A 47-year-old male is admitted with an acute myocardial infarction. He is cold & clammy and has severe sub-sternal chest pain with dyspnoea. Which of the following interventions nurse will implement on a priority basis?

1. A

   Administer adrenaline intra-cardiac

2. B

   Provide a light blanket

3. C

   Place the patient in semi-fowler position

4. D

   Administer morphine by slow IV push

Appeared in: AIIMS Bhatinda NO - 2019

Explanation

• The priority is to relieve the severe chest pain, as pain significantly increases cardiac workload and oxygen demand, which can extend the area of infarction.
• Morphine is the drug of choice for severe pain in MI.
• It acts as a potent analgesic and an anxiolytic, reducing patient distress.
• Morphine also causes venodilation, which decreases venous return to the heart (preload), and some arterial dilation, which reduces the pressure the heart pumps against (afterload).
• These hemodynamic effects collectively decrease the oxygen demand of the heart muscle, helping to limit infarct size.

Why Other Options Were Wrong

• Option A: Intra-cardiac adrenaline (epinephrine) is a potent vasoconstrictor and cardiac stimulant. It is used during cardiac arrest (asystole, pulseless electrical activity), not for a conscious patient with chest pain. Administering it would dangerously increase heart rate, blood pressure, and myocardial oxygen demand, worsening the MI.
• Option B: Providing a blanket addresses the symptom of feeling cold and clammy, which is due to sympathetic stimulation and peripheral vasoconstriction. While it is a valid comfort measure, it is not a life-saving priority and does not address the underlying cause of the MI or prevent further cardiac damage.
• Option C: Placing the patient in a semi-Fowler's position is a correct and beneficial intervention that helps ease dyspnoea by allowing for better lung expansion. However, it is not the highest priority compared to managing the severe pain that is actively increasing myocardial oxygen demand and worsening the infarction.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Priority nursing interventions in acute myocardial infarction (MI) to guide bedside assessment, documentation, and the next nursing action.
• Rapid assessment and management of chest pain in a patient with suspected MI is a critical nursing responsibility. Delay in pain relief can lead to increased myocardial damage and poorer outcomes.
• Nurses must be proficient in the MONA protocol (or similar institutional guidelines) and understand the rationale and contraindications for each medication.
• What if? If the patient's systolic blood pressure was less than 90 mmHg, morphine and nitroglycerin would be used with extreme caution or may be contraindicated, as their vasodilatory effects could cause profound hypotension. In such a case, the priority might shift to stabilizing blood pressure while still addressing oxygenation.

How to Approach the Question

• First, identify the patient's diagnosis: Acute Myocardial Infarction (MI).
• Next, analyze the key symptoms: severe chest pain, dyspnoea, and signs of shock (cold, clammy). The question asks for the priority intervention.
• Recall the standard immediate treatment for MI, often remembered by the mnemonic MONA (Morphine, Oxygen, Nitrates, Aspirin).
• Evaluate each option based on its ability to address the most life-threatening aspect of the current presentation. Severe pain in MI is not just a symptom; it drives up cardiac workload and worsens the infarction.
• Compare the high-priority interventions. While positioning (Semi-Fowler's) helps with breathing, pharmacological pain relief with morphine has a more direct and profound effect on reducing myocardial oxygen demand.
• Eliminate options that are clearly incorrect or non-priority. Intra-cardiac adrenaline is for cardiac arrest, and a blanket is a comfort measure. This leaves morphine and positioning as the most plausible options, with morphine being the higher priority for severe pain.

Concept Tested & Keywords

• Concept Tested: Priority nursing interventions in acute myocardial infarction (MI).
• Stem keywords: acute myocardial infarction, cold & clammy, severe sub-sternal chest pain, dyspnoea, priority basis
• Lead-in keywords: priority basis
• Clinical cues: The combination of severe chest pain and dyspnoea in a patient with acute MI indicates significant myocardial ischemia and stress, requiring immediate intervention to reduce cardiac workload.

Question ID

QSi-UR2LPuwhSlpg-8C728

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 2 p. 22-24

E6 Medicine Davidson Principles Practice 24e p. 518-520