a case study on non ST elevation MI ( NSTEMI)

a case study on non ST elevation MI ( NSTEMI)

• 1.
  A CASE STUDYON NON-ST- ELEVATION MYOCARDIAL INFARCTION (NSTEMI)
• 2.
  LEARNING OUTCOME By theend of this presentation, the learner will be able to: •Define Non-ST-Elevation Myocardial Infarction (NSTEMI) •Describe the pathophysiology and clinical presentation of NSTEMI •Analyze a patient case using a systematic nursing assessment •Apply appropriate nursing theories to patient care •Identify and prioritize nursing diagnoses and interventions •Discuss medical and nursing management for NSTEMI •Evaluate patient outcomes and formulate a discharge plan
• 3.
  INTRODUCTION:  NSTEMI isa type of acute coronary syndrome (ACS) caused by partial blockage of a coronary artery.  Partial occlusion leads to myocardial ischemia and injury but does not cause ST-segment elevation on ECG, unlike STEMI.  Myocardial injury is detected through elevated cardiac biomarkers (e.g., troponins).  It presents with chest pain, often radiating to the left arm or jaw, along with symptoms like SOB, nausea, and sweating.  Immediate treatment includes antiplatelet therapy, anticoagulants, and sometimes PCI to restore blood flow.
• 4.
  DEFINITION : “Non–ST-Elevation MyocardialInfarction (NSTEMI) is a type of acute coronary syndrome characterized by myocardial cell death due to prolonged ischemia, without persistent ST-segment elevation on electrocardiogram, but with elevated cardiac biomarkers such as troponins.” (Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition 2021)
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  INCIDENCE Globally: NSTEMI accounts forover 60% of acute coronary syndrome (ACS) cases (American Heart Association, 2023) UAE: Cardiovascular diseases are the leading cause of death, with about 40% of total mortalities (Ministry of Health and Prevention, UAE – MOHAP, 2022)
• 7.
  Significance of theStudy in Care Delivery: Early recognition of NSTEMI symptoms reduces complications and improves survival. 1 Nurses are vital in ECG monitoring, chest pain management, and risk factor education. 2 Increased NSTEMI admissions demand enhanced clinical judgment and evidence- based practice from nursing staff. 3
• 8.
  ASSESSMENT : HEALTH HISTORY Personal Data: Age:65 years Gender: Male Marital Status: Married Occupation: Retired school teacher Chief Complaint: Chest pain radiating to left arm Shortness of breath Sweating and nausea
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  HEALTH HISTORY (CONT…) Historyof Present Illness: Pain started 3 hours before ER visit Pressure-like pain, non-pleuritic Relieved partially by GTN 🩺 Past Medical History: Hypertension × 10 years Type 2 Diabetes Mellitus × 8 years Dyslipidemia
• 10.
  COLD SPA forPain Assessment (NSTEMI) C (Character): The pain is pressure-like and squeezing, located in the chest and radiates to the left arm. O (Onset): The pain started 3 hours ago before the patient arrived at the ER. L (Location): The pain is substernal, radiating to the left arm. D (Duration): The pain is continuous but partially relieved by GTN. S (Severity): The pain intensity is 7/10, moderate to severe. P (Pattern): The pain worsens with physical activity and stress, relieved partially by GTN. A (Associated Symptoms): The patient also experiences shortness of breath, sweating, and nausea.
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  HEALTH HISTORY (CONT…) FamilyHealth History: •Father: MI at 70 •Mother: Diabetic & hypertensive
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  HEALTH HISTORY (CONT…) Smoking:Former smoker – quit 5 years ago (or you can specify duration if known) Physical activity: Leads a sedentary lifestyle, minimal exercise Alcohol use: No history of alcohol consumption
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  PHYSICAL EXAMINATION 🧍 General Appearance: Alertand oriented to time, place, and person Mild distress due to chest pain Diaphoretic (sweaty) ❤️Cardiovascular: Blood Pressure: 150/90 mmHg Heart Rate: 102 bpm, regular rhythm No murmurs, gallops, or rubs Peripheral pulses palpable but slightly weak Capillary refill: <2 seconds
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  Physical Examination (cont…) • Chest pain(pressure-like, radiating to left arm) • Palpitations • Shortness of breath on exertion • No syncope or peripheral edema Cardiovascular: Respiratory: Respiratory Rate: 22 breaths/min • No crackles or wheezing • Mild shortness of breath Breath sounds: Clear bilaterally
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  Physical examination (cont…) • Nausea associatedwith chest pain • No vomiting, abdominal pain, or changes in bowel habits Gastrointestinal: • Alert and oriented • No dizziness, headache, or visual disturbances Neurological: • Poor glycemic control (based on diabetes history) • No signs of thyroid dysfunction Endocrine:
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  Developmental Theory: Erikson’sPsychosocial Stages Erikson’s Stage for Older Adults (65+ years): 🧠 Integrity vs. Despair •Older adults reflect on life and either feel a sense of satisfaction (integrity) or regret (despair). Application to Case Study (65-year-old male) •The patient may experience fear, anxiety, or regret following the cardiac event. •Nurse’s role: Support emotional well-being, encourage positive reflection, promote health goals, and involve family for psychosocial support.
• 17.
  Anatomy and Physiology (CardiovascularSystem)
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  HEART:  The heartis a muscular, hollow organ located in the thoracic cavity, between the lungs.  It functions as a pump to circulate blood throughout the body, supplying oxygen and nutrients to tissues.  The heart has four chambers: right atrium, right ventricle, left atrium, and left ventricle.  Valves between chambers ensure unidirectional blood flow and prevent backflow.  The heart works through a cardiac cycle of systole (contraction) and diastole (relaxation).  Electrical impulses from the SA node coordinate heartbeats.  It plays a central role in both systemic and pulmonary circulation.
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  Anatomy of theHeart: The Heart has four chambers: • Right Atrium (RA): Receives deoxygenated blood from the body. • Left Atrium (LA): Receives oxygenated blood from the lungs. • Right Ventricle (RV): Pumps blood to the lungs for oxygenation. • Left Ventricle (LV): Pumps oxygen-rich blood to the body through the aorta.
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  BLOOD SUPPLY TO THE HEART LeftCoronary Artery (LCA): Divides into: • Left Anterior Descending (LAD): Supplies anterior wall of the left ventricle ▪ Interventricular septum ▪ Apex of the heart ▪ • Left Circumflex Artery (LCx): Lateral and posterior walls of the left ventricle ▪ Left atrium ▪ Right Coronary Artery (RCA): Supplies: • Right atrium and right ventricle • Inferior part of the left ventricle • SA node (in 60% of people) • AV node (in 85% of people)
• 21.
  Coronary Arteries: The heartrequires a continuous supply of oxygenated blood to function effectively. The coronary arteries are responsible for delivering oxygen to the heart muscle (myocardium). 1.Left Coronary Artery (LCA): 1.Splits into the Left Anterior Descending (LAD) and Left Circumflex (LCx) arteries. 2.LAD is crucial in supplying the anterior wall of the left ventricle. 2.Right Coronary Artery (RCA): 1.Supplies the right atrium, right ventricle, and inferior portion of the left ventricle.
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  LAD occlusion Anteriorwall → infarction RCA occlusion Inferior wall → infarction LCx occlusion Lateral wall infarction →
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  DISEASE CONDITION
• 24.
  Non-ST-Elevation Myocardial Infarction(NSTEMI) is a type of acute coronary syndrome (ACS) caused by partial blockage of a coronary artery, resulting in reduced blood flow to the heart muscle. It leads to myocardial ischemia and injury without ST-segment elevation on the ECG, but is confirmed by the presence of elevated cardiac biomarkers, such as troponin.
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  RISK FACTORS : GENERALRISK FACTOR PRESENT CASE STUDY DETAILS AGE ✅ YES 65 YEARS OLD MALE MALE GENDER ✅ YES MALE PATIENT FAMILY HISTORY OF HEART DISEASE ✅ YES FATHER HAD MI AT 70 HYPERTENSION ✅ YES DIAGNOSED 10YEARS AGO DIABETIC MELLITUS (TYPE 2) ✅ YES DIAGNOSED 8YEARS AGO DYSLIPIDEMIA ✅ YES DIAGNOSED 10YEARS AGO SMOKING ✅ YES PAST SMOKER SEDENTARY LIFESTYLE ✅ YES NO REGULAE PHYSICAL ACTIVITY OBESITY NA STRESS NA
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  https://medical-junction.com/acute-myocardial-
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  https://www.rcemlearning.co.uk/modules/unstable-angina-and-non-stemi-risk-assessment-and-management/ lessons/context-123/
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  Clinical Manifestation: SIGNS &SYMPTOMS PATIENT PRESENTATION Chest pain Central chest pain radiating to left arm Shortness of breath Complains of breathlessness Sweating (diaphoresis) Noted profuse sweating during episode Nausea Experienced nausea Fatigue or weakness Appeared tired and weak Palpitations Complains of irregular heartbeat Anxiety or restlessness Appeared anxious and restless Cold and clammy skin Skin was cool and clammy to touch Elevated heart rate Mild tachycardia on assessment Elevated blood pressure Hypertensive on arrival
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  Diagnostic Procedures &Investigations Test Name Purpose Patient Result Normal Range ECG (Electrocardiogram) Detect ischemic changes; ST depression/T-wave inversion without ST elevation ST depression in anterior leads No ST depression or elevation; normal sinus rhythm Troponin I Cardiac biomarker – elevated in myocardial injury 2.3 ng/mL < 0.04 ng/mL CK-MB Additional cardiac enzyme (less specific than troponin) 8.5 ng/mL 0.0 – 7.0 ng/mL Complete Blood Count (CBC) Rule out anemia/infection and assess baseline status Hb: 13.5 g/dL, WBC: 7.2 x10^9/L Hb: 13.5–17.5 g/dL (male), WBC: 4–11 x10^9/L Lipid Profile Evaluate for dyslipidemia (risk factor) LDL: 160 mg/dL, HDL: 35 mg/dL, TG: 210 mg/dL LDL < 100, HDL > 40, TG < 150 mg/dL HbA1c Assess glycemic control in diabetic patients 8.2% < 5.7% (normal), < 7% (target for diabetics) Chest X-ray Rule out other causes of chest pain; assess heart size Normal cardiac silhouette; clear lung fields Normal cardiac size and clear lungs Echocardiography Assess wall motion, ejection fraction, cardiac function EF: 50%, Mild anterior wall hypokinesia EF: 55–70%, normal wall motion
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  MANAGEMENT : Relieve Relieve chestpain and ischemic symptoms Restore Restore coronary blood flow Prevent Prevent further myocardial damage Stabilize Stabilize the patient hemodynamically PRIMARY GOAL OF NSTEMI MANAGEMENT:
• 31.
  Management Area Standard Guidelines Applicationto Patient Case Initial Approach (MONA) Morphine, Oxygen (if SpO2 < 90%), Nitrates, Aspirin 300mg chewed Oxygen given as SpO2 was borderline; GTN given for chest pain; Aspirin 300mg stat given Cardiac Monitoring Continuous ECG, serial 12-lead ECGs, monitor vitals ECG showed ST depression; vitals monitored closely in ED Blood Tests Troponin, CK-MB, CBC, Lipid Profile, HbA1c, RFT, Coagulation profile Troponin elevated; HbA1c high (uncontrolled DM); Lipids elevated Antiplatelets Clopidogrel or Ticagrelor loading dose Clopidogrel 300mg given in ED Anticoagulants Enoxaparin or UFH Enoxaparin administered
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  Beta- blockers Start unless contraindicated (bradycardia, hypotension) Beta-blockerstarted once hemodynamically stable Statins High-dose Atorvastatin to stabilize plaque Atorvastatin 80mg started ACE Inhibitors/AR Bs Start if HTN, DM, or LV dysfunction Started due to history of HTN and DM Reperfusion Strategy Early coronary angiography ± PCI Angiography planned within 24–48 hours Lifestyle Smoking cessation, diet, Advised strict glycemic control,
• 33.
  Medication Medication Action &Indication Contraindications Used in Case Study? Aspirin Inhibits platelet aggregation (Thromboxane A2 blocker); first-line antiplatelet for NSTEMI. Active bleeding, PUD, aspirin allergy Yes Clopidogrel (Plavix) ADP receptor blocker; prevents platelet aggregation; part of dual antiplatelet therapy. Bleeding disorders, liver impairment Yes Enoxaparin (Lovenox) Low molecular weight heparin; inhibits clotting factor X to prevent clot extension. Recent stroke, HIT, active bleeding Yes Nitroglycerin Vasodilator; relieves ischemic chest pain by reducing myocardial oxygen demand. Hypotension, anemia, recent PDE5 inhibitor use Yes Metoprolol Beta-blocker; reduces HR and myocardial workload to prevent further ischemia. Bradycardia, asthma, heart block Yes Atorvastatin Statin; lowers LDL, stabilizes plaque, and reduces risk of future cardiac events. Liver disease, pregnancy Yes Morphine Opioid analgesic; for chest pain unrelieved by nitrates; also reduces preload and anxiety. Respiratory depression, hypotension, allergy No
• 34.
  Nursing Responsibilities forNSTEMI Patients Cardiac Monitoring • Continuously monitor ECG for ST changes, arrhythmias, and heart rate abnormalities. Pain Management • Assess chest pain frequently and promptly administer nitroglycerin and analgesics as prescribed. • Monitor response and escalate if pain persists (pain = ischemia). Administer first line Medications • Give prescribed antiplatelets (e.g., aspirin, clopidogrel), anticoagulants (e.g., enoxaparin), and beta-blockers. • Monitor for bleeding, hypotension, or bradycardia. Monitor Hemodynamic Status • Check vital signs every 15–30 minutes initially, then as per condition. • Watch for signs of hypotension, low cardiac output, or shock. Oxygen Therapy • Administer oxygen if SpO₂ < 94% or patient is dyspneic. • Titrate oxygen and avoid hyperoxia.
• 35.
  Nursing Responsibilities forNSTEMI Patients cont..) Ensure Bed Rest and Activity Restriction: Maintain strict bed rest during acute phase to reduce cardiac workload. Gradually reintroduce activity as per medical advice. Prepare for Possible Interventions Get the patient ready for angiography or PCI if indicated. Ensure NPO status, consent, and IV access. Psychological Support Reassure patient to reduce anxiety and oxygen demand. Explain care procedures and progress in simple terms. Educate on Lifestyle Modification (Later Phase) diet, smoking cessation, medication adherence, and follow-up care
• 36.
  NURSING DIAGNOSIS 1.Acute Pain relatedto myocardial ischemia as evidenced by chest pain and elevated troponin. 2.Decreased Cardiac Output related to myocardial tissue damage as evidenced by hypotension and dyspnea. 3.Ineffective Tissue Perfusion (Cardiac) related to coronary artery blockage and decreased myocardial blood flow, as evidenced by ECG changes, elevated troponin, and chest pain. 4.Risk for Impaired Gas Exchange related to decreased cardiac output and hypoxemia, as evidenced by shortness of breath, tachypnea, and low oxygen saturation. 5.Readiness for Enhanced Health Management related to expressed interest in lifestyle changes and disease understanding.
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  Nursing Diagnosis Goal/OutcomeNursing Interventions Rationale Evaluation Acute Pain related to myocardial ischemia as evidenced by chest pain and elevated troponin. Patient will report decreased pain level ( 3/10) within 30 ≤ minutes of intervention. - Assess pain level regularly - Administer prescribed analgesics and nitrates - Provide a calm environment - Helps evaluate severity and guide treatment - Relieves ischemic pain - Reduces anxiety and stress Patient verbalized pain relief; pain score decreased from 8/10 to 2/10. Decreased Cardiac Output related to myocardial tissue damage as evidenced by hypotension and dyspnea. Maintain stable cardiac output as evidenced by normal BP and oxygen saturation. - Monitor VS, ECG, SpO2 - Administer medications as ordered - Position in semi- Fowler’s - Detects changes in status - Supports cardiac function - Improves breathing and reduces preload Vital signs stable; O2 saturation maintained at 96%.
• 38.
  Ineffective Tissue Perfusion (Cardiac) relatedto coronary artery blockage as evidenced by ECG changes and chest pain. Improve myocardial perfusion as evidenced by normalizing lab results and reduced symptoms. - Monitor troponin levels - Administer antiplatelets/antic oagulants - Assess perfusion signs - Indicates infarct severity - Enhances reperfusion - Identifies worsening perfusion early Lab results improved; patient reports decreased discomfort. Risk for Impaired Gas Exchange related to decreased cardiac output and hypoxemia. Maintain adequate oxygenation with SpO2 95% ≥ throughout hospitalization. - Monitor respiratory rate and SpO2 - Administer oxygen as prescribed - Encourage deep breathing exercises - Detects respiratory distress early - Improves oxygen delivery - Promotes lung expansion Patient maintained SpO2 > 96% on nasal oxygen; no respiratory distress noted. Readiness for Enhanced Health Management Patient will verbalize understanding of - Educate on diet, exercise, and smoking cessation - Supports health promotion - Enhances recovery Patient verbalized understanding and agreed to attend
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  Client's Progress Chart(as per the record) Date Vital Signs Symptoms/ Complaints Interventions Provided Client Response/Progress Day 1 (Admission) BP: 160/95 mmHg HR: 110 bpm RR: 22 bpm Temp: 36.8°C SpO : 91% ₂ Severe chest pain, SOB, diaphoresis, nausea ECG, cardiac enzymes, O via ₂ nasal cannula, Aspirin 300 mg, GTN SL, Enoxaparin, Clopidogrel, Atorvastatin, IV fluids, cardiac monitoring Slight relief in pain after GTN. Patient stabilized, transferred to ward for observation Day 2 BP: 145/90 mmHg HR: 96 bpm SpO : 94% ₂ Mild chest discomfort Continued medications, cardiac monitoring, angiography scheduled Patient stable, informed consent obtained for angiography Day 3 BP: 138/85 mmHg HR: 82 bpm SpO : 96% ₂ No chest pain Coronary angiography performed (normal), continued medications, monitored vitals Procedure well tolerated. No complications, vitals stable Day 4 (Discharge) BP: 130/80 mmHg HR: 78 bpm SpO : 97% ₂ No new complaints Discharge education provided, medications prescribed, lifestyle modification advice, cardiology follow-up in 1 week Patient discharged in stable condition, understanding confirmed
• 40.
  Discharge plan : CategoryDetails M - Medication - Aspirin 75-100 mg daily for antiplatelet therapy. - Statins (Atorvastatin 20-40 mg daily) for lipid control. - Beta-blockers (e.g., Metoprolol 25-50 mg daily) to reduce workload on the heart. - ACE inhibitors (e.g., Ramipril 2.5 mg daily) for blood pressure control and heart protection. E - Exercise - Gradual resumption of physical activity (e.g., walking) post-discharge, starting with 10-15 minutes daily, increasing over time. - Encourage walking or light exercise, avoiding heavy lifting or intense activities initially.
• 41.
  Discharge plan (cont..) T- Treatment - Continue monitoring of BP, HR, and blood sugar levels. - Cardiac rehabilitation program after discharge to help strengthen the heart and reduce the risk of re-infarction. - Consider angioplasty/stenting if symptoms recur or if there are significant blockages in the future. H - Health Education/Teaching - Educate the patient about the importance of lifestyle changes, such as smoking cessation, weight management, stress reduction, and dietary modifications. - Teach the patient the signs and symptoms of a heart attack, and when to seek medical attention (e.g., sudden chest pain, difficulty breathing).
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  Discharge plan (cont..) O- Out-patient Schedule - Follow-up appointment with cardiologist in 1 week for check-up and review of medication adherence. - Follow-up appointments with endocrinologist for diabetes management and dietitian for dietary guidance. D - Diet - Low-sodium, low-fat diet, rich in fruits, vegetables, whole grains, and lean proteins. - Avoid high cholesterol foods, such as fried foods and processed meats. - Limit alcohol consumption and encourage hydration through water or low-sugar fluids
• 43.
  Application of Gordon'sFunctional Health Patterns: Marjory Gordon’s Functional Health Patterns theory provides a framework for assessing a patient's health across 11 interrelated areas. These patterns help nurses collect comprehensive data on physical, psychological, and social aspects of a patient’s well-being, guiding interventions and promoting holistic care.
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  Application of Gordon'sFunctional Health Patterns Health Perception and Management •Assessment: Patient's understanding of health and management of risk factors (e.g., hypertension, diabetes). •Intervention: Education on lifestyle changes, medication adherence. Nutritional-Metabolic •Assessment: Current diet and metabolic health (e.g., cholesterol, weight). •Intervention: Heart-healthy diet recommendations (low sodium, low fat). Activity-Exercise •Assessment: Ability to perform physical activity, current limitations. •Intervention: Gradual increase in physical activity as tolerated.
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  Application of Gordon'sFunctional Health Patterns (cont..) Coping-Stress Tolerance •Assessment: Level of stress and coping mechanisms. •Intervention: Stress reduction techniques (e.g., relaxation, emotional support). Value-Belief •Assessment: Patient's beliefs and values affecting health practices. •Intervention: Reinforce importance of lifestyle changes (smoking cessation, diet).
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  QUESTIONS 1 : Apatient with NSTEMI is being treated with aspirin. Which side effect should the nurse monitor for? A. Hypokalemia B. GI bleeding C. Hypertension D. Hyperglycemia
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  ✅ Correct Answer:B Rationale: Aspirin can cause gastric irritation and increase the risk of gastrointestinal bleeding, which should be closely monitored.
• 48.
  QUESTION 2 : 2.A patient with NSTEMI should be placed on which initial nursing priority? A. Range of motion exercises B. Strict fluid restriction C. Continuous cardiac monitoring D. High-fat diet
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  ✅ Correct Answer:C Rationale: Continuous cardiac monitoring helps detect life- threatening arrhythmias early, which are common in NSTEMI. It ensures prompt intervention and improves patient safety.
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  QUESTION 3 : Whichof the following is an appropriate initial intervention in the management of a patient with NSTEMI? A. Immediate coronary artery bypass grafting (CABG) B. Administration of oral anticoagulants C. Intravenous access and administration of morphine for pain control D. Immediate fibrinolytic therapy
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  ✅ Correct Answer:C Rationale: Morphine is given to control pain and reduce anxiety in the acute phase of NSTEMI, but fibrinolytics are not typically used in NSTEMI.
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  References:  Perry, A.G., Potter, P. A., Ostendorf, W. R., & Laplante, N. (2021). Clinical nursing skills and techniques (10th ed.). Elsevier.  Gulanick, M., & Myers, J. (2022). Nursing care plans: Diagnoses, interventions and outcomes (10th ed.). Elsevier.  Nettina, S. M. (2020). Lippincott manual of nursing practice (12th ed.). Lippincott Williams & Wilkins.  Weber, J. R., & Kelly, J. H. (2022). Health assessment in nursing (7th ed.). Wolters Kluwer.