Medical Surgical Labs Cardiac #5

Question

Which nursing diagnosis would take priority for the client with elevated CK-MB, troponin, and myoglobin?

Answers

  1. Acute pain
    • Rationale:

      This answer is correct because it is important to assess the client’s pain, which includes the quality, location, severity, duration, onset and what relieves the pain or makes it worse. It is also imperative for the client to understand the need to report pain as soon as it starts. This can secure prompt treatment and potentially minimize damage.

  2. Fear
    • Rationale:

      This answer is not correct because it does not take priority over acute pain in the client experiencing or has experienced a heart attack. But fear is an important nursing diagnosis for any disease or illness the client is experiencing.

  3. Risk for decreased cardiac output
    • Rationale:

      This answer is not correct because decreased cardiac output does not take priority over acute pain. Acute pain can be an early indicator of decreased cardiac output.

  4. Deficient knowledge
    • Rationale:

      This answer is not correct because the first priority should be stabilizing the client’s pain and the cause of the pain since it is due from an infarction. Education on diagnosis and diagnostic procedures would be more appropriate after the client is stabilized.

Overview

Elevated CK-MB, troponin, and myoglobin are indicators of myocardial infarction (heart attack). It is important to assess the client’s pain and it’s characteristics.

Explanation

Learning Outcomes

Elevated CK-MB, troponin, and myoglobin are indicators of myocardial infarction (heart attack). It is important to assess the client’s pain and it’s characteristics, which includes the quality, location, severity, duration, onset and what relieves the pain or makes it worse. It is also imperative for the client to understand the need to report pain as soon as it starts. This can secure prompt treatment and potentially minimize damage. Acute pain can be an early indicator of decreased cardiac output. Fear is an important nursing diagnosis for any disease or illness the client is experiencing. Education on diagnosis and diagnostic procedures would be more appropriate after the client is stabilized. This will also be a helpful intervention for fear.

Test Taking Tip

These elevated biomarkers indicate a heart attack. Time is muscle. So pain is a priority, as it is an indication of damage to heart muscle with elevated biomarkers. Pain causes increased oxygen demand on the heart. Ongoing pain requires immediate intervention since it signifies prolonged myocardial damage.

Video Rationale