Question

Consider the scenarios and answer the following questions:

Scenario 1: Angina Pectoris

Lita a 65 year-old retired secretary, is admitted to the medical surgical area for management of chest pain

caused by angina pectoris.

1. The patient asked the nurse ―What is causing this pain?‖ What is the best response by the nurse?

2. The patient is diagnosed with chronic stable angina. The nurse can anticipate that her pain may

follow what type of pattern?

3. Lita has nitroglycerin at her bed side to take PRN. The nurse knows that nitroglycerin acts in what

ways?

4. Lita took a nitroglycerin tablet at 10:00 AM, after her morning care. It did not relieve her pain, so 5

minutes later, she repeated the dose. 10 minutes later, and still in pain, she calls the nurse. What is

the priority intervention of the nurse?

Scenario 2: Decreased Myocardial Tissue Perfusion

Mr. Santos, a 46 year-old teacher, is brought to the ER by ambulance with a suspected diagnosis of MI. He

appears ashen, is diaphoretic, and tachycardic, and has a severe chest pain. The nursing diagnosis is

Decreased Cardiac Output related to Decreased Myocardial Tissue Perfusion

1. The nurse is aware that there is critical time period for this patient. When should the nurse be most

vigilant in monitoring this patient?

2. The nurse is interpreting the result of the ECG. What findings does the nurse understand are

indicative of initial myocardial injury?

3. What laboratory test are positive indicators of MI?

4. The nurse should closely monitor the patient for a complication of an MI that leads to sudden death

during the first 48 hours. Which complication should the nurse monitor for?

Books

American Heart Association (AHA). (2007). Heart disease and stroke statistics—2007 update. Dal

Answer 1

SCENARIO 1

1) The pain is usually due to not enough blood flow to the heart muscle.

2) Chronic stable angina is a clinical syndrome characterized by squeezing, heaviness or pressure discomfort in the chest, neck, jaw, shoulder, back, or arms which is usually precipitated by exertion and/or emotional stress and relieved by rest and/or Nitroglycerin.

3) The prophylactic use of nitroglycerin in patients with stable angina has been shown to increase physical exercise tolerance.  Nitroglycerin is a medication that can provide relief of your discomfort. Some patients have experienced side effects such as headache or lightheadedness from nitroglycerin.

4) Monitor a patient’s blood pressure, hold for a systolic BP of less than 90 mmHg.

SCENARIO 2

1) The nurse should be most vigilant when there is any alteration in heart rate, rhythm, and conduction.

2) In a patient with MI, ST elevation indicates myocardial injury.

3) A diagnosis of myocardial infarction is created by integrating the history of the presenting illness and physical examination with electrocardiogram findings and cardiac markers (blood tests for heart muscle cell damage).

1. Creatine kinase (total)

Creatine kinase (CK) is an enzyme present in cardiac and skeletal muscle that is released into the blood when cells are injured. An elevation in total CK means you either have skeletal muscle or cardiac muscle injury.

2. Creatine kinase (MB fraction)

CK-MB is a very good test for acute myocardial injury. It’s very specific (you don’t see elevations in CK-MB in other conditions very often), and it goes up very quickly and dramatically after MI (within 2-8 hours). It returns to normal within 1-3 days, which makes it a good test to use in diagnosing re-infarction.

3. Troponin I and T

Troponins are components of cardiac muscle that are released into the blood when myocardial cells are injured. They are very, very specific for myocardial muscle – even more specific than CK-MB. Troponins go up within 3-12 hours after the onset of MI (though the rise is more gradual than the steep bump you see with CK-MB). They remain elevated for a long time (5-9 days for troponin I and up to a couple weeks for troponin T).

4. Myoglobin

Myoglobin is a protein present in both skeletal and cardiac muscle that is released when cells are damaged. It’s a very sensitive indicator of muscle injury, and it’s also the first marker to go up in a myocardial infarction (even before CK-MB). It’s not specific for cardiac muscle, so you wouldn’t want to do this test as your only marker for ruling in an MI.

5. Lactate dehydrogenase

Lactate dehydrogenase (LDH) is an enzyme present in many different cells. There are 5 isoenzymes (1-5), each with different specificities for different types of tissue. In the case of cardiac injury, LDH isoenzyme 1 will go up, and usually you’ll see that isoenzyme 1 is higher than isoenzyme 2 (this is called a “flipped” pattern, because under normal circumstances, isoenzyme 2 is present in greater amounts than isoenzyme 1). The LDH starts going up in 12-24 hours following an MI, and it dissipates within a week or two.

4) Bradyarrhythmias and conduction disturbances are well-recognized complications of acute myocardial infarction (MI). They are induced by either autonomic imbalance or ischemia and necrosis of the conduction system.