Medsurg: Cardiovascular: Angina Pectoris

Front 1

Pathophysiology of Angina pectoris

Back 1

The imbalance between myocardial blood supply and demand causes temporary and reversible myocardial ischemia.
Reduced O2 -> anaerobic metabolism -> Lactic acid build up -> cell membrane permeability increases -> cell releases histamine, kinins, and enzyme -> stimulate terminal nerve fibers in cardiac muscle -> causes pain in upper body

Front 2

How long does it takes until ischemic cardiac cells becomes necrosis cells (irreversible)?

Back 2

30 minutes

Front 3

Name the 4 types of agina

Back 3

1. Stable angina
2. Prinzmetal's (Variant) angina
3. Unstable angina
4. Silent myocardial ischemia (asymtomatic ischemia)

Front 4

The most common and predictable form of angina.

Back 4

Stable angina

Front 5

Type of angina that occurs with predictable amount of activity or stress.

Back 5

Stable angina

Front 6

Type of angina that is a common manifestation of CHD.

Back 6

Stable angina

Front 7

Type of angina that usually occurs when the work of the heart is increased by physical exertion, exposure to cold, or by stress.

Back 7

Stable angina

Front 8

Type of angina that is releved by rest and nitrate.

Back 8

Stable angina

Front 9

The type of angina that is atypical and occurs unpredictably (unrelated to activity).

Back 9

Prinzmetal's (Variant) angina

Front 10

The type of angina that often occurs at night.

Back 10

Prinzmetal's (Variant) angina

Front 11

The type of angina that caused by coronary artery spasm with or without an atherosclerotic lesion.

Back 11

Prinzmetal's (Variant) angina

Front 12

Prinzmetal's (Variant) angina may result from (3)

Back 12

1. hyperactive sympathetic nervous system responses
2. altered calcium flow in smooth muscle
3. reduced prostagladins to promote vasodilation.

Front 13

The type of angina that occurs with increasing frequency, severity, and duration.

Back 13

Unstable angina

Front 14

The type of angina that have unpredictable pain and occurs with decreasing level of activity or stress and may occur at rest.

Back 14

Unstable angina

Front 15

The type of angina that puts the client at risk for MI.

Back 15

Unstable angina

Front 16

The type of ischemia that is thoght to be common in people with CHD.

Back 16

Silent myocardial ischemia
(asymtomatic ischemia)

Front 17

The type of ischemia that occurs with either activity or with mental stress.

Back 17

Silent myocardial ischemia
(asymtomatic ischemia)

Front 18

How does mental stress contributes to Silent myocardial ischemia
(asymtomatic ischemia)?

Back 18

Mental stress -> increases HR and BP -> increasing myocardial oxygen demand.

Front 19

What is the cardinal manifestation of angina?

Back 19

Chest pain

Front 20

Angina pain is typically precipitated by (5)

Back 20

1. physical activity
2. strong emotion
3. stress
4. eating heavy meal
5. cold exposure

Front 21

Describe locations of angina pain (3)

Back 21

1. tight, squeezing, heavy pressure, or constricting sensation
2. begins beneath sternum and may radiate to jaw, neck, or arm.
3. maybe felt in jaw, epigastric region, or back

Front 22

Describe the duration of anginal pain

Back 22

usually lasts less than 15 minutes

Front 23

What are the associated manifestation of angina? (5)

Back 23

1. Dyspnea
2. Pallor
3. Tachycardia
4. Anxiety
5. Fear

Front 24

Relieving factors for anginal pain (3)

Back 24

1. rest
2. position change
3. nitroglycerine

Front 25

List the diagnostic tests for angina pectoris (5)

Back 25

1. electrocardiography
2. stress electrocardiography
3. radionuclide testing
4. echocardiography
5. coronary angiography

Front 26

How does the ECG appeared during the period of ischemia? (2)

Back 26

1. ST segement is depressed or downward slopping
2. T wave may flatten or invert

Front 27

What are the purposes of the radionuclide testing?

Back 27

to evaluate myocardial perfusion and left vetricular function.

Front 28

Decribe the process of the radionuclide testing?

Back 28

A very small amount of radioisotope (Thallium 201) is injected intraveneously, and the heart is scanned with radiation detector. The ischemic or infarcted cells of the myocardium do not take up the radioisotope normally, appearing as a "cold spot" on the scan.

Front 29

How does radionuclide testing evaluate left ventricular function?

Back 29

the ejection fraction (portion of blood ejected from the left ventricle during systole) normally increases during exercise, may actually decrease in CHD and stress-induced ischemia.

Front 30

How is radionuclide testing done on cleint who are physically unable to exercise or to detect subclinical myocardial ischemia?

Back 30

In combination with vasodilator is injected to induced the same ischemic changes that occurs with exercise in the disease heart.

Front 31

Decribe myocardial steal syndrome during radionuclide testing.

Back 31

Coronary arteries unaffected by atherosclerosis dilate in response to the vasodilator drug, increasing blood flow to the already well-perfused tissue. This reduces flow to the ischemic muscle called myocardial steal syndrome.

Front 32

How does echocardiography work?

Back 32

High-frequency sound waves emitted from a transducer are reflected off of heart structures back to the transducer as echoes. These echoes are displayed on a screen revealing heart structure.

Front 33

This machine uses ultrasound to identify abnormal blood flow patterns as well as cardiac structures.

Back 33

Transesophageal echocardiography (TEF)

Front 34

What is the standard diagnostic test used for evaluating the coronary arteries?

Back 34

Coronary angiography

Front 35

How does Coronary angiography works?

Back 35

Guided by fluoroscopy, a catheter introduced into the femoral or brachial artery is treaded into the coronary artery. Dye is injected into each coronary opening, allowing visualization of the main coronary branches and any abnormalities such as stenosis or obstruction.

Front 36

What drug maybe injected into Pt. who is receiving angiogram and why?

Back 36

Ergonovine, to reduce coronary artery spasm and diagnose Prinzmetal's angina.

Front 37

Preoperative teaching:
Coronary angiography (6)

Back 37

1. You will be awake
2. It takes 1 to 2 hours
3. You may feel warm when the dye is injected
4. You may taste metalic in you mouth when the dye is injected.
5. You may experience "rapid pulse" or "skipped heart beat", this is normal
6. Void prior to going to cardiac cath lab.

Front 38

Does Pt. continues to receive regullarly ordered cardiac medications prior to receiving Coronary angiography?

Back 38

Yes, unless contraindicated.

Front 39

Preoperative assessment:
Coronary angiography (5)

Back 39

1. Pt's and family's knowlwdge and understanding of the procedure.
2. Hypersensitivity to iodine, radiologic contrast media, or seafood.
3. Baseline vital signs, height, and weight.
4. Mark the location of peripheral pulses
5. Document pulse equality and amplitude.

Front 40

Postoperative assessment:
Coronary angiography (4)

Back 40

1. vital signs
2. cath site for bleeding and hematoma
3. peripheral pulses
4. neurovascular status

Front 41

How often should postoperative assessment of Pt. who underwent coronary angiography ?

Back 41

every 15 minutes for the first hour, every 30 minutes for the nest hour, then hourly for 4 hours or until discharge.

Front 42

Postoperative Pt. teaching:
Coronary angiography

Back 42

1. Maintain bed rest as ordered
2. Elevate head of the bed by 30 degree
3. Keep a pressure dressing, sandbag, or ice pack in place over the arterial access site.
4. Avoid flexing or hyperextending the affected extremity for 12 to 24 hours.
5. Liberal fluid intake
6. Provide instruction on dressing changes
7. Followup appointment
8. Information on potential complications.

Front 43

Postoperative Pt. teaching Coronary angiography: what are signs that should be reported promptly?

Back 43

1. Deminished peripheral pulses
2. Formation of new hematoma or enlargement of and existing one
3. Severe pain at the insertion site or at the affected extremity
4. Chest pain
5. Dyspnea

Front 44

What is the goal of drug treatment for angina pectoris?

Back 44

To reduce oxygen demand and increase oxygen supply to the myocardium.

Front 45

What are the three main classes of drugs used to treat angina?

Back 45

1. Nitrate
2. Beta Blockers
3. Calcium channel blockers

Front 46

Nitroglycerin (8)

Back 46

1. Nitropaste
2. Nitro-Dur
3. Nitro-Bid
4. Nitrol
5. Transderm-Nitro
6. Nitrogard
7. Nitrodisc
8. Tridil
Class: Organic Nitrates

Front 47

Isosorbide dinitrate

Back 47

Isordil
Class: Organic Nitrates

Front 48

Isosorbide mononitrate

Back 48

ISMO
Class: Organic Nitrates

Front 49

Amyl Nitrate

Back 49

Class: Organic Nitrates

Front 50

What are indications of Nitrates? (2)

Back 50

1. Treat acute angina attacks
2. To prevent angina

Front 51

What is the drug of choice to treat acute angina? Why?

Back 51

Sublingual nitroglycerine; It acts within 1 to 2 minutes.

Front 52

Rapid-acting nitroglycerine is available in what forms?

Back 52

1. Sublingual nitroglycerine
2. Buccal Spray
3. Metered system

Front 53

How does fast-acting nitroglycerin works? (2)

Back 53

1. Decreasing myocardial work and oxygen demand through venous and arterial dilation.
2. Improve myocardial oxygen supply by dilating collateral blood vessels and reducing stenosis.

Front 54

What is the purpose of Longer-acting nitroglycerin?

Back 54

To prevent attacks of angina, not to treat an acute attack.

Front 55

What is the primary problem with long-term nitrate?

Back 55

The development of tolerance.

Front 56

How is development of tolerance to long-term nitrate prevented?

Back 56

By setting a dosing schedule that allows a nitrate-free period of at least 8 to 10 hours daily. This is usually schedule at night.

Front 57

What are the common side effects of Nitrate?

Back 57

1. Headache
2. Nausea
3. Dizziness
4. Hypotension

Front 58

How does coronary vasodilation relieves anginal pain?

Back 58

Vasodilation increases blood flow to the heart and in turns increases oxygen supply.

Front 59

How does venous dilation relieves anginal pain? (4)

Back 59

Venous dilation allows
1. Peripheral blood pooling
2. Reducing venous return
3. Reducing preload
4. Reducing cardiac work

Front 60

How does arterial dilation relieves anginal pain? (3)

Back 60

1. Reduces vascular resistance
2. Reduces preload
3. Reduces cardiac work

Front 61

Nitrate: Nursing responsibilities: IV Nitroglycerin (3)

Back 61

1. Dilute before infusing
2. Use only glass bottle for mixing
3. Use non-PVC infusion tubing

Front 62

Nitrate: Nursing responsibilities: Nitroglycerine paste (3)

Back 62

1. Wear gloves when applying paste
2. Measure does carefully
3. Spread evenly in a 2-by-3 inch area

Front 63

Client teaching: What form of nitrate can be used to treat acute angina?

Back 63

1. Sublingual
2. Buccal
3. Spray

Front 64

Name the 4 types of revascularization procedures

Back 64

1. Percutaneous coronary revascularization (PCR)
2. Coronary artery bypass grafting
3. Minimally invasive coronary artery surgery
4. Transmyocardial laser revascularization

Front 65

Percutaneous Coronary Revascularization (PCR) is used to treat client with:

Back 65

1. Moderately severe, chronic stable angina unrelieved by medical therapy
2. Mild angina but objective evidence of coronary ischemia
3. Unstable angina
4. Acute myocardial infarction

Front 66

PCR procedures

Back 66

1. A catheter is introduce into the arterial circulation is guided into the opening of the narrowed coronary artery.
2. A flexible guidewire is then used to thread an angioplasty ballon, arterial stent, or other therapeutic device into the narrowed segment of the artery.

Front 67

What kind of anesthesia is use during PCR procedures?

Back 67

Local anesthesia

Front 68

What is Percutaneous transluminal coronary angioplasty (PTCA) is primary use in combination with? Why?

Back 68

Stent placement or atherectomy; PTCA has a high risk of abrupt vessel closure and restenosis.

Front 69

What are the complications of PCR procedures (8)?

Back 69

1. Hematoma at the catheter reinsertion site
2. Embolism
3. Hypersensitivity to contrast dye
4. Dysrhythmias
5. Bleeding
6. Vessel perforation
7. Restenosis
8. Reocclusion of the treated vessel

Front 70

PCR: Preoperative teaching.

Back 70

Possible sensation:
1. Flushing or warm sensations as contrast dye is injected
2. Metallic taste in the mouth as contrast dye is injected
3. Feeling of pressure or chest pain during the balloon inflation

Front 71

PCR: Postoperative assessment.

Back 71

1. Head to Toe assessment
2. Note any complaint of chest pain
3. Note evidence of decrease cardiac output or MI

Front 72

PCR: Post operative monitoring

Back 72

1. Vital signs and cardiac monitoring continuously
2. Signs of ischemia (if develop, obtain a 12-lead EKG and notify physician)
3. Chest pain
4. Distal pulses, color, movement, sensation, and temperature of the effected leg.
5. I&O
6. Serum electrolytes, BUN, Creatinine, CBC, PTT, and cardiac enzyme

Front 73

How often should the nurse monitor distal pulses, color, movement, sensation, and temperature of the effected leg of a patient who underwent PCR?

Back 73

Every 15 minutes for the first hour, every 30 minutes for the next hour, every 8 hours for next 8 hours, then every 4 hours.

Front 74

PCR: During sheath removal, what should the nurse monitor for?

Back 74

1. Bradycardia
2. Lightheadedness
3. Hypotension
4. Diaphoresis
5. Loss of consciousness

Front 75

PCR: During sheath removal the nurse must be sure to have what at the bed site and why?

Back 75

Atropine, because vasovagal reaction. Atropine decreases vagal tone and increases heart rate.

Front 76

What is coronary artery bypass grafting (CABG)

Back 76

A patent blood vessel from another part of the body is grafted to the affected coronary artery distal to the lesion. The new vessel bypasses the obstruction.

Front 77

What vessels are the most commonly used in CABG?

Back 77

1. Internal mammary arteries.
2. Greater or lesser saphenous veins from the legs
3. Basilic veins

Front 78

CABG is recommended for what types of patient?

Back 78

1. Multiple vessel disease
2. Impaired left ventricular function
3. Diabetes
4. Significant obstruction of the left main coronary artery

Front 79

CABG: Preoperative laboratory and diagnostic tests

Back 79

1. CBC
2. Coagulation profile
3. Urinalysis
4. Chest X-Ray
5. Coronary angiogram
6. Type and Cross match

Front 80

Patient underwent CABG usually leave the operating room with what in place?

Back 80

1. Systemic arterial catheter
2. Pulmonary artery catheter

Front 81

What are the early complications from heart surgery?

Back 81

1. Hypotension or hypertension
2. Hemorrhage
3. Dysrhythmias
4. Decreased cardiac output
5. Fluid and electrolyte imbalance
6. Pericardial bleeding
7. Fever or hypothermia
8. Poor gas exchange
9. Gastric distension
10. Changes in level of consciousness

Front 82

What are the sings of cardiac tamponade?

Back 82

1. Increase heart rate
2. Decrease BP
3. Decrease urine output
4. Increase central venous pressure
5. Sudden increase in chest tube output
6. Muffle/distance heart sounds
7. Diminish distal pulses

Front 83

What are the main goals of nursing care for patient with angina?

Back 83

1. Reduce myocardial oxygen demand
2. Improve oxygen supply

Front 84

Name two nursing diagnosis for patient with angina

Back 84

1. Ineffective tissue perfusion: Pain
2. Risk for ineffective therapeutic regimen management

Front 85

What are the nursing interventions for ineffective tissue perfusion: pain, due to angina?

Back 85

1. Have nitroglycerin tablets at bed side.
2. Start oxygen at 4 to 6 L/min
3. Teach about long-acting and short-acting medications.
4. Instruct Pt. to take sublingual nitroglycerin prior to activities that precipitate angina.
5. Encourage Pt. to implement and maintain an exercise program.
6. Refer to a smoking cessation program

Front 86

What are the nursing interventions for risk for ineffective therapeutic regimen management?

Back 86

1. Assess knowledge and understanding of angina.
2. Teach about angina as needed.
3. Provide written and oral instructions about prescribed medications and their use.
4. Stress the importance of chest pains seriously while maintaining a positive attitude.
5. Refer to a cardiac rehabilitation program or other organized activities and support group.

Front 87

What teaching should be included in home care for patient with angina?

Back 87

1. The relationship between the pain and reduce blood flow to the heart muscle.
2. Use and effects of prescribed medications.
3. Do not stop medications abruptly.
4. Nitroglycerine use for acute angina.
5. The importance of calling 911 or going to the ER immediately for unrelieved chest pain.
6. Appropriate storage of notroglycerine

Front 88

Teaching: Nitroglycerine use for acute angina

Back 88

1. Always carry several tablets (not entire supply)
2. Prophylactic use before activities that often cause chest pain
3. Take tablet at first indication of pain rather than waiting to see of the pain develops
4. Seek immediate medical assistance if three nitroglycerine tablets over 15 to 20 minutes do not relieve the pain
5. Storage in cool, dry, dark place.
6. No more than 6 month supply should be kept on hand.

Front 89

Teaching for Pt. undergone cardiac surgery should include:

Back 89

1. Respiratory care, activity, and pain management
2. The importance of actively participating in rehabilitation
3. Manifestation of infection or other potential complications and their management.