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Zorluk: OrtaPhysiological Adaptation

During morning rounds on the progressive cardiac care unit, a nurse evaluates a 68-year-old individual who sustained an anterior ST-segment elevation myocardial infarction 36 hours ago. The client is newly restless, diaphoretic, and reports a 'sense of impending doom.' Current vital signs include a blood pressure of 98/82 mm Hg, heart rate of 122 beats per minute, respiratory rate of 26 breaths per minute, and oxygen saturation of 93% on room air. The urinary catheter has drained 15 mL over the previous hour. Which intervention represents the highest priority?

  1. Alert the rapid response team and prepare to administer inotropic medicationsCevap
  2. B
    Increase the rate of the continuous intravenous fluid infusion to correct the oliguria
  3. C
    Administer the prescribed as-needed anti-anxiety medication to manage the client's restlessness
  4. D
    Document the assessment findings and repeat the vital signs in 30 minutes

Cevap

The correct action is to alert the rapid response team and prepare to administer inotropic medications.
The clinical presentation—a narrowed pulse pressure of 16 mm Hg, tachycardia, severe oliguria, and restlessness following an anterior myocardial infarction—strongly indicates early cardiogenic shock. Because the left ventricle is failing as a pump, cardiac output drops significantly, activating compensatory mechanisms that cause vasoconstriction and tachycardia. The immediate priority is to activate the rapid response team to escalate care. The client will urgently need advanced interventions, such as inotropic medications or mechanical circulatory support, to improve contractility and tissue perfusion.

Adım Adım Çözüm

1
Analyze the vital signs and clinical presentation to determine the client's physiological status.
The client presents with a significantly narrowed pulse pressure (98 - 82 = 16 mm Hg), tachycardia, tachypnea, oliguria (15 mL/hr), and altered mental status (restlessness).
Identifying abnormal trends and clustering assessment data is the critical first step in recognizing physiological deterioration.
2
Correlate the assessment findings with potential post-myocardial infarction complications.
The combination of these signs in a client who recently suffered an anterior wall myocardial infarction strongly indicates the onset of cardiogenic shock.
An anterior myocardial infarction causes extensive damage to the left ventricle, creating a high risk for severe pump failure and decreased cardiac output.
3
Determine the most appropriate immediate nursing intervention to address the complication.
The priority is to immediately escalate care by notifying the rapid response team and preparing for pharmacological support, such as inotropes, to improve myocardial contractility.
Cardiogenic shock is an unstable, life-threatening medical emergency that requires advanced hemodynamic interventions to restore adequate tissue perfusion.

Anahtar Kavram

Early recognition and urgent management of cardiogenic shock
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Konular

Physiological Adaptation

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