Physiological Adaptation Q 129
A patient arrives at the emergency department complaining of midsternal chest pain. Which of the following nursing actions should take priority?
A. A complete history with emphasis on preceding events.
B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation.
Correct Answer: C. Careful assessment of vital signs.
The priority nursing action for a patient arriving at the ED in distress is always an assessment of vital signs. This indicates the extent of the physical compromise and provides a baseline by which to plan further assessment and treatment. Monitor vital signs every 5 min during the initial anginal attack. Blood pressure may initially rise because of sympathetic stimulation, then fall if cardiac output is compromised. Tachycardia also develops in response to sympathetic stimulation and may be sustained as a compensatory response if cardiac output falls.
Option A: A thorough medical history, including the onset of symptoms, will be necessary. Identify precipitating events, if any: frequency, duration, intensity, and location of the pain. Helps differentiate this chest pain, and aids in evaluating possible progression to unstable angina.
Option B: It is likely that an electrocardiogram will be performed as well, but this is not the first priority. Monitor heart rate and rhythm. Patients with unstable angina have an increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and/or stress.
Option D: Similarly, chest exams with auscultation may offer useful information after vital signs are assessed. Observe for associated symptoms: dyspnea, nausea, and vomiting, dizziness, palpitations, desire to micturate. Decreased cardiac output (which may occur during an ischemic myocardial episodes) stimulates sympathetic and parasympathetic nervous systems, causing a variety of vague sensations that the patient may not identify as related to the anginal episode.