Study topic
Acute coronary syndromes
NCLEX ACS chapter: STEMI recognition and reperfusion urgency, nitroglycerin and cath-site priorities, cardiogenic shock after MI, and core cardiopulmonary assessment cues.
Acute coronary care is two skills glued together: recognize the ischemic emergency and prove you can assess perfusion and breath sounds well enough to catch the next failure early.
STEMI and unstable ischemic pain
Sudden crushing substernal pain, radiation to the arm or jaw, diaphoresis, and ST-segment elevation mean the coronary artery needs opening now. Support ABCs, keep the client on a monitor, establish IV access, and activate the reperfusion pathway (PCI when available). Adjuncts such as antiplatelet therapy, anticoagulation, and symptom drugs follow orders and allergies.
- Stable angina teaching still matters between crises: know triggers, carry nitroglycerin, and rest at the first pain.
- After MI, watch for complications: dysrhythmias, heart failure, cardiogenic shock, and pericarditis-type pain patterns later in the course.
Nitroglycerin and the cath lab aftermath
Sublingual nitroglycerin
- Sit or lie down before the dose (syncope risk).
- Place under the tongue; allow to dissolve. Do not swallow like a tablet with water.
- Repeat per the teaching plan if pain persists (commonly every 5 minutes up to 3 doses) and seek emergency care when pain does not resolve as instructed.
- Hold the nitrate plan and escalate if blood pressure is already critically low, or if the client recently used a PDE-5 inhibitor for erectile dysfunction.
Post cardiac catheterization (femoral)
Immediate priority is bleeding and limb ischemia at the access site: inspect the dressing and under the client, check distal pulses, color, temperature, and sensation, and enforce activity/bedrest limits. A soft blood pressure cuff on the same limb is not the win if the site is pouring.
When the infarct breaks the pump
Hours to a couple of days after a large MI, hypotension, tachycardia, cool clammy skin, crackles, and oliguria point to cardiogenic shock. Treat as pump failure with the ordered vasoactive and respiratory supports. Do not treat it like outpatient dehydration.
Safety
Inferior STEMI with right ventricular involvement can leave the client preload-dependent. Hypotension after nitrates in that picture needs a different response than “give more nitro for chest pain.” Follow the RV-MI fluid and nitrate caution in the orders/protocol.
Cardiopulmonary assessment that the exam still asks
| Skill | Rule |
|---|---|
| Apical pulse landmark (adult) | 5th intercostal space, left midclavicular line |
| Capillary refill | Normal roughly ≤2 seconds; several seconds delayed means poor peripheral perfusion |
| Pulse oximetry | About 95–100% is expected for most adults on room air; know the client's baseline if COPD/chronic hypoxemia exists |
| Crackles | Often fluid in small airways/alveoli (HF, pneumonia picture) |
| Expiratory wheeze | Narrowed lower airways (asthma/COPD pattern) |
| Stridor | Upper airway emergency. Act now. |
| Foot blood flow | Dorsalis pedis and/or posterior tibial pulses plus color/temp/cap refill |
| Early hypoxia | Restlessness and agitation often precede late cyanosis |
| Pericarditis cue | Positional chest pain that eases leaning forward; may hear a rub |
Priority map
| Picture | First move |
|---|---|
| Crushing pain + ST elevation | STEMI reperfusion pathway + ABCs |
| Angina + home nitro teaching | Sit, SL nitro per plan, know when to call emergency services |
| Fresh femoral cath + site risk | Site pressure/inspection + distal pulses |
| Post-MI cool clammy + crackles + low BP | Cardiogenic shock escalation |
| Stridor on assessment | Airway emergency, not routine wheeze care |
Must know
- 1Crushing substernal pain with diaphoresis and ST elevation is a STEMI pathway: ABCs, ECG already speaking, notify for emergent reperfusion (PCI preferred when available).
- 2Sublingual nitroglycerin for angina: sit/lie down, one tab under tongue, may repeat per teaching (commonly up to 3 doses 5 minutes apart) and call emergency services if pain persists as taught. Expect headache/hypotension risk; no nitrates with recent PDE-5 inhibitors.
- 3Post femoral cardiac cath: priority is the puncture site and distal limb perfusion (bleeding, hematoma, pulse, color, sensation) plus bedrest per protocol.
- 4Cardiogenic shock after MI: hypotension, tachycardia, cool clammy skin, pulmonary congestion, poor urine output. This is pump failure, not simple dehydration.
- 5Inferior MI / right ventricular involvement can present with hypotension that worsens with preload reducers. Follow the ordered fluid/nitrate caution for that picture.
- 6Apical pulse (adult): 5th intercostal space, midclavicular line (mitral area).
- 7Capillary refill: normal is usually within 2 seconds; 5 seconds is delayed perfusion.
- 8Crackles often mean fluid in alveoli. Expiratory wheeze suggests narrowed airways. Stridor is an airway emergency.
- 9Early hypoxia: restlessness/agitation often before late cyanosis. Normal SpO2 for most adults is roughly 95–100% on room air unless a different baseline is known.
- 10Foot perfusion: assess dorsalis pedis / posterior tibial pulses. Pericarditis pain often improves leaning forward and may have a rub.
Memory hooks
ST up, door to balloon
ST-elevation MI is a reperfusion clock. Nursing priorities protect airway/IV access and move the client toward PCI or the ordered reperfusion plan.
Site before sandwich
Right after femoral cath, the arterial site and distal pulses beat meal trays and casual ambulation.
Fifth midclavicular
Adult apical impulse/auscultation landmark: 5th ICS, left midclavicular line.
How it's tested
Stems show crushing pain with ST elevation, a femoral site that starts to bleed, or a basic assessment item (apical landmark, refill time, breath sound meaning). Distractors walk the fresh cath client, give nitro through profound hypotension without reassessment, or treat stridor like ordinary wheeze.