Please identify the following heart rhythm:

Choice A rationale:

While educating the patient about the pathophysiology of acute coronary artery disease (ACAD) is important, it is not the priority intervention during an acute episode.

The patient is likely experiencing significant discomfort and anxiety, and their ability to process information may be impaired.

Providing immediate relief of symptoms and stabilizing the patient's condition take precedence over education at this time.

Choice B rationale:

Supplemental oxygen may be beneficial for patients with ACAD, but it is not the highest priority intervention.

Oxygen therapy can improve oxygen saturation levels in the blood, but it does not directly address the underlying issue of coronary artery occlusion.

It is important to administer nitroglycerin first to dilate the coronary arteries and improve blood flow to the heart muscle.

Choice C rationale:

Sublingual nitroglycerin is a vasodilator that relaxes and widens blood vessels, improving blood flow to the heart muscle.

It is a first-line medication for the treatment of acute angina (chest pain) and is often used in the setting of ACAD.

Nitroglycerin can rapidly relieve chest pain and other symptoms of ischemia, such as shortness of breath, and can help prevent further damage to the heart muscle.

Choice D rationale:

Staying with the patient to decrease anxiety is important, but it is not the priority intervention.

While providing emotional support can help to calm the patient and reduce stress, it does not directly address the underlying issue of myocardial ischemia.

It is crucial to administer nitroglycerin to dilate the coronary arteries and improve blood flow to the heart muscle.

Rationale for Choice A:

Monitoring the insertion site for hematoma and bleeding is crucial following cardiac angiogram with stent placement. Here's a detailed explanation:

Vascular Injury: The procedure involves accessing a major artery, usually the femoral artery in the groin. This creates a risk of bleeding or hematoma formation at the puncture site.

Anticoagulation: Patients often receive anticoagulant medications during and after the procedure to prevent blood clots from forming around the stent. These medications can increase the risk of bleeding.

Early Detection and Intervention: Prompt identification of bleeding or hematoma formation is essential to prevent complications such as hypotension, shock, or compartment syndrome.

Assessment: Regular assessment of the insertion site includes:

Visual inspection for swelling, bruising, or active bleeding.

Palpation for tenderness, firmness, or expanding hematoma.

Monitoring vital signs for tachycardia, hypotension, or signs of shock.

Interventions: If bleeding or hematoma is detected:

Apply direct pressure to the site.

Notify the healthcare provider immediately.

Implement additional measures as prescribed, such as reversal of anticoagulation or surgical intervention.

Rationale for Choice B:

Maintaining strict bedrest after cardiac angiogram with stent placement is no longer routinely recommended. Here's why:

Early Ambulation Benefits: Research has shown that early ambulation (usually within 6-8 hours) is associated with several benefits, including:

Reduced risk of deep vein thrombosis (DVT)

Improved circulation

Quicker recovery

Shorter hospital stays

Individualized Assessment: The decision regarding ambulation timing should be individualized based on patient factors such as:

Bleeding risk

Procedural complications

Overall health status

Comfort level

Balanced Approach: While early ambulation is encouraged, it's important to balance activity with rest to promote healing and prevent complications.

Rationale for Choice C:

Monitoring for dysrhythmias is essential following cardiac angiogram with stent placement due to several reasons:

Cardiac Irritation: The procedure involves manipulation of catheters and devices within the heart, which can potentially irritate the heart's electrical system.

Electrolyte Imbalances: Contrast dye used during the procedure can cause electrolyte imbalances, which can also trigger dysrhythmias.

Underlying Heart Disease: Patients undergoing angioplasty often have underlying heart disease, which already predisposes them to rhythm disturbances.

Early Detection and Intervention: Prompt identification of dysrhythmias allows for timely interventions to prevent hemodynamic instability, heart failure, or cardiac arrest.

Continuous Monitoring: Continuous ECG monitoring is typically used to detect dysrhythmias, and patients are closely observed for symptoms such as palpitations, lightheadedness, or chest pain.

Rationale for Choice D:

Assessing heart sounds is a crucial nursing intervention following cardiac angiogram with stent placement. Here's why:

Stent Placement Effects: The placement of a stent can alter blood flow patterns within the coronary arteries, which may be audible as changes in heart sounds.

Complication Detection: Heart sounds can provide valuable clues about potential complications such as:

Pericardial effusion (fluid around the heart)

Myocardial infarction (heart attack)

Valvular dysfunction

Baseline Assessment: It's important to establish a baseline assessment of heart sounds prior to the procedure to compare with post-procedure findings.

Regular Auscultation: Regular auscultation of heart sounds should be performed to monitor for changes and promptly report any concerns to the healthcare provider.