In 2011, a joint task force of the American College of Cardiology Foundation and the American Heart Association published updated guidelines for the treatment of unstable angina (UA) with non-ST elevation myocardial infarction (NSTEMI). These guidelines recommend that all patients with this diagnosis receive ASA on admission, and throughout hospitalization, if tolerated. If a patient is scheduled for percutaneous coronary intervention (PCI), it is recommended that a second anti-platelet therapy be added, such as clopidogrel (Plavix).

Myocardial rupture can be a catastrophic sequelae of acute myocardial infarction. It can occur in several sites in the heart after AMI, including the left papillary muscle. This event typically occurs 3-5 days after the AMI has occurred, and is more common in women who have a history of hypertension and are over the age of 60. The posteromedial papillary muscle is twice as likely to rupture as the anterolateral papillary muscle, due to the additional blood supply to the latter. Symptoms may include hypotension, shortness of breath, acute pulmonary edema and shock. Generally, mitral valve replacement is the most effective treatment.

The most likely cause for Norman's condition is nursing home-associated pneumonia (NHAP). NHAP is a subcategory of institutional-acquired pneumonia (IAP), which also includes healthcare associated pneumonia (HCAP). Patients in these settings are at increased risk for exposure to multi-drug resistant (MDR) bacteria. Debility and compromised health status increase the potential for infection.

The presence of the "spine sign" on chest x-ray is indicative of bilateral lower lobe pneumonia. The spinal markings disappear at the level of bilateral lower lobe pulmonary infiltrates, which occlude visibility of the vertebrae.

Although drawing a STAT blood glucose level may be part of a number of initial interventions, it should not be the first, since results will take too long to obtain. Patients who are suffering from acute hypoglycemia are at high risk of incurring permanent neurological damage, since the primary energy source for the brain is sugar. Patients who are conscious should consume a simple sugar which will absorb rapidly, like orange juice or glucose tablets. Patients who are unconscious outside the hospital setting or without IV access in the hospital setting should receive IM glucagon. Patients who are conscious in the hospital setting with IV access may be given IV dextrose.

When frequent episodes of hypoglycemia occur, the phenomenon of hypoglycemia unawareness can occur. This is more common in Type I diabetics, and is the result of the body's loss of ability to release epinephrine and other stress hormones during episodes of hypoglycemia. Without the symptoms associated with the release of epinephrine and stress hormones, an individual is not aware that blood sugar levels are dropping, which prevents them from taking early action to correct hypoglycemia. Another term for this condition is hypoglycemia-associated autonomic failure (HAAF).

Idiopathic thrombocytopenic purpura (ITP) is caused by the presence of Immunoglobulin G (IgG) autoantibodies on the surface of the platelets. It is defined as isolated thrombocytopenia with normal bone marrow function and the absence of other causes of thrombocytopenia. Clinically, there are two syndromes which manifest; acute in children and chronic in adults. Depending on the patient's status, treatment may or may not be indicated. If indicated, glucocorticoids and IVIg are the typical mainstays of medical therapy, and surgical options may include splenectomy in adults.

Although IVIg is quite expensive, socioeconomic status should never be a consideration in whether a patient receives needed therapy. IVIg contains immunoglobulins which are extracted from thousands of human donors, so it carries some of the same risks as other blood products, but is generally much safer. Various brands of IVIg are available, and differ in how they're prepared. Some manufacturers use sucrose as a stabilizing agent, others may use maltose or amino acids. This is a consideration in choosing the correct brand match regarding the effect on the patient in light of medical history and comorbidities.

The anterior communicating artery is the most common site of cerebral aneurysm rupture with resultant subarachnoid hemorrhage (SAH). There are usually no precipitating signs prior to rupture at this site, but afterward various abnormal signs may be present, including nuchal rigidity, decreased level of consciousness, and abnormal pupillary findings (usually dilation).

Donna is most likely experiencing vasospasm of one or more of her cerebral arteries. When this occurs, it is generally within 4-14 days for patients who have never had a cerebral bleed in the past, and sooner if this bleed is a recurrence. Usually, the site of spasm is unrelated to the site of rupture. Vasospasm is a serious complication, as it can lead to impaired cerebral autoregulation, cerebral ischemia, and infarction.

A Cullen sign is defined as ecchymosis involving the umbilicus, and is an indication of retroperitoneal hemorrhage. Ecchymosis which involves the flanks is called the Grey Turner sign, and also indicates retroperitoneal hemorrhage. Retroperitoneal hemorrhage is difficult to diagnosis clinically, and these signs typically take hours or days to appear.

If bowels sounds are audible when auscultating Matthew's breath sounds, a diaphragmatic tear should be suspected. Assessment of the trauma victim must be very systematic, and focuses on priorities in resuscitation and diagnosis based on hemodynamic stability and amount of injury. The ACLS protocol is followed, which includes identifying and treating the most life-threatening injuries first. Significant blunt trauma injuries are easily missed if a systematic process is not followed, as more dramatic injuries may receive the most attention.

Acute renal failure (ARF) which occurs secondary to cardiogenic shock is considered prerenal failure. ARF, also known as acute kidney injury (AKI) is classified according to etiology: prerenal failure occurs as a response to hypotension and volume depletion, intrinsic failure occurs in response to damage within the kidney itself from various toxic, ischemic or inflammatory causes, and postrenal failure occurs from urinary flow obstruction of any cause.

The "R"in RIFLE stands for Risk of renal dysfunction. The remainder of the acronym represents the following: Injury to the kidney, Failure or Loss of kidney function, and End-stage kidney disease. These indicators are used in the context of glomerular filtration rate (GFR) or urine output (UO) criteria, or both.

Due to his weakness and inability to position himself, Andrew is susceptible to positional asphyxia. Positional asphyxia is associated with compromised respiratory function due to external factors which impair chest expansion, or create occlusion of the upper airway due to abnormal body position. Victims of positional asphyxia are unable to remove themselves from situations which compromise their respiratory status for various reasons, including cognitive and coordination impairment due to intoxication, sedation, neurological abnormalities, impaired consciousness, physical impairment or restraint.

Ramona is experiencing biphasic anaphylaxis. The onset of the late phase varies, but usually occurs within 8-10 hours. Risk factors associated with biphasic anaphylaxis include severity of the initial phase, delayed or subtherapeutic dosing of epinephrine, initial airway edema or hypotension, delayed onset of symptoms after exposure, and a history of previous episodes of biphasic anaphylaxis.

Bruising around the breasts and genitals should trigger concern for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on the behalf of vulnerable populations, such as the elderly. According to the National Center of Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation and self-neglect.

The pattern of aggression or violence of bipolar disorder includes irritability, agitation, and violent behavior during manic or psychotic episodes, which is highly co-morbid with substance use, which worsens the prognosis. The Diagnostic and Statistical Manual of Mental Disorders identifies several disorders which may carry a higher risk for violent and/or aggressive behaviors, which is a concern when patients with co-morbid psychiatric disorders are admitted to the ICU or general floor for medical-surgical needs.

The ethical principle of justice supports Emily's right to access of an insulin pump, since her socioeconomic status should not impact her ability to receive care. Nurses must advocate for equal treatment for all patients, regardless of circumstances.

Discussing the situation with the doctor privately and professionally will allow the doctor the opportunity to feel less threatened by your concerns. This provides the opportunity for both parties to express viewpoints, understand each other's perspectives, and build rapport, which will ultimately benefit the patient.