Question

A client who is in the Cardiac Care Unit complains of mediastinal chest pain, dyspnea, and anxiety. The nurse gives the client a nitroglycerine tablet sublingual. The client now complains of being dizzy. Which is the priority nursing intervention? A. Get a 12 lead ECG B. Raise the side rails on the bed C. Open the D5W IV to 100 cc per hour D. Take vital signs including pulse oximetry

Short answer

The priority nursing intervention is D. Take vital signs including pulse oximetry.

Step-by-step solution

Analyze the Client's Symptoms

Identify and understand the patient's symptoms: mediastinal chest pain, dyspnea, anxiety, and new onset of dizziness after administration of a nitroglycerine tablet sublingually. Recognize that dizziness can be a side effect of nitroglycerine and could indicate a drop in blood pressure.

Understand the Interventions

Review each intervention to determine its relevance to the patient's symptoms and the urgency of the situation. Interventions must be prioritized based on the patient's immediate needs and safety.

Prioritize Nursing Interventions

ECG helps in assessing cardiac rhythm but is not the immediate need. Raising side rails is a safety measure but secondary prevention. Adjusting IV fluids doesn't address the immediate concern. Taking vital signs including pulse oximetry provides immediate information on the client's cardio-pulmonary status and could help determine the cause of dizziness.

Key concepts

Nitroglycerine Administration

Nitroglycerine is a critical medication in managing chest pain, particularly in acute coronary syndrome. Administered sublingually, it acts quickly by dilating the blood vessels, which reduces the heart's oxygen demand and eases chest pain.

When administering nitroglycerine, the nurse must remember to check the patient's blood pressure beforehand because the medication can cause vasodilation leading to hypotension. Following administration, it is crucial to monitor the patient's response to the medication, noting the relief of chest pain and any side effects such as dizziness or headaches.

Patient Education and Monitoring

Educate the patient about potential side effects, ensuring they understand the importance of staying seated or lying down due to the risk of dizziness or fainting. Continuous monitoring of vital signs, particularly blood pressure and heart rate, is essential to detect any significant changes that might require immediate intervention.

Nursing Interventions

When a patient reports new symptoms or changes in condition, the nurse's response should be prompt and effective. Nursing interventions are actions taken to assess, monitor, and manage patient symptoms.

In the scenario where the patient experiences dizziness post nitroglycerine administration, the primary goal is ensuring the patient's safety while promptly determining the cause. In this context, the priority nursing intervention is to take vital signs, including pulse oximetry. This critical step offers immediate data about the patient's hemodynamic status and oxygen saturation, enabling the nurse to assess the impact of the medication and the severity of the patient's symptoms.

Algorithmic Approach to Symptom Management

A systematic approach to symptom assessment, such as the ABC (Airway, Breathing, Circulation) method, can help prioritize interventions. Always consider the safety and the immediate needs of the patient when choosing an intervention.

Patient Safety in Cardiac Care

Ensuring patient safety in cardiac care is a fundamental responsibility for healthcare providers. Cardiac patients are at high risk for complications due to the nature of their condition; hence, preventive measures must be employed diligently.

Among these measures is the act of raising the side rails on the bed to prevent falls, a common safety protocol when a patient is at risk of dizziness or altered mental status. Other safety interventions include regular monitoring of cardiac rhythm, maintaining access to emergency equipment, and education on the safe use of prescribed cardiac medications.

Creating a Safe Environment

In designing a safe care environment, remember to adjust the setting to the needs of the patient. This includes setting up telemetry for continuous monitoring, ensuring IV access is secure for medication administration, and providing clear instruction to the patient and family about warning signs that necessitate calling for help.