A. AIRWAY– Maintaining a clear airway is always considered a high priority because the airway is essential for gas exchange. However, the patient has a patent airway (Ramkumar, 2011).
The nursing strategy is to conduct an airway assessment “look, listen and feel” continuously to detect any changes. This is to provide immediate respiratory care if the patient’s airway is compromised (Higginson, Jones & Davies, 2011). This is a low priority.
B. BREATHING – Respiration is altered due to left ventricular failure. The patient is tachypnoeic due to an increased pressure in the pulmonary veins that will lead to pulmonary congestion that lessens pulmonary compliance, which raises the respiratory rate. Also, increased blood flow in the lungs can cause shallow or less effective breathing and the oxygen uptake will be inadequate, therefore the patient’s breathing is laboured (Barthel, Wensel, Bauer, Muller, Wolf, & Ulm et al., 2012). Whereas, hypoxia is due to damaged alveolar capillary interface due to inhibition of oxygen and carbon dioxide exchange. The presences of bilateral crackles are due to pulmonary congestion and collapsed alveoli caused by fluid accumulation in the lungs (Gallagher & Driscoll, 2015). The nursing strategy is to place the patient in a high fowlers position while continuously monitoring the patient’s respirations such as rate, rhythm, depth, pattern, and colour. …show more content…
This will promote chest expansion and reduced the workload of the heart. Early detection of respiratory distress will assist in emergency interventions and reduce the risk of complications (Jaffe & Cabrera, 2016). This is considered a high priority. C. CIRCULATION – The contraction of heart muscle is less effective due to necrotic tissue in the myocardium. Therefore, cardiac contractility and cardiac output is impaired. There is a progressive ischaemia because the oxygenated blood is unable to impel in the myocardium due to the damaged ventricle (Wagner & Hardin-Pierce, 2014). The heart will compensate for decreased cardiac output from the failing ventricle. Therefore, tachycardia will develop as an effect of sympathetic stimulation while hypotension is due to compromised coronary flow (Bucher, Johnson & Rolley, 2015). The increased SNS stimulation creates vasoconstriction, which will prolong the capillary refill and the extremities will be cool, clammy and mottled due to reduced tissue perfusion (Bucher et al., 2015). The increased JVP indicates fluid overload due to left ventricle failure and pulmonary oedema. Peripheral pulses are rapid and faint because of the decreased circulation and tachycardia. Bilateral ankle oedema is caused by accumulation of fluid and reduces blood flow out of the heart. The 3rd heart sounds indicate left ventricular dysfunction and the rapid filling of the ventricle. The temperature of 37.5°c is a systemic manifestation of the inflammatory process caused by myocardial cell death (Bucher et al., 2015). The nursing strategy is to assess the patient’s cardiac and hemodynamic status through monitoring the arterial line, ECG, and fluid status. Immediate detection of complications is essential to minimise the risk and maintain hemodynamic stability (Jones & Rushton, 2012). This is a medium priority. D. DISABILITY – The patient’s GCS is normal and she is orientated to person, time and place. However, she is anxious and restless these are associated with persistent chest pain. Anxiety increases when there is a stimulation of sympathetic nervous system and decreased cerebral oxygenation (Bucher et al., 2015). The nursing strategy is to stay with the patient and encourage verbalization of feelings that will create reduction of anxiety. Monitor the characteristics of pain because this will assess the effectiveness of the treatment (Bucher et …show more content…
The PaO2 is low because less oxygen is dissolved in the blood and signifies hypoxemia. The PaCO2 is normal, which means the amount of carbon dioxide gas dissolved in the blood is adequate and represents the effectiveness of ventilation. This is evident by increased respiratory rate of the patient. A low HCO3 indicates acidosis in the metabolic component. The base excess is higher than the normal range, which suggests a metabolic cause. An elevated lactate indicates lactic acidosis as a result of tissue hypoxia as evidence by decreased in systemic blood flows (Ringdal & Gullick, 2015). Therefore, the patient has metabolic acidosis due to an injury to the myocardium that caused a decreased in cardiac output, tissue hypoxia, and low bicarbonate due to rise in lactic acid Also, it is uncompensated as per the PaCO2 is normal (Gandhi & Akholkar,