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110 Cards in this Set

  • Front
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Acute Coronary Syndrome
Myocardial Infarction
•Acute coronary syndrome (ACS) is an umbrella term which includes:

1. angina which is Ischemia of the myocardium and is reversible

a. stable angina-occurs predictably with exertion

b. unstable angina-increasing frequency, possibly at rest

2. NSTEMI (non-ST segment elevation myocardial infarction) may be either ischemia or injury

3. STEMI (ST segment elevation myocardial infarction)
Definition
•Acute Myocardial Infarction (AMI):
•Acute Myocardial Infarction (AMI): Rapid development of Myocardial Necrosis

•Rupture of plaque

•Platelet adhesion & thrombus formation

•Occlusion of coronary artery

•Resulting in reduction of oxygenated blood supply to myocardium
Acute Coronary Syndrome
Precipitating Stressors
–Anything that increases O2 demand

•increases in preload, afterload, contractility

•stress, physical exertion, increased metabolism

–Anything that decreases O2 delivery

•anemia-There must be adequate hemoglobin to carry the oxygen
•vasoconstriction (hypertension), vasospasms

•narrowed arterial lumen-commonly a result of atherosclerosis
Define Preload
Preload is the volume of blood that returns to the heart via vena cava. Decreases may be caused by systemic vasodilation, or systemic volume depletion.
Increases may be caused by right ventricular failure commonly a consequence of a right coronary infarction
Define Afterload
Afterload requires energy that is produced with oxygen
Afterload is the resistance from the aorta which the left ventricle has to overcome in order to eject blood into the arterial system. Increases may be due to hypertension or anything that stimulates the sympathetic nervous system
Contractility-Increased contractility requires ____
Increased contractility requires increased oxygenation
Acute Coronary Syndrome
Mortality/Morbiditys
•AMI is the leading cause of death in U.S.

•More than one half of deaths occur in prehospital setting

•CHF and ventricular arrythmia are the leading cause of in-hospital death.

•Up to one-half of patients with unstable angina will develop an MI within hours.
Acute Coronary Syndrome
Pathophysiology
Total occlusion for more than 4-6 hours results in irreversible myocardial cell death.

Lactic acid resulting from anerobic metabolism (occurs when lack of oxygen is available for aerobic metabolism)

Enzyme release, upon myocardial cell death, referred to as biomarkers (CPK, Troponin, myoglobin, LDH)

Increased WBCs (neutrophils), may cause fever; as they clean up dead cell myocardial muscle becomes thinner.
Initial treatment:

treatment
Initial treatment: restore perfusion to save as much of jeopardized myocardium as possible
--"Pain Relief" to help stop the cycle of ischemia

–restoration of balance between O2 supply/demand

–prevention & treatment of complications
Acute coronary syndrome (ACS) is an umbrella term used to describe all of the following EXCEPT:

a. Angina

b. Cardiac Tamponade

c. Non ST segment elevation MI

d. St segment elevation MI
b. Cardiac Tamponade
Acute coronary syndrome (ACS)
Major Risk Factors
•Nonmodifiable risk factors
•Nonmodifiable risk factors
–Age

•male > 45

•female > 55

–Family History of a first degree relative experiening coronary artery disease before age:

•male <55

•female <65
Acute coronary syndrome (ACS)
Major Risk Factors
Modifiable risk factors
–Hyperlipidemia
–Hyperlipidemia

•LDL: optimal <100 mg/dl

•HDL: keep > than 40 mg/dl in men and 50 mg/dl in women

•Triglycerides: <150 mg/dl
Acute coronary syndrome (ACS)
Major Risk Factors
Modifiable risk factors
Hypertension
Hypertension

•treat with medication if greater than 140/90

•if diabetic or renal disease treat at 130/80

•Treat with lifestyle modification if equal to or greater than 120/80

•Short acting calcium channel blockers should NOT be used for treatment of hypertension
Acute coronary syndrome (ACS)
Major Risk Factors
Modifiable risk factors
–Smoking
–Smoking

•increases atherosclerosis

•increases platelet aggregation

•increases vasoconstriction and coronary spasm

•impairs O2 transport

risk decreases by 50% after 1 yr. Cessation

high priority to reduce this risk factor
Acute coronary syndrome (ACS)
Major Risk Factors
Modifiable risk factors
Diabetes
Diabetes

•Hypoglycemic therapy should achieve HbA1C of less than 7%

•Fasting glucose should be 110 or less

•Thiazolidinediones (Actos) should not be used in patients recovering from STEMI who have heart failure
Acute coronary syndrome (ACS)
Major Risk Factors
Modifiable risk factors
Weight management
Weight management

•Desirable body mass index range is 18.5 to 24.9

•Desirable waist circumference is less than 40 inches in men and 35 inches in women

•Regular aerobic exercise

•Diet low in fat, high in fiber
Acute coronary syndrome (ACS)
Major Risk Factors
Modifiable risk factors
Other Risk Factors
Other Risk Factors
•Stress and personality

•Substance abuse

•Sedentary life style

•Factors that increase oxygen consumption

•Factors that decrease oxygen delivery
Up to how many patients with UA will develop an MI within hours of arriving at the ED?

a. one-eighth

b. one-third

c. one-fourth

d. one-half
d. one-half
Which of the following patients is at high risk for acute MI? The patient:

a. age 65 with a hemoglobin of 5

b. age 25, female, and uses the pill

c. age 45, female, sedentary, with a waist circumference of 35

d. age 55, female, new onset of Diabetes II
a. age 65 with a hemoglobin of 5
Acute coronary syndrome (ACS)
Subjective Assessments
History :
Onset: when did it begin

•Manner of onset: sudden or gradual

•Duration: how long did it or has it lasted

•Precipitating factors: surrounding circumstances

•Location: pain may radiate to jaw, neck, arms, back, and epigastrium. Left arm more frequently affected than right

•Quality: tightness, pressure, crushing, or squeezing

•Intensity:Pain scale

•Chronology & frequency: years, months, weeks, days.
Acute coronary syndrome (ACS)
Associated symptoms:
–dyspnea

–nausea/abdominal pain/vomiting

–anxiety

–lightheadedness & syncope

–cough

–diaphoresis, cool, clammy skin

–wheezing

Elderly patients and diabetics may have subtle presentations such as fatigue, syncope, or weakness, or altered mental status.
Acute coronary syndrome (ACS)
Pneumonic:
To help remember how to assess chest pain
To help remember how to assess chest pain

•P: precipitating factors

•Q: quality of pain

•R: region of pain

•S: severity of pain

•T: time
Question
The most common form of chest pain in unstable angina, NSTEMI, and STEMI is

a. Epigastric pain

b. Neck pain

c. Shoulder pain

d. Substernal pain
d. Substernal pain
Acute coronary syndrome (ACS)
Physical Assessment
May be normal

•Low grade fever (increased WBCs) (Caused by inflammatory response)

•Pallor and diaphoresis (decreased cardiac output)

•Hypertension-Sympathetic nervous system response

•Hypotension-Decreased Cardiac output or heart failure

•Murmurs and extra heart sounds (decreased ventricular compliance)

•JVD (right heart failure)

•Crackles (left heart failure)

•Dysrhythmias-Caused by irritable myocardium, electrolyte imbalance, hypoxia, infarction of conductive myocardium
Acute coronary syndrome (ACS)
Physical Assessment
Symptoms
Symptoms (example: left anterior decending (LAD) artery--congestive heart failure) may depend on specific location or the coronary artery affected by the occlusion.

•subendocardial - involves only 1-2 layers of myocardium

•transmural- involves all three layers

•anterior wall (LAD or left anterior descending coronary artery)

–damage of ventricle (hypotension, shock, crackles, S3 or S4, JVD)

–includes 40-50% of infarcts

•lateral wall (circumflex artery)

–damage of ventricle (same as above)

•inferior wall (RCA or right coronary artery)

–damages AV and SA nodes (dysrhythmias, JVD)
Acute coronary syndrome (ACS)
Differential Diagnoses
list other possible causes of chest pain.
This is a list of other possible causes of chest pain.
•Angina

•Anxiety

•Aortic stenosis

•Cholecystitis

•Dissection, aortic

•Endocarditis/Myocarditis

•Gastroenteritis/GERD

•Pancreatitis

•Pericarditis/Cardiac Tamponade

•Pulmonary Embolism

•Esophageal spasm
Acute coronary syndrome (ACS)
Lab

Bio Markers (enzymes)
Bio Markers (enzymes)
•Should be drawn on all patients w/chest pain consistent with ACS.

•If negative within 6 hours of pain, another sample should be drawn between 6-12 hours.
Acute coronary syndrome (ACS)
Lab

Bio Markers (enzymes)
–Tropin I preferred
–Tropin I preferred-Used to differentiate between angina and myocardial infarction
Specific to Cardiac muscle

–released only when myonecrosis occurs

–superior sensitivity and specificity to CK-MB

–detectable in 3-6 hours, remains in serum 14 days.
Acute coronary syndrome (ACS)
Lab

Bio Markers (enzymes)
Creatinine Kinase-MB (CK-MB)
•Myoglobin
Creatinine Kinase-MB (CK-MB)
–enzyme released upon cell death, may also be released with skeletal muscle disease or injury including surgery.

•Myoglobin
–early marker of acute myocardial necrosis, but not specific for myocardial necrosis
Acute coronary syndrome (ACS)Other Lab
•Complete Blood Count (CBC)
•Complete Blood Count (CBC)
–leukocytosis within several hours
–may be useful to identify anemia as a precipitant
–elevated LDH
–platelet count, particularly
if a IIb/IIIa agent is considered (integrilin)
What is the leukocytosis caused by?
–may be useful to identify anemia as a precipitant
inflammation,inflammatory response,inflammatory reaction.
How can anemia precipitate myocardial ischemia?
Decreased oxygen carrying capacity,
Less hemoglobin.
Acute coronary syndrome (ACS)
Chemistry profile
–monitor K+ and magnesium levels (abnormal levels may increase risk of deadly dysrythmias)

–creatinine level prior to treating with ACE inhibitor (to monitor renal function)

•C-reactive protein (CRP)
–measure of inflammation

•Complete lipid panels
Question
Which lab test has the most accuracy in confirming myocardial infarction?

A. myoglobin

B. C-reactive protein

C. CBC

D. LDH
A. myoglobin
Troponin is best though
ACS
Diagnostics
Imaging
Imaging
•Chest x-ray

–assesses patient's heart size and CHF with or without pulmonary edema

–may provide clues to an alternative or complicating diagnosis
ACS
Diagnostics
Echocardiography
–reflects regional wall motion abnormality (example, ventricular aneurism)

–defines extent of infarction and overall ventricular function

–identifies mitral regurgitation, left papillary muscle rupture, or pericardial effusion
ACS
Diagnostics
Thallium scanning
Thallium scanning
–Thallium accumulates in the viable myocardium,

–Estimates the amount of blood reaching the myocardium during rest & exercise.
ACS
Diagnostics
Electrocardiogram
Electrocardiogram
•STAT

•Approx. 1/2 of patients have diagnostic changes on their initial EKG

•Serial EKGs used to evaluate progression and assess change of pain.

•Convex ST-segment elevation with upright or inverted T-waves generally is indicative of AMI.

•In absence of ST elevation, there is no evidence of benefit of fibrinolytic therapy--may cause harm
ACS
Risk stratification
•ST segment elevation Myocardial Infarction (or new Left Bundle Branch Block) (STEMI)

–high probability ST-elevation MIs

•ST depression or T-wave inversion (NSTEMI) non st segment MI

–high-risk unstable angina/ non-ST elevation MI

•Normal or nondiagnostic changes in ST-segment or T wave

–low-risk unstable angina
ACS
Risk stratification
STEMI-drugs
•High probability = ST-segment elevation greater than 1 mm in 2 contiguous leads & new Q waves.

•Should receive:

–fibrolytics, unless cardiogenic shock or contraindicated

–beta blockers

–Nitroglyerin

–Heparin

–ACE inhibitors
ACS
Risk stratification
NSTEMI-drugs
NSTEMI
•High risk = ST-segment depression or T-wave inversion, Q-waves, and ST-T wave abnormalities that are known to be old, or unstable angina (possible PCI)

Treat with:

--PCI (coronary angioplasty)

–Heparin

–ASA

–Glycoprotein IIb/IIIa inhibitors

–Nitroglycerin

–Beta blockerss
ACS
Risk stratification
Non diagnostic
Low probability (nondiagnostic, does not exclude possibility of AMI) (serial ECGs, enzymes)

Treatment

–if meets criteria for USA or NOA or Troponin positive follow high risk protocol

–otherwise: admit to monitored bed, serial 12 lead ECG, consider echocardiography or radionuclide or stress test.
ACS
Risk stratification
Cycle of chest pain:
Cycle of chest pain:
The cycle of chest pain begins with ischemia (lack of oxygenated blood flow) triggering the sympathethetic nervous system which increases heart rate and vasoconstriction, which continues to increase chest pain. The goal is to break the cycle. Pain medicine and beta blockers are two points of breaking the cycle.
What is the primary purpose for giving beta blockers to patients with AMI? To decrease:

A. heart rate

B. blood pressure

C. anxiety

D. workload on heart and O2 demand
D. workload on heart and O2 demand
ACS
Pharmacology
Thrombolytic Therapy
Name drugs and action
Thrombolytic Therapy
•T-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Action: a tissue plasminogen activator and enzyme which binds to fibrin in a thrombus and converts plasminogen to plasmin which digests fibrin and dissolves the clot.

•ST elevation > 1 mm in 2 or more contiguous leads. (search for new LBBB that obscures ST-segment)

•Improves survival rate if given w/12 hours

•Risks outweigh benefits over 12 hours & 75 y/o.
ACS
Pharmacology
Thrombolytic Therapy
Contraindications
Extreme caution
•T-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Contraindications: Active or internal bleeding, severe uncontrolled hypertension, intracranial or intraspinal surgery or trauma within 2 months, stroke.

–Extreme caution: recent major surgery, organ biopsy, or trauma, recent GI or GU bleeding, hypertension (systolic BP above 180 and/or diastolidc BP above 110, - high likelihood of left heart thrombus, pregnancy or recent childbirth, septic thrombophlebitis, advanced age, anticoagulants
ACS
Pharmacology
Thrombolytic Therapy
Adverse reactions
•T-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Adverse reactions:

•bleeding

•reperfusion arrhythmias

•hypotension
ACS
Pharmacology
Thrombolytic Therapy
–Nursing care:
•T-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Nursing care:

•monitor for reperfusion ventricular arrhythmias

•have antiarrythmics at bedside

•avoid rough handling including too-frequent BP monitoring

•avoid use of razors & toothbrushes

•establish separate IV site

•obtain appropriate clotting studies

•baseline assessment

•maintain strict bedrest

•monitor frequently for pain and signs of bleeding

•apply pressure dressing to any recently invaded site

•watch for hematuria, hematemesis, bloody stool

•do neuro checks every hour
ACS
Pharmacology
Antithrombotics
Aspirin
Aspirin

–actions: inhibits further platelet aggregation

–give to all patients with ischemic chest pain unless hypersensitivity exists or bleeding tendency, then give clopidogrel

–for patients with chest pain chew 324 mg
ACS
Pharmacology
Antithrombotics
GP IIb/IIIa
–action:
GP IIb/IIIa-receptor agonists (Eptifibatide, tirofiban, abciximab, Integrilin)

–action: decreases platelet aggregation by reversibly antagonizing the binding of fibrinogen to the glycoprotein IIb/IIIa binding site on platelet surfaces.

–May give in addition to aspirin and unfractionated heparin and in whom a PCI (heart catheterization and angioplasty) is anticipated.
ACS
Pharmacology
Antithrombotics
GP IIb/IIIa
-contraindications:
–Adverse reaction:
GP IIb/IIIa-receptor agonists (Eptifibatide, tirofiban, abciximab, Integrilin)

–contraindications:

•severe hypertension

•active internal bleeding

•history of intracranial hemorrhage

•trauma or stroke in past 2 months

–Adverse reaction:

•bleeding (including GI and intracranial, hematuria, and hematomas)
ACS
Pharmacology
Antithrombotics
GP IIb/IIIa
Nursing interventions
GP IIb/IIIa-receptor agonists (Eptifibatide, tirofiban, abciximab, Integrilin)–

Nursing interventions

•monitor for bleeding

•obtain PTT and ACT

if platelet count drops below 100,000 discontinue
ACS
Pharmacology
Antithrombotics
Clopidogrel (Plavix) given for one month after MI
–Action:
–Action: inhibits platelet aggregation by irreversibly inhibiting the binding of ADP to platelet receptors.
ACS
Pharmacology
Antithrombotics
Clopidogrel (Plavix) given for one month after MI
-contraindications:
–Adverse reaction:
–Contraindications: hypersensitivity, pathologic bleeding (peptic ulcer, intracranial hemorrhage), laceration

–Adverse reactions:

•bleeding, neutropenia, thrombocytopenia
ACS
Pharmacology
Antithrombotics
Clopidogrel (Plavix) given for one month after MI
Nursing interventions
Nursing interventions:

•monitor for bleeding as with other antiplatelet drugs

•monitor for signs of thrombocytopenia, neurologic findings, renal dysfunction, fever.

•Monitor bleeding times throughout therapy
ACS
Pharmacology
Antithrombotics
--Heparin:
--Heparin:

•Action: augments activity of antithrombin III

Prevents conversion of fibrinogen to fibrin

•Does not lyse preformed clot, but is able to inhibit further thrombus formation.

•Has an established role in administration with t-PA, but not streptokinase.
ACS
Pharmacology
Antithrombotics
Low molecular weight heparin (LMWH)
LMWH (Enoxaparin)

•also prevents thrombus formation

Contraindications: severe thrombocytopenia, hypersensitivity to heparin. Uncontrolled bleeding except in DIC.


•monitor platelets, no PTT required

•Can not be used interchangeably with unfractionated or other LMW heparins
Pharmacology
Antithrombotics
Low molecular weight heparin (LMWH)
•Adverse reactions:
•Nursing interventions:
•Adverse reactions: bleeding, anemia, thrombocytopenia

•Nursing interventions:

–assess for bleeding and hemorrhage

–monitor PTT, hematocrit, and platelets

–protamine sulfate is antidote, however, due to short half-life overdose can often be treated by withdrawing the drug.
Beta Blockers
Name
What are the actions
Metoprolol, esmolol, atenolol, and other 'olols

•Actions:

–reduces ischemia by inhibiting chronotropic, inotropic, and vasoconstricting responses to beta-adrenergic stimulation thereby decreasing oxygen consumption.

–Given to all patients suspected of MI in absence of complications

–Can reduce ventricular fibrillation (deadly dysrthymia)
Beta Blockers
Adverse effects
Precautions
contraindications
Adverse effects: hypotension, bradycardia, heart block, asypmtomatic hypoglycemia

•Precautions: concurrent IV administration with IV calcium channel blocking agents like verapamil or cardizem may cause severe hypotension

•Contraindicated in presence of HR <50 bpm, systolic BP < 100, AV blocks. Avoid in bronchospastic diseases (Check baseline vital signs)
Beta Blockers
Nursing interventions:
–monitor blood pressure/heart rate, and ECG

–assess routinely for signs and symptoms of CHF (dyspnea, crackles, rales)

–hold for pulse of 50 or less (check baseline vital signs)

–monitor K+ levels
Nitrates
•Actions:
–Produces vasodilation decreasing preload and afterload and subsequent myocardial workload and oxygen demand.

–Intravenous nitroglycerin is indicated the first 48 hours after STEMI for treatment of persistent ischemia, CHF, or hypertension.
Nitrates
contraindications
Contraindications: hypersensitivity, severe anemia, concurrent use of Viagra, BP less than 90 or HR less than 50, tachycardia, or RV infarction
Nitrates
Nursing interventions:
•Nursing Interventions:

--In the hospital setting may give every 5 minutes times three for pain relief or as IV

–IV nitroglycerin-- titrate to pain control, but do not substitute for narcotic analgesics

–Monitor BP and HR frequently (before, during , after administration)

•Instruct patients to take ONE nitroglycerin dose sublingually in response to chest discomfort/pain. If chest discomfort /pain is unimproved or worsening 5 minutes after one nitroglycerin, the patient should call 911 immediately

–Caution patient to rise slowly & avoid alcohol

–advise patient to keep tablets in dark container, with cotton removed and replace q 6 mo.

–Explain difference between sublingual and PO medications

–If continuous therapy is planned with oral or topical form, a nitrate-free interval should be incorporated.
ACE Inhibitors
Angiotensin-converting enzyme inhibitor
Name
Actions
Captopril, enalapril, lisinopril, & other 'prils

•Action: block conversion of angiotensin I; also reduces aldosterone levels. Net effect: decreased blood pressure and after load.
ACE Inhibitors
Angiotensin-converting enzyme inhibitor
Adverse effects
Precautions
Precautions: pt with renal or hepatic impairment, hypovolemia, hyponatremia, elderly patients, concurrent diuretic therapy.

•Adverse reactions: angiodema, cough, hypotension, proteinureia, neutropenia. ARBs (Angiotensin II receptor antagonists) should be administered to patients intolerant of ACE inhibitors
ACE Inhibitors
Angiotensin-converting enzyme inhibitor
Nursing interventions:
Nursing interventions

–monitor BP and HR

–monitor weight & fluid status

–monitor creatinine and electrolytes

–assess urine protein prior to and periodically during therapy

–monitor WBC with differential to assess for neutropenia
Morphine
What is the primary purpose and action of Morphine
Primary purpose: to decrease oxygen demand on heart

•Action: alters perception of and response to painful stimuli while producing generalized CNS depression.
Morphine
Adverse effects
Precautions
contraindications
Contraindicated: hypersensitivity

•Precautions: hypotensive, pulmonary disease, hypoxia

•Adverse reactions

–confusion

–respiratory depression

–hypotension

–constipation
Morphine
Nursing interventions:
Nursing interventions

–monitor respirations, HR, and BP

–monitor pain control

–monitor oxygenation status
Which of these includes the major components of initial therapy for the patient with acute ischemic chest pain and a nondiagnostic ECG?

A. reperfusion therapy, aspirin, heparin,

B. beta-blockers, and nitrates, monitoring for high risk status, antithrombin therapy, glycoprotein IIbIIIa inhibitors,

C. Prophylactic lidocaine, fluid bolus, and vasopressor infusion

D. Serial ECGs with ST-segment monitoring, serum cardiac markers, and further risk assessment with perfusion radionuclide imaging and stress echocardiography, aspirin.
D. Serial ECGs with ST-segment monitoring, serum cardiac markers, and further risk assessment with perfusion radionuclide imaging and stress echocardiography, aspirin.
Which medication should be given for one month post AMI?

A. Aspirin

B. Coumadin

C. Heparin

D. Plavix
D. Plavix
Surgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty)

explain
Surgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty).
Alternative therapy to thrombolytics (if door time to inflation of balloon less than 90 minutes
decreased risk of bleeding
greater coronary patency when stents and GB IIb/IIIa therapy used, than thrombolytics
instant knowledge of underlying disease
Surgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty)
Advantages
Advantages:

1. There is greater coronary patency when stents & GB IIb/IIIa therapy used, than thrombolytics

2. There is instant knowledge of underlying disease

–Indicated with

•patients who do not fit criteria for thrombolytic therapy

•persistent ischemia

•cardiogenic shock

•failed thrombolysis
Surgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty)
Process
Process

•insertion of catheter into femerol artery then up through the aorta

•coronary arteriography- inject dye into coronary arteries to identify blockages

balloon tipped catheter inflated several time at blockage to compress plaque and open artery

stent (mesh scafold) opened to keep artery open

dye injected again to view opened blockage
–Nursing Interventions
pre-cath
•post cath
–Nursing Interventions

•pre-cath

–base-line assessments

–mark pedal pulses & document

–NPO or clear liquid breakfast

–permit

–allergies

–foley or void

•post cath

–VS, pedal pulses, check dressing according to institutional protocol, assess site.

–Immobilize extremity

–hold pressure on artery when lines pulled

–keep flat

–encourage fluids

–PO when awake

–monitor for signs of decreased myocardial perfusion.
CABG
describe
(coronary artery bypass graft): emergent or urgent CABG indicated in patients in whom angioplasty fails or develop papillary muscle rupture-further discussed in Cardiac Trauma lecture.
Which medication is commonly given to patients in whom a PCI is expected?

A. Enoxaparin

B. glycoprotein IIb/IIIa inhibitors

C. Coumadin

D. TPA
B. glycoprotein IIb/IIIa inhibitors
Which patient with acute continuing ischemic chest pain is most likely to benefit from beta-blocker therapy? The patient with:

A. second or third degree heart block.

B. severe left ventricular failure

C. a systolic arterial blood pressure of 90/60 and sinus rhythm of 55 bpm

D. ST segment elevation MI and blood pressure of 180/104
D. ST segment elevation MI and blood pressure of 180/104
Further Inpatient Care
monitor for/what
Diet
Oxygen therapy until stable for 6 hours

•Continuous ECG monitoring

•Careful ST segment monitoring

•Monitoring for ischemia and other complications

•May transfer to step down or intermediate care unit 12-24 hours after admission if no complications

Diet
•Initial NPO
Activity
Initial bedrest—generally 12-24 hours—then BSC (bedside commode), with assisted bathing and light ambulation

•Avoidance of valsalva maneuver

•Should not be on bedrest more than 24 hours if free of recurrent ischemic discomfort, CHF, or serious dysrthymias.

•Activity slowly accelerate as tolerated

•Initiate cardiac rehabilitation prior to discharge
Discharge
Education
Education--begin during early phase of hospitalization

–include family or support persons
Discharge
Medication --purpose, when , & how to take
Blood pressure control

Diabetes management

Weight management
Medication --purpose, when , & how to take

–lipid management--statins preferred--with follow up liver panel

–antiplatelet therapy--ASA 75-162mg/daily

–ACE inhibitor (ARB if intolerant)

–Beta Blocker

-Nitroglycerin

Blood pressure control

Diabetes management

Weight management
Discharge
Exercise prescription
Smoking cessation
Support groups:
Arrange for follow-up within -__ weeks of discharge

Arrange for cardiac ________________
Exercise prescription

•ideally 30 minutes daily but at least 3-4 X week

•walking, jogging, or other aerobic activity

•may be spread out over 2-3 segments during the day

Smoking cessation--risk of recurrent events decreases 50% at 1 year of cessation

Diet: Low fat

Support groups: ie. Mended Hearts

Arrange for follow-up within 2 weeks of discharge

Arrange for cardiac rehabilitation
Which medication has been proven to increase survival after an MI?

a. ACE inhibitors

b. Beta blockers

c. Aspirin

d. Morphine Sulfate
b. Beta blockers
What are the primary nursing interventions post catheterization?

A. Patient comfort and pain control

B. Monitor pedal pulses and catheter insertion site

C. Getting up to chair within the first hour.

D. Food and fluids
B. Monitor pedal pulses and catheter insertion site
Rehabilitation
Long Term program that involves:
•Purpose
Long Term program that involves

–medical evaluation

–prescribed exercise

–education

–counseling

•Purpose

–limit physiological and psychological effect of cardiac illness

–reduce risk for sudden death or reinfarction
Rehabilitation
Variety of setting
physicians office

–hospital

–community facility

•Safe activity can be determined by comparing performance on a graded exercise test with MET level required for desired activity
Rehabilitation after surgical treatment
Exercise may include
Other activities
–stationary bicycling

–treadmill, calisthenics

–walking

–jogging

•Activity should be terminated with chest pain, dyspnea, excessive fatigue, or dizziness

•Other activities

–daily walking can be encouraged immediately

–sexual activity with the usual partner can be resumed within 1 week to 10 days

–driving can begin 1 week after discharge
Complications after surgical treatment
Arrhythmia's

–major cause of mortality

–monitor electrolyte disturbances –

•VF (ventricular fibrillation) within first 48 hours

•If ventricular arrythmias occur later, further workup is indicated.

•Recurrent ischemia may be due to incomplete reperfusion –cardiac cath and revascularization needed
Complications after surgical treatment
•Heart failure:
•Heart failure:
If enough myocardium is infarcted the heart cannot pump adequately and cardiac output is reduced.
•Cardiogenic shock: defined as systolic BP less than 90 mm Hg in the presence of organ hypoperfusion. Inotropes (dopamine & dobutamine) or intraaortic balloon pump.

•Acute mitral regurgitation: 2ndary to necrosis or rupture of LV papillary muscle. Echocardiogram confirms.
The nurse teaches the client that the major difference between angina and pain associated with myocardial infarction (M.I.) is that

angina is relieved with nitroglycerine and rest.
angina may be fatal.
M.I. pain always radiates to the left arm.
M.I. pain cannot be treated.
angina is relieved with nitroglycerine and rest.

Angina pain is uncomfortable but is rarely fatal. It is usually immediately relieved by nitroglycerine.
The teaching plan for a client with angina includes the action of antianginal drugs. The nurse teaches that these drugs
increase heart rate.
increase preload.
increase contractility.
decrease afterload.
decrease afterload.

Antianginal drugs act by decreasing myocardial oxygen demand. This is accomplished by decreasing heart rate, decreasing preload, decreasing contractility, and decreasing afterload
The ability of organic nitrates to dilate coronary arteries is most effective for treating which type of angina?
Stable angina
Unstable angina
Variant angina
Classic angina
Variant angina

Dilation of coronary arteries is no longer considered the primary mechanism of nitrate action in stable angina. It is important in variant angina, in which chest pain is caused by coronary artery spasm. The drug can relax the spasms and terminate the pain.
The nurse cautions the client receiving isosorbide dinitrate for treatment of angina to be aware of the occurrence of
tolerance.
tachycardia.
hypotension.
urinary retention.
tolerance.

Tolerance is a common problem with the use of longer acting organic nitrates. Clients are often instructed to remove the transdermal patch for 6-12 hours each day in order to delay development of tolerance to the drug.
The nurse prepares discharge teaching for a client receiving isosorbide dinitrate for treatment of angina. What information must the nurse include?
Limit exercise to 30 minutes twice per week
Avoid alcohol consumption
Monitor intake and output
Report skin flushing to physician
Avoid alcohol consumption

Alcohol intake has additive vasodilation effect. Concurrent use may cause severe hypotension and cardiovascular collapse.
The nurse recognizes the mechanism for action of beta-adrenergic blockers in the treatment of angina is
positive chronotropic effect.
negative inotropic effect.
positive inotropic effect.
antidysrhythmia.
negative inotropic effect.

Beta blockers decrease the workload of the heart by slowing heart rate (negative chronotropic effect) and reducing contractility (negative inotropic effect).
The teaching plan for a client receiving a beta-blocker for treatment of angina should include
discontinue drug if heart rate is <60.
do not discontinue drug abruptly.
exercise heart rate should be 110-120.
monitor for hyperglycemia.
do not discontinue drug abruptly.

Beta-blocker treatment should never be abruptly discontinued. With abrupt cessation, a rebound excitation occurs and adrenergic receptors are stimulated. This can exacerbate angina, increase heart rate, and may cause myocardial infarction.
Calcium channel blockers prescribed for treatment of angina exert their effect by
increasing preload.
decreasing afterload.
positive chronotropic effect.
positive inotropic effect.
decreasing afterload.

Calcium channel blockers cause arteriolar smooth muscle relaxation leading to lowered peripheral resistance and decreased blood pressure (decreased afterload) This decreases myocardial oxygen demand and reduces frequency of anginal pain.
The nurse recognizes which of the following indicates effective treatment of a client receiving a beta-adrenergic blocker for treatment of myocardial infarction?
Tachycardia
Hypertension
Decreased dysrhythmias
Decreased urinary output
Decreased dysrhythmias

Beta blockers have the ability to decrease heart rate, decrease contractility, and decrease blood pressure leading to decreased oxygen demand. They also slow conduction which suppresses dysrhythmias.
A nurse is explaining the anatomy and physiology of the heart to a group of adults participating in a wellness program. When a participant asks for an explanation of the purpose of the superior vena cava, the nurse provides which of the following information?
Returns blood from the body area above the diaphragm
Returns blood from the body below the diaphragm
Drains blood from the heart
Receives freshly oxygenated blood from the lungs through the pulmonary veins
Returns blood from the body area above the diaphragm

The superior vena cava returns blood from the body area above the diaphragm, the inferior vena cava returns blood from the body below the diaphragm, and the coronary sinus drains blood from the heart. The left atrium receives freshly oxygenated blood from the lungs through the pulmonary veins.
Implementation; Health Promotion and Maintenance; Application
A client with left ventricular hypertrophy asks the nurse to explain the purpose of the left ventricle. The nurse informs the client that which of the following is the purpose of the left ventricle?
Receives deoxygenated blood from the vena cavas
Receives freshly oxygenated blood from the lungs
Receives freshly oxygenated blood from the left atrium and pumps it out the aorta to the arterial circulation
Pumps deoxygenated blood through the pulmonary artery to the lungs for oxygenation
Receives freshly oxygenated blood from the left atrium and pumps it out the aorta to the arterial circulation

The left ventricle receives freshly oxygenated blood from the left atrium and pumps it out the aorta to the arterial circulation. The right ventricle receives deoxygenated blood from the right atrium and pumps it through the pulmonary artery to the lungs for oxygenation. The left atrium receives freshly oxygenated blood from the lungs. The right atrium receives deoxygenated blood from the vena cavas.
Implementation; Health Promotion and Maintenance; Application
A nurse, assessing a client's cardiovascular status, recognizes which of the following does not influence cardiac output?

Metabolic rate
Age
Body size
Gender
Gender

Cardiac output is influenced by activity level, metabolic rate, physiologic and psychologic stress responses, age, and body size. Gender is not a factor.
Assessment; Health Promotion and Maintenance; Analysis
A nursing instructor is teaching a beginning anatomy and physiology course to nursing students. The instructor explains that the normal "pacemaker" of the heart is which of the following?

The atrioventricular (AV) node
The sinoatrial (SA) node
The Purkinje fibers
The bundle of His
The sinoatrial (SA) node

The sinoatrial (SA) node is the normal pacemaker of the heart, usually generating an impulse 60 to 100 times per minute. This impulse travels across the atria via internodal pathways to the atrioventricular (AV) node, in the floor of the interatrial septum. Small junctional fibers of the AV node slow the impulse, slightly delaying its transmission to the ventricle. It then passes through the bundle of His at the AV junction and continues down the interventricular septum through the right and left bundle branches and out to the Purkinje fibers in the ventricular muscle walls.
Implementation; Health Promotion and Maintenance; Application
A nurse, assessing a client's cardiovascular status, simultaneously palpates the radial pulse while listening to the apical pulse. The nurse notes the radial pulse falls behind the apical pulse and recognizes this as an indication of which of the following?

Inaccurate assessment technique
Congestive heart failure
Weak, ineffective contractions of the right ventricle
Weak, ineffective contractions of the left ventricle
Weak, ineffective contractions of the left ventricle

Simultaneously palpating the radial pulse while listening to the apical pulse allows detection of a pulse deficit which is seen when the radial pulse falls behind the apical pulse, indicating weak, ineffective contractions of the left ventricle.
Assessment; Health Promotion and Maintenance; Analysis
A nurse, assessing a male client admitted with chest pain 2 days ago, notes a visible pulsation in the area of the midclavicular line in the left fifth intercostal space. The nurse's most appropriate action is which of the following?

Notify the physician immediately
Obtain a stat EKG
Document the finding; it is a normal assessment
Ask the client if he is experiencing any chest pain
Document the finding; it is a normal assessment

Visible pulsation in the area of the midclavicular line in the left fifth intercostal space is called an apical impulse and is a normal finding in about half of the adult population. No intervention is necessary.
Assessment; Health Promotion and Maintenance; Application
While assessing a client's heart sounds, the nurse notes a murmur which is clearly heard. Which of the following grades will the nurse document this murmur as?

Grade I
Grade II
Grade III
Grade IV
Grade III

Murmurs are graded according to the following scale:
I = barely heard
II = quietly heard
III = clearly heard
IV = loud
V = very loud
VI = loudest, may be heard with stethoscope off the chest.

Assessment; Health Promotion and Maintenance; Analysis
While assessing a client's apical pulse, the nurse notes a 76 bpm heart rate and a pattern of gradual increase and decrease in heart rate that correlates with inspiration and expiration. The nurse documents this finding as which of the following?

Sinus arrhythmia
Bradycardia
Tachycardia
Bigeminy
Sinus arrhythmia

A pattern of gradual increase and decrease in heart rate that is within normal heart rate and that correlates with inspiration and expiration is called sinus arrhythmia, and may be a normal finding in children and adults.
Assessment; Health Promotion and Maintenance; Application
A nursing student is learning cardiac assessment. The student correctly identifies the first heart sound as which of the following?

Closure of the semilunar valves
Closure of the atrioventricular valves
S3
S4
Closure of the atrioventricular valves

Closure of the atrioventricular (AV) valves at the onset of contraction produces the first heart sound (characterized by "lub" sound). Closure of the semilunar valves at the onset of relaxation produces the second heart sound (characterized by the "dub" sound). S3 and S4 are extra heart sounds identified as gallops.
Assessment; Health Promotion and Maintenance; Analysis
A nurse correctly assesses for the heart's high pitched sounds when which of the following is demonstrated?

Ask the client to remain in the supine position during assessment
Ask the client to exhale and hold the breath while listening to heart sounds
Auscultate each area with the bell of the stethoscope
Auscultate each area with the diaphragm of the stethoscope
Auscultate each area with the diaphragm of the stethoscope

High-pitched sounds such as S1 and S2, murmurs, and pericardial friction rubs are auscultated with the diaphragm of the stethoscope. Lower-pitched sounds such as S3 and S4, and other murmurs are auscultated with the bell of the stethoscope. Asking the client to exhale and hold the breath allows for assessment of effects of respirations on each sound. The client should be assessed in the sitting or supine position, then lying on the left side, and sitting up and leaning forward to bring the heart closer to the chest wall and enhance auscultation.
Assessment; Health Promotion and Maintenance; Application