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Zorluk: ZorPhysiological Adaptation

A nurse in the coronary care unit is caring for a client admitted with an acute inferior wall ST-segment elevation myocardial infarction (STEMI) with right ventricular involvement. The client is restless, diaphoretic, and reports substernal chest pain rated 7 on a 0 to 10 scale. Current vital signs are blood pressure 80/52 mm Hg, heart rate 112 beats/minute, and respiratory rate 20 breaths/minute. Lung sounds are clear bilaterally, and marked jugular venous distention is present. Which of the following prescribed interventions should the nurse implement first?

  1. Administer an intravenous bolus of 0.9% sodium chloride.Cevap
  2. B
    Administer sublingual nitroglycerin to relieve the chest pain.
  3. C
    Administer intravenous furosemide to decrease cardiac workload.
  4. D
    Administer intravenous morphine sulfate to reduce sympathetic tone.

Cevap

Administer an intravenous bolus of 0.9% sodium chloride.
The correct intervention focuses on maximizing preload. A right ventricular myocardial infarction impairs the right ventricle's ability to contract. To compensate, the heart relies on a higher venous pressure (preload) to passively push blood through the right side of the heart, into the lungs, and ultimately to the left ventricle. Administering an isotonic fluid bolus provides the necessary volume to increase this pressure and improve cardiac output, reversing the hypotension.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has an inferior wall STEMI with right ventricular involvement, exhibiting severe hypotension, clear lungs, and jugular venous distention.
Identifying the specific pathophysiology of the myocardial infarction is critical, as right ventricular involvement requires a completely different treatment approach than left ventricular failure.
2
Determine the physiological requirements of the right ventricle during an infarction.
The damaged right ventricle relies on high filling pressures (preload) to act as a passive conduit and maintain blood flow to the left side of the heart.
Understanding altered hemodynamics allows the nurse to anticipate which interventions will support or harm the client's cardiac output.
3
Evaluate how each option affects preload.
Nitroglycerin, furosemide, and morphine all decrease preload. Isotonic sodium chloride increases preload.
Medications typically used in the standard 'MONA' protocol for myocardial infarctions can be lethal in this specific condition due to their preload-reducing properties.
4
Select the priority intervention.
Administering the intravenous bolus of 0.9% sodium chloride is the priority to stabilize the client's hemodynamics.
Correcting the severe hypotension and restoring adequate right ventricular preload must take precedence over pain management in this critical situation.

Anahtar Kavram

Hemodynamic Management in Right Ventricular Myocardial Infarction
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Konular

Physiological Adaptation

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