Priority Nursing Action Question HELP!!

  1. I'm studying for an exam, and I can't find a definitive answer for:

    What is the Priority Nursing action for a patient with aortic aneurysm who presents with sudden severe chest pain?

    administer pain meds

    start 2 large bore IV's

    draw serum cardiac biomarkers

    obtain an electrocardiogram

    One of my nclex books says pain meds, but my nursing2006 magazine article infers that it's the IV's.

    Thanks.
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  2. 12 Comments

  3. by   Jolie
    Think of your ABCs.

    Is this patient's airway compromised? No

    Is the patient's breathing compromised? Not yet, but probably soon will be.

    Is this patient's circulation compromised? It will be imminently. Sudden, severe chest pain in a patient with a known aortic aneurysm most likely indicates rupture of the aneurysm. Massive internal bleeding is now occuring, and immediate access to multiple IV sites is imperative to prevent circulatory collapse while you prepare the patient to go to the OR.

    Don't fret about pain meds at this point. Your patient will be unconscious in a matter of seconds and won't complain about pain.
  4. by   jayjaykay
    Thanks Jolie,

    You really put it in perspective for me ----

    Jamie
  5. by   jayjaykay
    Jolie,

    Would the priority be the same if the patient had no aneurysm? Just presents with severe chest pain?

    Jamie
  6. by   NurseguyFL
    I would not choose pain meds as the primary intervention for that patient, for the reason already stated by Jolie. The question and answer options would be worded differently if the examiners were expecting an answer other than the one to obtain IV access, as would be the nursing priority.

    If the question had stated acute chest pain in a 47 year old man, and didn't mention anything else, you will immediately begin to think of angina or MI, and your answer options might look something like: MONA, EKG, cardiac markers, or get IV access. You will eventually do all of these things but the first intervention would be MONA because the likely cause of the chest pain is blockage of one of the coronary arteries (another clue would be that the man is at age where angina and MI are typical in people with advancing atherosclerosis). You want to prevent tissue hypoxia and cell death so the most urgent priority is to give nitrates for systemic vasodilation and supplemental O2 to facilitate better tissue perfusion. The nursing priority changes according to the symptoms that the patient presents with.
  7. by   Jolie
    OK, now it's your turn to teach me.

    I assume MONA is an acronym for interventions in suspected MI patients. My guess is that M=monitor, O=oxygen, N=nitroglycerin, A=aspirin.

    How is this old NICU nurse doing?
  8. by   NurseguyFL
    You did great!

    The M = morphine
  9. by   AnnieOaklyRN
    priorty for chest pain patient would be oxygen. ABC.

    Swtooth
  10. by   NurseguyFL
    Quote from swtooth
    priorty for chest pain patient would be oxygen. ABC.

    Swtooth

    Yes, and oxygen is a part of MONA.
  11. by   jayjaykay
    SO, would it be oxygen or morphine FIRST?

    jamie
    student nurse
  12. by   epipusher
    O2 First. Never lose sight of the ABC's. Many doc's want a 12 lead baseline EKG before you start giving meds.
  13. by   NurseguyFL
    Chest pain protocol is that you would put O2 on the patient first. Chest pain r/t ACS is a circulatory issue because it results from blockage of the coronary arteries. However, it is hypoxic injury to the cells and tissues thats causing the pain, so you FIRST want to increase the oxygenation of the patient's blood. Oxygenation is always the first priority---no matter what else is going on with the patient. Remember the ABCs and you'll always get the right answer.

    Morphine is never the first consideration. It is given after nitro, to relieve pain and to help relax the patient so that cardiac workload and oxygen consumption are reduced. The acronym MONA is just to help students remember the elements of the chest pain protocol. There are other steps, but many times the order in which they are implemented depends on the patient's history (if known) and presentation, as well as the ER physicians orders. For example, you need to get baseline vitals before you give nitro or morphine because it may not be safe to give either of them. You also have to question the patient about recent use of PDE5 inhibitors like Viagra, because if he tells you he just took a dose you can't give him nitro. And, if the patient tells you he once had an allergic reaction to morphine you can't give that either.
    Last edit by NurseguyFL on Feb 19, '07
  14. by   AnnieOaklyRN
    um, yeah thanks NurseguyFL, I know what MONA stands for! I was meaning that out of all of those things oxygen would be the FIRST drug!

    Jayjaykay, oxygen would be first!

    Swtooth

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