Nursing Diagnosis: Acute Chest Pain

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Questions and Answers

Which of the following characteristics may indicate acute myocardial infarction (AMI) pain? (Select all that apply)

Pain occurring primarily in the evening

Pain radiating to the jaw, back, and left arm (correct)

Pain relieved by rest or nitroglycerin

Crushing substernal pain (correct)

If a patient has chest pain for less than 6 hours, they may be a candidate for thrombolytic therapy.

True

What should be monitored in patients during pain episodes and medication administration?

Vital signs including heart rate and blood pressure.

What is the rationale for assessing for contraindications to thrombolytic agents?

To ensure safe administration of medication and prevent complications. Signup and view all the answers

Why is bed rest recommended during periods of pain?

To reduce the oxygen demand of the heart. Signup and view all the answers

What is the target oxygen saturation level when administering oxygen therapy?

Above 90%. Signup and view all the answers

What is the purpose of administering IV nitrates?

To act as both coronary and peripheral vasodilators. Signup and view all the answers

What does the administration of morphine sulfate aim to achieve?

To reduce the workload on the heart and relieve chest pain. Signup and view all the answers

What should be assessed before administering thrombolytic agents?

Signs of bleeding. Signup and view all the answers

What should be monitored frequently to assess for complications of intracranial bleeding?

Neurological status. Signup and view all the answers

What is the goal of administering IV heparin after thrombolysis?

To maintain vessel patency. Signup and view all the answers

What are the possible interventions if signs of reperfusion are not evident?

Cardiac catheterization, PTCA, or coronary bypass graft surgery. Signup and view all the answers

The nursing diagnosis for acute chest pain is _____

Acute Chest Pain Signup and view all the answers

Match the treatment with its purpose:

Oxygen therapy = Ensure adequate oxygenation Morphine sulfate = Reduce workload on the heart Aspirin = Decrease platelet aggregation Beta-blockers = Slow heart rate and increase myocardial perfusion Signup and view all the answers

Study Notes

Acute Myocardial Infarction (AMI) Pain Characteristics

Crushing substernal pain is common in AMI; may feel like intense pressure.
Pain can radiate to the jaw, back, and left arm indicating severity.
Pain may occur unexpectedly, often in the early morning hours.
Typically, pain is unrelieved by rest or nitroglycerin, requiring stronger analgesics like narcotics.
Duration of pain lasts 30 minutes or longer, signaling a possible cardiac event.

Thrombolytic Therapy Consideration

Assess the time since onset of chest pain; candidates for thrombolytics must present within 6 hours.

Prior Treatments Assessment

Evaluate any prior pain management measures, such as sublingual nitroglycerin and aspirin, taken before hospital arrival.

Vital Signs Monitoring

Closely monitor heart rate and blood pressure during episodes of chest pain and medication administration for nonverbal pain indications.

Diagnostic ECG Surveillance

Baseline ECG should be reviewed for T- and ST-segment changes and the development of Q waves to identify ischemia or injury.

Cardiac Marker Monitoring

Serial cardiac markers help in the diagnosis and confirmation of myocardial infarction.

Ongoing Pain Assessment

Continuous evaluation of chest pain and the effectiveness of medications is critical; persistent pain necessitates immediate intervention.

Thrombolytic Agents Contraindications

Identify absolute contraindications such as active internal bleeding, bleeding diathesis, or a history of hemorrhagic stroke to ensure safe medication administration.

Bed Rest Implementation

Rest is crucial during pain episodes to lower the heart's oxygen demand.

Oxygen Therapy Administration

Administer oxygen at 4-6 L/min to keep oxygen saturation above 90%, aiding in myocardial oxygenation.

IV Nitrates Use

Initiate nitrates as they provide both coronary and peripheral vasodilation, managing blood flow and pressures.

Morphine Sulfate for Pain Relief

Morphine reduces heart workload via venodilation and alleviates chest pain effectively.

Beta-Blockers Administration

Beta-blockers help decrease heart rate, enhance myocardial perfusion, and lower myocardial contractility.

Aspirin Administration

Aspirin limits platelet aggregation, lowering mortality rates in AMI patients.

ACE Inhibitors Role

Administer ACE inhibitors to mitigate the risks of heart failure and mortality, especially in large transmural MIs or diabetic patients.

Thrombolytic Agents Timing

These medications should be given within the first 6 hours of a coronary event for effective restoration of perfusion.

Monitoring for Bleeding

Continuous assessment for signs of bleeding is essential to manage complications arising from thrombolytic therapy.

Intracranial Bleeding Vigilance

Frequent neurological status checks are necessary to detect potential intracranial bleeding complications due to thrombolytic agents.

Heparin Administration Guidelines

IV Heparin dosage must maintain aPTT levels at 1.5 to 2 times the normal range for optimal vessel patency post-thrombolysis.

Preparing for Advanced Interventions

Be ready for possible cardiac catheterization, PTCA, or coronary bypass graft surgery if reperfusion signs are absent and infarction is progressing.

Blood Pressure Monitoring

After administering medications, monitor blood pressure closely; intervene if systolic BP is below 100 mm Hg or drops significantly from previous readings.

Nursing Diagnosis for AMI

Acute chest pain is the primary nursing diagnosis in cases of myocardial infarction.

Patient Outcomes for Pain Management

Effective pain management is confirmed when the patient verbalizes pain relief and appears comfortable.

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Description

Test your knowledge on the nursing diagnosis and interventions related to acute chest pain, specifically focusing on the characteristics of acute myocardial infarction (AMI). This quiz will cover assessment criteria and rationale for early treatment options in nursing practice.