# A 58-year-old patient is admitted to the coronary care unit with an acute ST-elevation myocardial infarction. What is the priority nursing intervention?

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## 문제

A 58-year-old patient is admitted to the coronary care unit with an acute ST-elevation myocardial infarction. What is the priority nursing intervention?

## 보기

1. Administer prescribed morphine for chest pain relief
2. Increase oxygen flow rate to 4L nasal cannula
3. Assess for signs of cardiogenic shock and notify physician immediately **✔ 정답**
4. Provide emotional support and anxiety reduction techniques

**정답: 3**

## 해설

Post-PCI STEMI patients with hemodynamic instability and hypoxemia are at high risk for cardiogenic shock, requiring immediate assessment and physician notification. Other options (pain relief, oxygen, emotional support) are important but secondary to life-threatening complications.

## 심화 해설

Clinical Context: STEMI in the Coronary Care Unit

A patient presenting with an acute ST-elevation myocardial infarction (STEMI) is experiencing a complete thrombotic occlusion of a major coronary artery. The immediate therapeutic goal is rapid reperfusion, typically via primary percutaneous coronary intervention (PCI). The American Heart Association emphasizes that a well-coordinated system of care is critical, where minimizing delays from first medical contact to device activation directly reduces morbidity and mortality [4]. While the patient is in the coronary care unit (CCU) awaiting or preparing for catheterization, the nurse's primary responsibility shifts from initial triage to vigilant monitoring for life-threatening complications.

Priority Intervention Analysis

The question asks for the *priority* nursing intervention. Using the ABC (Airway, Breathing, Circulation) framework and the nursing process, assessment must precede implementation, except in cases where a life-threatening condition is immediately evident. In a STEMI patient, the most immediate circulatory threats are lethal arrhythmias, acute pump failure, and cardiogenic shock. Therefore, continuous assessment to detect early signs of hemodynamic deterioration is the foundational step upon which all other interventions depend. Studies on optimizing care for acute chest pain patients highlight that structured, evidence-based nursing processes—which prioritize rapid assessment and monitoring—significantly improve rescue success rates and reduce adverse reactions [2]. A critical part of this assessment is identifying signs of cardiogenic shock, a state of profound tissue hypoperfusion resulting from the heart's inability to pump effectively. Early detection and immediate physician notification can trigger life-saving interventions like inotropic support or emergency revascularization, which is the core of the "systems of care" approach for STEMI [4].

While administering morphine (Option 1) and providing emotional support (Option 4) are important comfort measures, and adjusting oxygen (Option 2) is a supportive action for hypoxia, none of these address the potential for rapid clinical deterioration. A patient can appear stable one moment and decompensate into a lethal rhythm or profound shock the next. The nurse must first establish a baseline and continuously reassess circulatory status. The concept of continuous improvement in pre-examination processes for chest pain underscores that systematic, evidence-based assessment protocols are fundamental to effective management . Similarly, systems designed to reduce false cardiac catheterization laboratory activations rely on precise clinical assessment to ensure appropriate and timely team mobilization without compromising patient safety . This reinforces that accurate, ongoing assessment is the bedrock of safe and effective care in the hyperacute STEMI period.

The nurse's immediate priority is to assess for signs of cardiogenic shock—such as hypotension (systolic BP less than 90 mmHg), altered mental status, cool and clammy skin, oliguria, and tachycardia—and to notify the physician immediately. This assessment directly informs the next steps in the patient's critical care pathway and aligns with the highest priority of preventing irreversible end-organ damage and death.

References (research sources)

- [2]Effects of optimizing emergency nursing care process on success rate of rescue and incidence of adverse reactions in patients with acute chest pain.Research articleZhu H, Ding D. (2025) · DOI: 10.3389/fmed.2025.1727151

- [4]Systems of Care for ST-Segment–Elevation Myocardial Infarction: A Policy Statement From the American Heart AssociationResearch articleAlice K. Jacobs, Murtuza J. Ali, Patricia J. Best, Mark C. Bieniarz, Vincent J. Bufalino, William J. French (2021) · DOI: 10.1161/cir.0000000000001025

## 임상 시나리오

STEMI Monitoring in the CCUPrioritizing Assessment for Hemodynamic Collapse
For a patient with an acute STEMI, the priority nursing action is continuous assessment for complications, particularly cardiogenic shock. This aligns with the nursing process where assessment must precede intervention.

Key assessment parameters include frequent monitoring of blood pressure (looking for systolic BP < 90 mmHg), heart rate, urine output (< 30 mL/hour), and signs of peripheral hypoperfusion such as cool, clammy skin and altered mental status.

CautionDo not delay physician notification if signs of shock develop. While pain management and emotional support are important, they are secondary to detecting and reporting a life-threatening circulatory crisis. Routine supplemental oxygen is not indicated unless the patient is hypoxemic.

## 핵심 개념

- **Cardiogenic shock** — A state of end-organ hypoperfusion due to cardiac pump failure, often following a STEMI, characterized by hypotension, altered mental status, oliguria, and cool extremities.
- **ST-elevation myocardial infarction (STEMI)** — A severe heart attack caused by a complete thrombotic occlusion of a coronary artery, resulting in transmural myocardial ischemia and injury.
- **Hemodynamic surveillance** — Continuous monitoring of blood pressure, heart rate, and perfusion status to detect early signs of decompensation such as cardiogenic shock.
- **Reperfusion therapy** — Emergent treatment to restore blood flow to the blocked coronary artery, typically via percutaneous coronary intervention (PCI) or thrombolytics.
- **End-organ hypoperfusion** — Inadequate blood flow to vital organs, manifesting as altered mental status, decreased urine output, and cool, clammy skin.

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