Question 1

What are the key nursing diagnoses for acute coronary syndrome?

Accepted Answer

The primary nursing diagnoses for ACS are acute chest pain related to reduced blood flow to the heart and ineffective breathing patterns related to pulmonary edema. These diagnoses are based on patient reports of severe, crushing chest pain that may radiate to the left arm and evidence of shortness of breath or labored breathing. Formulating accurate diagnoses guides targeted interventions to relieve pain, prevent myocardial damage, and maintain effective respiratory function.

Question 2

How should nurses position ACS patients to improve breathing and comfort?

Accepted Answer

Nurses should position ACS patients in a semi-Fowler's position at a 45-degree angle to improve chest expansion and facilitate breathing. Allowing patients to lean forward if tolerated further enhances comfort and ventilation. This positioning reduces the work of breathing and helps manage symptoms related to pulmonary edema or congestion.

Question 3

What objective assessments are essential in ACS nursing management?

Accepted Answer

Essential objective assessments include continuously monitoring vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation to detect hemodynamic instability. Nurses perform cardiovascular examinations noting abnormal heart sounds, conduct respiratory assessments for pulmonary congestion, check peripheral vascular perfusion, analyze 12-lead ECG readings, and measure cardiac biomarkers like troponins and CK-MB to confirm myocardial injury.

Question 4

What medications are commonly administered for ACS pain management?

Accepted Answer

Nitroglycerin is administered to relieve chest pain and improve blood flow to the heart. Aspirin is given as ordered to reduce platelet aggregation and prevent clot formation. Morphine may be prescribed for pain management while closely monitoring for hypotension and respiratory depression. All medications require careful vital sign monitoring and documentation of patient response.

Question 5

How do nurses manage oxygen therapy in ACS patients?

Accepted Answer

Nurses administer supplemental oxygen if oxygen saturation falls below 90 percent, maintaining a target saturation range of 90 to 94 percent. Oxygen therapy improves myocardial oxygenation and reduces ischemic injury. Nurses continuously monitor oxygen saturation levels and adjust oxygen delivery based on patient response and clinical status.

Question 6

What breathing techniques should nurses teach ACS patients?

Accepted Answer

Nurses teach diaphragmatic breathing and pursed-lip breathing techniques to improve ventilation and reduce dyspnea. Encouraging frequent deep breathing and coughing exercises helps prevent pulmonary complications and promotes gas exchange. These techniques empower patients to actively participate in their recovery and manage breathing difficulties.

Question 7

How should nurses evaluate and adjust the ACS care plan?

Accepted Answer

Nurses regularly assess patient outcomes including pain levels, respiratory function, and hemodynamic stability to evaluate care effectiveness. Based on these assessments, the care plan is modified to address changing patient needs and ensure optimal recovery. Continuous evaluation and adjustment of interventions demonstrate responsiveness to patient progress and promote evidence-based nursing practice.

תסמונת כלילית חריפה V: ניהול סיעודי

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