor oxygen saturation levels & administer oxygen as ordered. Administer antidysrhythmic medications PRN. Monitor cardiac markers. Monitor invasive hemodynamic labs.
Why is it important to monitor vital signs in patients with decreased cardiac output?
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What does a change in level of consciousness indicate?
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What is the rationale for monitoring ECG in patients?
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Why should oxygen and ABG levels be monitored?
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What is the rationale for administering antidysrhythmics?
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What is the primary nursing diagnosis for coronary artery disease?
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What are the goals and outcomes for a patient at risk for CAD?
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What are the outcomes for a patient with symptomatic CAD?
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What nursing implementation is necessary for ineffective health maintenance?
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What is the recommended amount of regular exercise?
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What nursing diagnosis is related to angina?
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What is the patient goal for pain management?
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What nursing interventions should be implemented for chest pain?
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Why is administering oxygen important?
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What is the rationale for promoting rest in patients with chest pain?
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Why is nitroglycerin administered in heart patients?
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What is the rationale for administering morphine?
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Study Notes
Nursing Diagnoses for Coronary Artery Disease
- Primary Diagnosis for Acute Myocardial Infarction: Ineffective Tissue Perfusion due to decreased compliance, contractility, and cardiac output.
Goals for Ineffective Tissue Perfusion
- Patients will learn medication management and symptoms that require reporting.
- Patients will manage activity levels to ensure optimal tissue perfusion.
- Patients will outline emergency responses for chest pain occurrences.
Nursing Implementation for CAD with MI
- Regular monitoring and documentation of vital signs.
- Observe for changes in consciousness and symptoms of impaired tissue perfusion.
- Auscultate heart and lung sounds for abnormalities.
- Continuous ECG monitoring to identify dysrhythmias.
- Check oxygen saturation levels and provide oxygen as needed.
- Administer antidysrhythmic medications as required.
- Monitor cardiac markers and invasive hemodynamic lab results.
Rationale for Monitoring Vital Signs
- Cardiac output reduction triggers compensatory responses like tachycardia and vasoconstriction, increasing cardiac workload.
Rationale for Assessing Level of Consciousness
- Changes in consciousness often signal altered cardiac perfusion due to the brain's dependence on a consistent oxygen supply.
Rationale for Continuous ECG Monitoring
- Dysrhythmias can exacerbate decreased cardiac output and impair tissue perfusion.
Rationale for Monitoring Oxygen and ABGs
- Oxygen saturation indicates gas exchange efficiency and tissue perfusion.
- ABGs measure blood oxygen levels and provide an overview of acid-base balance.
Rationale for Antidysrhythmic Medications
- Dysrhythmias can compromise tissue perfusion by reducing cardiac output.
Primary Diagnosis for Coronary Artery Disease
- Ineffective Health Maintenance linked to the inability to identify CAD risk factors.
Goals for Patients at Risk for CAD
- Patients will recognize modifiable risk factors for CAD.
- Patients will articulate dietary adjustments to mitigate risks.
- Patients will change lifestyle habits, including increased activity and smoking cessation.
Goals for Symptomatic CAD Patients
- Patients will identify lifestyle choices that may exacerbate CAD.
- Patients will follow treatment regimens to prevent cardiac damage.
- Patients will manage blood pressure with medications, dietary changes, and exercise.
RN Implementation for Ineffective Health Maintenance
- Educate about CAD risk factors.
- Explain benefits of smoking cessation and provide resources.
- Aid in identifying psychosocial and physical support for lifestyle modifications.
- Promote regular exercise and identify enjoyable activities.
- Provide educational material on prescribed medications.
Benefits of Regular Exercise
- Aim for 30 minutes of continuous aerobic activity, 4 to 5 times per week.
- Suggest exercising with a buddy to maintain motivation.
Nursing Diagnosis Related to Angina
- Acute Pain due to myocardial ischemia.
Patient Goal for Angina Management
- Patients will maintain a tolerable level of pain.
Nursing Implementation for Angina
- Administer oxygen (2-5 liters per minute via nasal cannula).
- Encourage physical and psychological rest.
- Carefully titrate IV nitroglycerin as prescribed for pain and BP management.
- Provide IV morphine (2 to 4 mg) for chest pain as needed.
Rationale for Administering Oxygen
- Enhances oxygen delivery to the myocardium, alleviating ischemia and pain.
Rationale for Encouraging Rest
- Rest diminishes cardiac workload and sympathetic nervous system stimulation, enhancing comfort and reducing anxiety.
Rationale for Administering Nitroglycerin
- Relieves chest pain by dilating peripheral vessels, improving circulation to ischemic heart tissue.
Rationale for Administering Morphine
- Eases pain and anxiety, acts as a venodilator, reduces respiratory rate, decreases preload, and lessens cardiac workload and oxygen use.
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Description
Test your knowledge on nursing diagnoses related to coronary artery disease, especially in patients experiencing acute myocardial infarction. This quiz covers key concepts such as ineffective tissue perfusion and relevant care plans.