A nurse is caring for a 45-year-old patient with a history of asthma and obesity who presents with acute chest pain and diaphoresis. Which nursing action should the nurse prioritize first?
The patient reports feeling increasingly short of breath over the past 2 days and has gained 5 pounds since the last visit. Vital signs show: BP 160/95 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air, temperature 98.6°F, and blood glucose is 380 mg/dL.
1Administer supplemental oxygen✓ 정답
2Prepare to administer insulin for hyperglycemia management
3Administer prescribed diuretic medication for fluid overload
4Administer arterial blood gas analysis to assess acid-base balance
해설
The ABCs principle guides priority setting. Oxygen saturation of 88% indicates significant hypoxemia requiring immediate intervention (administer supplemental oxygen). Other options address hyperglycemia or fluid overload but are less urgent.
Priority Assessment and Intervention in Acute Chest Pain
The nurse must prioritize the action that addresses the most immediate threat to life, following the airway, breathing, and circulation (ABC) framework. The patient presents with acute chest pain and diaphoresis, which are classic symptoms of acute coronary syndrome (ACS). The critical finding here is an oxygen saturation of 88% on room air, indicating severe hypoxemia.
Rationale for Prioritizing Oxygen Administration
Administering supplemental oxygen is the first priority because hypoxemia can worsen myocardial ischemia. The heart muscle is already under stress from a potential ACS event, and low oxygen levels further deprive the myocardium of the oxygen it desperately needs. This can lead to a larger infarction, life-threatening dysrhythmias, and cardiac arrest. Evidence-based clinical guidelines for ACS emphasize that timely and coordinated care, including immediate oxygen therapy for hypoxic patients, is crucial to improving outcomes . Delays in implementing such foundational interventions, often due to systemic barriers in the pre-examination process, can lead to poor patient outcomes [1,2]. The study on improving the pre-examination process for acute chest pain highlights that a structured, evidence-based approach from the first point of contact is vital for effective management . For this patient, correcting the hypoxemia takes precedence over the other options because it directly supports a vital function.
Why Other Options Are Not the First Priority
- Administering insulin: While a blood glucose of 380 mg/dL is significantly elevated and requires management, hyperglycemia is not an immediate threat to life in the same way that severe hypoxemia is. It is a secondary concern that can be addressed after the patient’s oxygenation and hemodynamic status are stabilized.
- Administering a diuretic: The patient’s history of weight gain, shortness of breath, and hypertension may suggest fluid overload. However, in the context of acute chest pain and diaphoresis, these symptoms could also be signs of acute heart failure secondary to a massive myocardial infarction. Administering a diuretic without first confirming the diagnosis and ensuring adequate oxygenation and perfusion could be dangerous. The priority is to stabilize the ABCs.
- Arterial blood gas (ABG) analysis: An ABG is a valuable diagnostic tool to assess acid-base balance and quantify the degree of hypoxemia. However, it is a diagnostic procedure, not a therapeutic intervention. The nurse must first treat the evident, life-threatening hypoxemia with oxygen while a provider orders the ABG. Delaying oxygen therapy to perform a diagnostic test violates the principle of prioritizing interventions over assessments when a life-threatening condition is already apparent. The systematic review on ACS guideline implementation identifies that such delays in initiating critical treatments are a key barrier to optimal patient care .
For a patient with suspected Acute Coronary Syndrome and hypoxemia (SpO2 88%), the priority is to administer supplemental oxygen. This directly addresses the life-threatening breathing compromise and prevents worsening myocardial ischemia.
Follow the ABC framework: Airway and Breathing take precedence over Circulation and secondary assessments like blood glucose or detailed diagnostics. Correcting hypoxia is the foundational intervention.
Caution
Do not delay oxygen therapy for diagnostic procedures like ABG analysis. While hyperglycemia (380 mg/dL) and fluid overload are concerns, they are not the immediate threat to life in the presence of severe hypoxemia and acute chest pain.
Hypoxemia — Abnormally low oxygen level in the blood, often defined as SpO2 < 90%, requiring immediate oxygen therapy.
ABC Framework — A systematic approach to prioritization: Airway, Breathing, and Circulation, addressing the most life-threatening issues first.
Acute Coronary Syndrome (ACS) — A spectrum of conditions involving sudden, reduced blood flow to the heart, including unstable angina and myocardial infarction.
Supplemental Oxygen — Administration of oxygen at a concentration greater than room air to treat or prevent hypoxemia and tissue hypoxia.