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29 Cards in this Set
- Front
- Back
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What are characteristics about chest pain? |
• More prolonged, tightness pain • Usually the worst pain they’ve ever had • Typically more common in the morning • Diabetics don’t have chest pain |
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Differential diagnoses of retrosternal chest pain. |
• Acute Myocardial Infarction / Unstable angina • Stable angina • Pericarditis • Anxiety disorder • GERD • Musculoskeletal (Chest wall pain, costochondral pain, rib fracture) • Pneumonia • Heart failure • Pulmonary embolism |
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Characteristics of chest pain in males |
• Squeezing, heavy sensation • Indigestion or heart burn • Short of breath/ can’t catch your breath • Radiates to Left arm/ shoulder/ jaw/ back • Fatigue • Diaphoretic • Loss of consciousness if concomitant arrhythmia |
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Characteristics of chest pain in females (atypical) |
• Nausea/vomiting • Indigestion or heart burn • Dyspnea (SOB) • Chest pressure • Fatigue |
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How does coronary perfusion work? What are the factors that affect it? |
• Coronary arteries are perfused during diastole when ventricles are relaxed, so blood flows passively into the coronary arteries • Changes in diastole, ex hypertension, tachycardia, reduce perfusion |
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How does coronary perfusion work? What are the factors that affect it? |
• Coronary arteries are perfused during diastole when ventricles are relaxed, so blood flows passively into the coronary arteries • Changes in diastole, ex hypertension, tachycardia, reduce perfusion |
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What are the risk factors of CAD? Modifiable and non modifiable |
• Modifiable o Smoking, high fat/sugar/salt diet, physical inactivity, obesity, increased waist girth, dyslipidemia, hypertension, diabetes, stress, increased homocysteine levels • Non modifiable o Genetic (50% risk), race (white = increased risk), gender male (male death under 55, female death under 65), age, complications during pregnancy (preterm labour, hypertension, preeclampsia, etc.) |
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Explain the pathophysiology of atherosclerosis, the three stages, and complications. |
• Deposits of lipids within the endothelial walls of the artery • Stages, 1- fatty streak, 2-fibrous plaque, 3- complicated lesion Complications: • Angina (stable, unstable) • MI (STEMI, NSTEMI, MINOCA [myocardial infarct from non-obstructed coronary arteries]) |
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CAD nursing management and patient education |
Nursing management • Promotion of physical activity, diet (avoid fats from red meat, egg yolk, while milk, alcohol, simple sugars), increase omega-3 fatty acids (fatty fish), low saturated-fats, high-fibre, ASA for antiplatelet therapy Patient education • Smoking cessation, diet modification (reduce saturated fats and refined sugars), weight reduction and maintenance, daily exercise, stress management |
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Stable angina: patho (conditions), definition, S&S, precipitating factors |
Pathophysiology • Cardiac workload and myocardial oxygen demands exceed the ability of coronary arteries to supply an adequate amount of oxygenated blood o Ex. anemia, hypertension, exertion, COPD, asthma, heart failure, tachycardia • Stable: retrosternal chest pressure precipitated by a predictable event or activity caused by myocardial ischemia, resolved with nitroglycerin, no myocardial injury S&S: • Pressure/aching in chest, defined as squeezing, heavy, choking, suffocating, does not change with position or breathing, indigestion or burning sensation • Pain is brief and episodic (5-15 mins), provoked by exertion, relived by rest or nitro Precipitating factors • Physical exertion, temperature extremes, strong emotions, tobacco use, sexual activity, stimulants, |
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Stable angina: patho (conditions), definition, S&S, precipitating factors |
Pathophysiology • Cardiac workload and myocardial oxygen demands exceed the ability of coronary arteries to supply an adequate amount of oxygenated blood o Ex. anemia, hypertension, exertion, COPD, asthma, heart failure, tachycardia • Stable: retrosternal chest pressure precipitated by a predictable event or activity caused by myocardial ischemia, resolved with nitroglycerin, no myocardial injury S&S: • Pressure/aching in chest, defined as squeezing, heavy, choking, suffocating, does not change with position or breathing, indigestion or burning sensation • Pain is brief and episodic (5-15 mins), provoked by exertion, relived by rest or nitro Precipitating factors • Physical exertion, temperature extremes, strong emotions, tobacco use, sexual activity, stimulants, |
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Stable angina: medical management & pharmacology (ABCDEF), nursing management, patient education |
Medical management • ABCDEF: Antiplatelet agent, Antianginal therapy, ACE inhibitor, B-blocker, lower Blood pressure, Cigarette smoking cessation, lowering Cholesterol, Diet, Diabetes management, Exercise, Flu vaccination • Focus on decreasing oxygen demand or increasing oxygen supply • Pharmacological options o Short-acting nitrates (nitroglycerin) Dilating peripheral blood vessels, reduces cardiac workload Dilating coronary artery, increases blood flow to heart Nursing management • Administration of oxygen • Vital signs • 12 lead ECG • Pain relief with nitro, then opioid • Auscultation of heart • Positioning of patient (semi-fowler) Patient education • Prevention is key • Educate about CAD, angina, precipitating factors, medication, risk-factor reduction |
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ACS definition |
ACS: plaque disruption where a sufficient quantity of thrombogenic substances are exposed (plaque rupture), lumen of coronary artery becomes obstructed by combination of platelet aggregates, fibrin, and RBCs |
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Unstable angina: S&S |
• Pain unrelieved by rest, position change, nitrate administration (heaviness, pressure tightness, burning, constriction/crushing feeling), pain lasts for more than 30 mins • SNS stimulation: skin may appear ashy, clammy, and cool to touch • Cardio: BP and HR are elevated, BP can drop due to decreased CO, pulmonary edema for LV failure, jugular distension, peripheral edema from RV dysfunction, S3 and S4 sounds • N/V: from reflex stimulation from pain • Fever: systemic manifestation of inflammatory process from myocardium damage o Ashen skin, diaphoresis, S3 & S4, N/V |
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Unstable angina: S&S |
• Pain unrelieved by rest, position change, nitrate administration (heaviness, pressure tightness, burning, constriction/crushing feeling), pain lasts for more than 30 mins • SNS stimulation: skin may appear ashy, clammy, and cool to touch • Cardio: BP and HR are elevated, BP can drop due to decreased CO, pulmonary edema for LV failure, jugular distension, peripheral edema from RV dysfunction, S3 and S4 sounds • N/V: from reflex stimulation from pain • Fever: systemic manifestation of inflammatory process from myocardium damage o Ashen skin, diaphoresis, S3 & S4, N/V |
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STEMI/NSTEMI/MINOCA diagnosis |
STEMI: • Presence of criteria o Retrosternal chest pain o Increased cardiac markers (troponin) o ECG changes • ECG changes: increase ST segment > 0.1 mm in 2 adjacent leads or new LBBB • Q wave is a sign of complete/prolonged coronary occlusion • Common complication • Emergency situation (requires patient to arrive in Cath lab 90 mins after diagnosis -> PCI) NSTEMI: • Presence of retrosternal chest pain and an increase in cardiac markers without ECG changes MINOCA • Myocardial infarct from non-obstructive coronary arteries is microvascular CAD (formerly Syndrome X) • Typical angina/ chest pain that is relieved by rest or nitroglycerin. • Normal coronary arteriograms (eg, no atherosclerosis, embolism, or inducible arterial spasm) • Some of these patients have ischemia detected during stress testing; others do not. • If presenting with ACS, troponin levels will rise. No ECG changes |
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Unstable angina: S&S |
• Pain unrelieved by rest, position change, nitrate administration (heaviness, pressure tightness, burning, constriction/crushing feeling), pain lasts for more than 30 mins • SNS stimulation: skin may appear ashy, clammy, and cool to touch • Cardio: BP and HR are elevated, BP can drop due to decreased CO, pulmonary edema for LV failure, jugular distension, peripheral edema from RV dysfunction, S3 and S4 sounds • N/V: from reflex stimulation from pain • Fever: systemic manifestation of inflammatory process from myocardium damage o Ashen skin, diaphoresis, S3 & S4, N/V |
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STEMI/NSTEMI/MINOCA/silent ischemia diagnosis |
STEMI: • Presence of criteria o Retrosternal chest pain o Increased cardiac markers (troponin) o ECG changes • ECG changes: increase ST segment > 0.1 mm in 2 adjacent leads or new LBBB • Q wave is a sign of complete/prolonged coronary occlusion • Common complication • Emergency situation (requires patient to arrive in Cath lab 90 mins after diagnosis -> PCI) NSTEMI: • Presence of retrosternal chest pain and an increase in cardiac markers without ECG changes MINOCA • Myocardial infarct from non-obstructive coronary arteries is microvascular CAD (formerly Syndrome X) • Typical angina/ chest pain that is relieved by rest or nitroglycerin. • Normal coronary arteriograms (eg, no atherosclerosis, embolism, or inducible arterial spasm) • Some of these patients have ischemia detected during stress testing; others do not. • If presenting with ACS, troponin levels will rise. No ECG changes Silent Ischemia • Seen most often in diabetics, they can develop myocardial ischemia without any symptoms. • Usually found during routine ECG. • Unknown mechanism, possibly due to loss of peripheral nerve endings, higher pain threshold, higher levels of endorphins. |
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Info about ECG changes post STEMI and Troponin info |
ECG • After STEMI event, the ECG will never return to normal, so they will have a new baseline Troponin • Troponin T and Troponin I • High specificity and sensitivity for myocardial injury • Increase 3-12 h after onset • Peak at 24-48h • Return to baseline at 5-14 days |
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PPT info for ACS interventions: OVEN |
OVEN: • Oxygen (airway) o Effective agent in an emergency situation To increase O2 supply in blood Should be administered if: • Dyspneic • Hypoxemic • Obvious signs of HF • ** only if O2 Sat <90%/according to protocol ** Start with 2L/min (*or 4L/min if on cardio floor ), increase rate or change to facemask • Vital signs • ECG • Nitroglycerin as per MD/NP o Indicated for Angina/MI, Acute Pulmonary Edema o Action: vasodilates peripheral vessels and coronary arteries: blood flow through coronaries and collaterals ↓systemic vascular resistance ↓preload and O2 consumption ↓blood return to ♥ • Stay with the client and maintain a calm approach • Ask pt to stop everything and return to bed/ position bed in semi-Fowler’s • Advise the physician • Start a peripheral IV (Administer morphine, ASA, heparin as per MD/NP) |
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Textbook ACS interventions for initial nursing management |
• Oxygenation o Ensure patent airway. o Administer O2 by nasal cannula or nonrebreather mask. • Cardiac monitoring o Obtain 12-lead ECG. o Initiate continuous ECG monitoring and identify underlying rhythm. o Obtain portable chest radiograph. • Insert two IV catheters. • Assess pain, using “PQRST” mnemonic (see Table 36-7). o Medicate for pain as ordered (e.g., morphine, nitroglycerin). • Obtain baseline blood test results (e.g., cardiac markers). o CBC, electrolytes, troponin • Hemodynamic/cardiac medications o Assess for antiplatelet, anticoagulation, or fibrinolytic therapy or for PCI o Administer ASA (Aspirin) and β-adrenergic blockers for cardiac- related chest pain unless contraindicated. o Administer antidysrhythmic medications as indicated. |
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Pharm interventions for ACS/CAD/angina |
nitroglycerin ACEi/ARB Beta-blocker CCB Statins Morphine ASA/antiplatelets Diphosphate receptor antagonist (clopidogrel) Heparin WHAT DOES PCI STAND FOR |
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Pleural effusion: patho, causes, Tx |
• Pathophysiology o An accumulations of fluid within the pleural space. o They have multiple causes and usually are classified as transudates or exudates. o Thoracentesis and pleural fluid analysis are often required to determine cause. o Transudative effusions are caused by some combination of increased hydrostatic pressure and decreased plasma oncotic pressure. • Causes o Heart failure is the most common cause, followed by cirrhosis with ascites and by hypoalbuminemia, usually due to the nephrotic syndrome. o Exudative effusions are caused by local processes that lead to increased capillary permeability, resulting in exudation of fluid, protein, cells, and other serum constituents. o Causes are numerous; the most common are pneumonia, cancer, pulmonary embolism, viral infection, and tuberculosis. • Treatment: chest tube • Symptomatic transudates and almost all exudates require thoracentesis, chest tube drainage, pleurectomy, or a combination |
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Pericarditis: patho, S&S, Tx |
• Pathophysiology o Acute pericarditis develops quickly, causing inflammation of the pericardial sac and often a pericardial effusion. Inflammation can extend to the epicardial myocardium (myopericarditis). Adverse hemodynamic effects and rhythm disturbance are rare, although cardiac tamponade is possible. o More common among males, especially post COVID, sometimes post vaccine
• S&S o Chest pain – Typically sharp and pleuritic, improved by sitting up and leaning forward. o Pericardial friction rub – A superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border. o Electrocardiogram (ECG) changes – New widespread ST elevation or PR depression. o CRP elevation o Pericardial effusion. Treatment • ASA (high dose NSAIDs) o High dose NSAIDs are used for their anti-inflammatory property. o ASA 650mg po QID or Ibuprofen 600mg po TID o Increased bleeding risk o Given with PPI (Pantoprazole) to reduce risk of GI bleed • Colchicine is used to reduce the migration of neutrophils to the site of inflammation. o Treatment for a minimum of 3 months o Side effect is diarrhea. |
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Nursing management post cardiac event |
• Monitor for recurrent pain, dysrhythmias, and potential post MI complications • Perform post PCI assessments to quickly recognize complications related to the procedure • Promote rest and comfort while encouraging gradual activity resumption when indicated • Provide emotional support From textbook • Monitor vital signs, level of consciousness, cardiac rhythm, and O2 saturation. • Monitor response to medications (e.g., decrease in chest pain) and readminister or titrate medications (e.g., nitroglycerin) as needed. • Provide reassurance and emotional support to patient and family. • Explain all interventions and procedures to patient in simple terms. • Anticipate need for intubation if respiratory distress is evident. • Prepare for CPR, defibrillation, transcutaneous pacing, or cardioversion. |
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Chest tubes: indications |
• Chylothorax: Collection of lymph/chyle fluid in the pleural space • Hemothorax: Collection of blood in the pleural space • Pleural effusion: Exudate or transudate in the pleural space • Pneumothorax: Collection of air in the pleural space • Tension Pneumothorax: Air builds up in the pleural space and forces a mediastinal shift leading to decreased venous return to the heart and lung collapse/compression causing acute life-threatening respiratory and cardiovascular compromise. |
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Chest tubes: indications |
• Chylothorax: Collection of lymph/chyle fluid in the pleural space • Hemothorax: Collection of blood in the pleural space • Pleural effusion: Exudate or transudate in the pleural space • Pneumothorax: Collection of air in the pleural space • Tension Pneumothorax: Air builds up in the pleural space and forces a mediastinal shift leading to decreased venous return to the heart and lung collapse/compression causing acute life-threatening respiratory and cardiovascular compromise. |
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Chest tube: nursing care after insertion, post-removal |
Nursing care q shift • Ensure that there is emergency equipment at bedside including: o At least two drain clamps per drain (For use in emergency only) o Two suction outlets - x1 chest drain and x1 for airway management • Auscultate the chest • Assess the chest tube and system tubing (i.e. for kinks, dislodgement etc) as well as the drain dressing to ensure it is intact and for any signs of infection or leakage. • Check that the drain is anchored appropriately. • Check that collection system is secure (taped to floor). • Drain is on suction and that the amount of suction correlates with the medical team order. • Assess for any leakages or movement in water chamber o Monitor for bubbling (air leak) • Check that the drain in not clamped (unless ordered by medical staff). • Record on the Pleur-Evac box as well as the In & Out sheet the amount of drainage at the end of every shift. Nursing care post removal • Monitor dressing for leakage. • Ensure dressing covers insertion site and the occlusive dressing is sealed (pink tape). • Monitor vital signs especially respiratory rate and saturation. • Complication post removal: pneumothorax (air gets sucked into the pleural cavity as the tube is being removed). |
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Patient teaching for CAD/ACS/post-STEMI (everything lol) |
Discharge teaching • Diet o Eat foods high in omega-3 (tofu, walnuts, tuna) • Activity (reduce strenuous activity until symptoms have resolves and biomarkers are normalized) • Weight management (weight loss) • Smoking cessation • Alcohol consumption (reduce amount consumed) • Medication (medication adherence) • Symptom recognition (educate on S&S of ACS) • Return to work • Stress management • Return to drive (4 weeks) • Follow up appointment (4 weeks) Discharge teaching: psychosocial adaptation • Depression post cardiac event o Brush with death o Faced with their own mortality o “Survived” o Affects recovery time o Second chance at life • Social support o Spouses, family, friends (Make sure to speak to the family as well since the event has a very significant impact on the surrounding support system) |
