MONA or ONAM...for NCLEX?

[jujubee<3]

I have always been taught that it is oxygen first while in school, but every time I answer one of these questions on Kaplan it is always morphine. I am torn with how to answer this type of question on NCLEX. Any suggestions?

[Loo17]

Mild anxiety is actually conducive to successful studying...you get more focused under mild anxiety! Also, MONA is correct: Morphine to reduce oxygen needs of the myocardium, dilate vessels, and reduce pain/anxiety (all of which will improve oxygenation; Oxygen to provide essential needs for the myocardium and systemically; Nitroglycerin for vasodilation; Aspirin to thin blood for clot reduction. GOOD LUCK!

The order is not MONA anymore, I believe the ACS protocol changed in 2012. I made a typo in my previous post (OANM is correct) but it was too late to edit.

The current recommendations are OANM. You give oxygen if the saturation is below 94%, followed by aspirin 324mg chewable to slow platelet aggregation and reduce the risk of further occlusion or reocclusion of the coronary artery or a recurrent ischemic event.

Typically an ECG is performed at this time as well and an IV is inserted. My hospital policy states Nitro can not be given until an IV is established.

After the Aspirin, Nitro 0.4mg is given (as long as the SBP is >100). Nitro is a vasodilator that relaxes vascular smooth-muscle beds. It improves blood flow to ischemic areas. It also decreases myocardial oxygen consumption, allowing the heart to work with a lower oxygen demand. Nitro doses can be repeated every 3-5 minutes if the SBP remains greater than 100. It is always important to ensure the patient has not taken meds for erectile dysfunction prior to giving as well.

Lastly, Morphine is administered if chest pain doesn't resolve with Nitro and the BP is stable. Morphine helps with pain but also acts as a vasodilator, reducing ventricular preload and cardiac oxygen requirements. With a true MI usually the Nitro helps but the patient still has pain and is given Morphine.

Usually all of these steps happen rather quickly and I can say in the real world Morphine is never the first thing I think about when a patient presents with chest pain. I am thinking about getting them on the monitor, getting vitals, ECG, IV and labs, aspirin, nitro, then morphine. I want to know if their pain improves after the nitro or if it does nothing. If the Nitro does not help could this be a muscle strain or anxiety? How do their lungs sound? What were they doing when it started, how long ago did it start, have they had this pain before, what is their medical history? Are they diaphoretic, pale, or short of breath?

I would be really surprised if an answer on the actual NCLEX was the nurse should anticipate to give Morphine first when a patient presents with chest pain radiating to their left arm.

[springchick1, ADN, RN]

We were taught int HURST review that MONA is bi more. It's now OANM.

[chare]

Morphine first.

Also, MONA is correct.

Please provide evidence based sources for these.

Think about the time required to place a nasal cannula on the patient (which was always at every bedspace when I worked in the ED) if indicated. Then contrast this with the time required to start an IV on the patient, go the Pyxis, remove the morphine, draw it up, and then administer it. In my opinion, this is a no-brainer.

However, for the rationale whether morphine sulfate should be the first intervention. From the 2000 ECC Guidelines Part 7: The Era of Reperfusion: Section 1: Acute Coronary Syndromes (Acute Myocardial Infarction) section on morphine (emphasis added):

Although nitroglycerin effectively relieves ischemic-type chest discomfort due to ACS, it should not be used as a substitute for narcotic analgesia, which is often necessary to relieve pain associated with MI. Morphine is indicated for continuing pain unresponsive to nitrates.

And the 2005 ECC Guidelines Part 8: Stabilization of the Patient With Acute Coronary Syndromes morphine section (emphasis added):

Morphine sulfate is the analgesic of choice for continuing pain unresponsive to nitrates, and it is also effective in patients with pulmonary vascular congestion complicating ACS.

And finally, the 2010 ECC Guidelines Part 10: Acute Coronary Syndromes section on analgesia (emphasis added):

Providers should administer analgesics, such as intravenous morphine, for chest discomfort unresponsive to nitrates. Morphine is the preferred analgesic for patients with STEMI (Class I, LOE C). However, analysis of retrospective registry data raised a question about the potentially adverse effects of morphine in patients with UA/NSTEMIs…

The acronym MONA was introduced in the 2000 ECC Guidelines Part 7: The Era of Reperfusion: Section 1: Acute Coronary Syndromes (Acute Myocardial Infarction), Initial General Measures section:

…Administer morphine, oxygen, nitroglycerin, and aspirin (MONA”) to patients without contraindications. Determine the immediate treatment necessary, rapidly assess reperfusion eligibility, and administer necessary adjunctive treatments.

The intent was not to indicate a specific order of intervention, although it was frequently taught that way in ACLS by instructors who hadn't read the guidelines and were teaching only from the ACLS text. Further, these interventions were listed in the following order: Oxygen, nitroglycerin, morphine, and aspirin.

The MONA acronym was not contained in either the 2005 ECC Guidelines Part 8: Stabilization of the Patient With Acute Coronary Syndromes or the 2010 ECC Guidelines Part 10: Acute Coronary Syndromes. My suspicion, although I can't verify it, is that this was due to the confusion regarding the order in which these interventions were applied. In the 2005 ECC Guidelines the order in which these interventions was discussed was changed to the following: Oxygen, aspirin, nitroglycerin, and morphine sulfate. This order was retained in the 2010 Guidelines, however the phrasing was changed to the following: Oxygen, aspirin and nonsteroidal anti-inflammatory drugs, nitroglycerin, and analgesia.

The order is not MONA anymore, I believe the ACS protocol changed in 2012. I made a typo in my previous post (OANM is correct).

As Loo17 is correct, neither MONA nor ONAM would be correct.

Good luck on the NCLEX!

[whofan, ADN, BSN, RN]

The word always and never should be red flag, to get you to stop and think before choosing an answer.

[SongofaNurse]

At Hurst Live Review they said Oxygen Aspirin (chewable) Nitro and Morphine ...