What order to give MONA?

[xmilkncookiesx]

I am studying MI and I've been told different ways to give MONA. I went onto ACLS site and although it says MONA isn't given the way it looks, it doesn't provide the actual steps.

Here is what my critical thinking is if a patient came into the ED. and please correct me if I'm wrong:

Patient comes in c/o CP. The patient is diaphoretic, SOB, nauseated, radiating pain to jaw, neck, arm (all left side).

I would assess them (full cardiac assessment, and respiratory assessment), ask OPQRST questions, then put an EKG on them and maintain it, start IV line, then as per order slap O2 on them, administer ASA (chew and swallow), nitro (SL), morphine, then if theres any other standing orders like a BB or heparin, administer those as well.

I feel like I may have something wrong??

[MunoRN, RN]

It's not the heparin as much as the streptokinase ( breaks up clots) which can result in a large bleed. Generally you don't want punctures in non compressible sites.

If you troponins increased, I would call the doctors. By the time the troponins results come back, your patient should already be getting prepped for Cath lab or receiving streptokinase, so they might not do a ting further. If the patient is still having chest pain despite interventions, I would also alert the doc. As long as it isn't a contraindication to nitro (inf MI c right sided involvement/viagra/cialis etc) try might put on a nitro infusion.

If the patient is a known stroke and being treated, the docs probably won't do much. However, a new elevated trop will result in an ecg, Asa, a cxr, etc.

Are there places that are still using streptokinase to treat an MI?

[JKL33]

This is what I do (assuming I'm working from a protocol)

1) Put on monitor, obtain and review 12-lead, start IV, apply oxygen if indicated (hopefully some things can be done simultaneously)

2) Give the ASA if no clear contraindication; chew and swallow

3) Only give nitro if it is desired by provider on a patient-specific basis (12-lead has been reviewed, contraindications such as PDEI use has been assessed, etc)

4) Give morphine if indicated on a case-by-case basis.

[psu_213, BSN, RN]

So would it be best to start 2 IV lines, since heparin might be given, and then to draw blood?

Personally, I would only start one IV if the pt has an EKG that does not show STEMI. In that case, I would only start a 2nd line if I needed it. People's veins can only tolerate so many IVs before the good veins are ruined. Generally speaking, I am not a fan of starting multiple IVs "just in case."

Now, if the pt's EKG showed STEMI or the pt was otherwise unstable, then I would start more than 1 line.

[LovingLife123]

Are you in real world or nursing school world?

[nursinghealth]

Thanks for clarifying.

I should have quoted the post I was responding to that asked what she should do in the following scenario:

"If the troponin levels are elevated, what do I do? I know its elevated when there is CP and indicates that there has been some injury/damage to the heart. Would I call the MD and get orders on what to do?"

[nursinghealth]

Sorry guys, I'm new to replying on these boards and I'm not using the quote function correctly. Eeek.

[nursinghealth]

This is what I do (assuming I'm working from a protocol)

1) Put on monitor, obtain and review 12-lead, start IV, apply oxygen if indicated (hopefully some things can be done simultaneously)

2) Give the ASA if no clear contraindication; chew and swallow

3) Only give nitro if it is desired by provider on a patient-specific basis (12-lead has been reviewed, contraindications such as PDEI use has been assessed, etc)

4) Give morphine if indicated on a case-by-case basis.

This is how it works on our floor. Morphine is only given if pain relief is not achieved with Nitro, and Nitro is only given if not contraindicated based on the results of the EKG.

[akulahawkRN, ADN, RN, EMT-P]

Here's how I would do this, generally speaking:

1) Obtain history while getting vital signs, O2 if SpO2

2) Obtain 12-lead EKG, take quick look at it myself and pass off to MD.

3) Give patient aspirin if not contraindicated by actual allergy.

4) Consider sublingual nitro if BP sufficiently high and no sign of RVI.

5) Obtain IV access and draw labs if not already done

6) Consider 2nd SL nitro after VS done and 3rd if not effective and VS OK

7) administer opiate for pain relief if VS ok.

8) Begin preparation to transfer out of cath lab

9) Administer any other meds as ordered by MD, such as Heparin or tPA.

10) remember to breathe...

Funny thing is most of the stuff up to #7 can be done in the field... and I've done those in the field (except labs).

[Guest374845]

Yeah, not everyone with chest pain needs or should receive nitro. An inferior or RV infarct will not be very receptive to that. And what clinically looks like an MI can turn out to be things like a thoracic AA or PE, so don't bias yourself into treating a heart attack that hasn't even been differentiated.

[JKL33]

This is what I do (assuming I'm working from a protocol)

1) Put on monitor, obtain and review 12-lead, start IV, apply oxygen if indicated (hopefully some things can be done simultaneously)

2) Give the ASA if no clear contraindication; chew and swallow

3) Only give nitro if it is desired by provider on a patient-specific basis (12-lead has been reviewed, contraindications such as PDEI use has been assessed, etc)

4) Give morphine if indicated on a case-by-case basis.

I feel I've been a little negligent here and would like to correct myself for the sake of newer nurses who may read this thread.

If you are indeed working from a protocol or standing orders, you wouldn't make any adjustments to that protocol/standing order that were not yours to make. In my setting I can discuss the course of care with the provider face-to-face. If we make patient-specific adjustments, I indicate this through official order mechanisms, either noting "not desired by provider" or "cancelled by Dr. X" or similar. So when I say that I give nitro and morphine on a case-by-case basis, that determination is ultimately decided by the provider, although I may be the one to initially suggest that which seems appropriate (say, if I've assessed the patient before the provider has).

Didn't want anyone to get the idea that you can just pick and choose when working with a protocol unless the protocol itself lays out parameters. Thanks!