Medical 6-MS41-Intreventions Critically Ill With Acute Coronary Syndromes

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Coronary artery disease is a broad term that includes?: stable angina pectoris
acute coronary syndromes
Coronary artery disease affects which arteries?: provides blood, oxygen, and nutrients to the myocardium
Define infarction?: necrosis or cell death occurring when severe ischemia is prolonged and irreversible damage to tissue results
Define ischemia?: occurs when insufficient oxygen is supplied to meet the requirements of the myocardium
Which ethnic groups have a higher risk of CAD?: Black and Hispanic women
Define angina pectoris?: "strangling of the chest"...temporary imbalance between coronary arteries' ability to supply oxygen and the cardiac muscle's demand for oxygen
Ischemia that occurs with angina is _________ in duration, and it doesn't cause permanent damage of myocardial tissue: limited
What two types of angina are there?: stable
unstable
Define stable angina?: chest discomfort that occurs with moderate to prolonged exertion in a pattern that's familiar to the chest
The frequence, duration, and intensity of stable angina symptoms remains?: stable over preceding several months
Stable angina results in only slight ________ of _________ and is usually associated with stable _______ plaque: limitation
activity
atherosclerotic
Stable angina is usually relieved by __________ or REST and often is managed medically with _______ _______ _________ and _______-_______ medications.: nitroglycerin
calcium channel blockers
beta-blockers
Rarely does stable angina require _________ treatment.: agressive
Do more men or women experience angina?: women....esp. atypical angina
How does atypical angina manifest itself? Hint: PICA: indigestion
pain between shoulders
aching jaw
choking sensation on exertion
Angina in women has often been diagnosed as what 5 conditions?: panic disorder
stress
menopause-related prolonged
GI disease
hypochondriasis
What happens to coronary arteries in acute coronary syndromes? platelet aggregation (clumping) thrombus (clot) formation vasoconstriction: atherosclerotic plaque in the coronary artery ruptures...this results in what 3 things?
The amount of disruption of the atherosclerotic plaque determines the degree of?: obstruction of the coronary artery and the specific disease process (unstable angina or MI)
What percentage of clients with unstable angina progress to having an MI in 1 year and what percentage dies of MI in 5 years?: 10% to 30%

29%
Define unstable angina (USA)?: chest pain or discomfort that occurs at rest or with exertion and causes marked limitation of activity
What 2 criteria characterize USA? 15 minutes, or it may be poorly relieved by rest or nitroglycerin: an increase in the number of
attacks
increase in intensity of
pain...the pain may last
longer than?
What are some broad spectrums of USA?: new-onset angina
variant (Prinzmetal's) angina
preinfarction angina
crescendo angina
Which disorders make up acute coronary syndromes?: unstable angina
subendocardial MI
MI or heart attack (most
serious)
Define MI?: occurs when myocardial tissue is abruptly and severely deprived of oxygen
Ischemia can develop when how much blood flow is acutely reduced?: 80% to 90%
What are most MIs the result of? coronary artery spasm platelet aggregation emboli from mural thrombi (thrombi lining the walls of cardiac chambers): atherosclerosis of a coronary
artery...resulting in
rupture of the plaque...subsequent thrombosis...occlusion of blood flow...what other 3 factors may be implicated?
Often MIs begin with infarction (necrosis) of which layer? has longest myofibrils greatest oxygen demand poorest oxygen supply: subendocardial...and why is that?
What two zones are around the initial area of infarction (zone of necrosis)?: zone of injury (tissue that is injured, but not necrotic)

zone of ischemia (tissue that is oxygen deprived
How does atypical angina manifest itself?: indigestion
pain between shoulders
aching jaw
choking sensation on exertion
What 5 conditions in women has often been diagnosed in women with angina?: panic disorder
stress
menopause-related problems
GI disease
hypochondriasis
What happens with acute coronary syndromes? obstruction of the coronary artery and the specific disease process (unstable angina or myocardial infarction): atherosclerotic plaque in
coronary artery ruptures...results in platelet aggregation
("clumping")
thrombus (clot) formation
vasoconstriction...

the amount of disruption of atherosclerotic plaque determines the degree of?
What percentage of patients with USA progress to an MI in one year and what percentage die of MI in 5 years?: 10% to 30%

29%
What characterizes USA? 15 minutes, or it may be poorly relieved by rest or nitro: increase in the number of
attacks
increase in intensity of pain...pain may last longer than?
USA describes a broad spectrum of which disorders?: new-onset angina
variant (Prinzemetal's)
angina
preinfarction angina
crescendo angina
What is the term used to describe unstable angina, subendocardial MI and MI?: acute coronary syndromes
MI is a heart attack and is the most serious of acute coronary syndromes and occurs when blood flow is acutely reduced by what percentage?: 80% to 90%...this is when ischemia develops
Ischemia can lead to injury and necrosis which is termed?: infarction
What are most MIs a result of? (4) coronary artery spasm platelet aggregation emboli from mural thrombi (thrombi lining walls of cardiac chambers): atherosclerosis of a coronary artery
rupture of plaque
subsequent thrombosis
occlusion of blood flow...what other 3 factors may be implicated?
What layer is initially affected by MI? has longest myofibrils greatest oxygen demand poorest oxygen supply: subendocardial...and why is that?
What are 2 other zones that are injured, but not necrotic due to MI?: zone of injury (tissue that is injured but not necrotic)

zone of ischemia (tissue that is oxygen deprived)
Hypoxia is a dynamic process that doesn't occur instantly, rather evolves over how many hours?: several
How does hypoxia from ischemia affect blood vessels and acid base balance?: increase vasodilation and acidosis in localized area
What leads to suppression of normal conduction and contractile functions when hypoxia occurs? epinephrine and NE...and what does this cause?: imbalance of calcium, potassium, magnesium as well as acidosis at cellular level...automaticity and ectopy are enhanced...which catecholemines are released in response to hypoxia and pain?

increase in heart rate, contractility and afterload...increasing oxygen requirements in tissue that's already deprived extending in the two other zones
What 3 factors determine the actual extent of the zone of infarction?: collateral circulation
anaerobic metabolism
workload demands on the
myocardium
Define subendocardial MI? transumural which has more effect on wall motion and cardiac output: involves only subendocardium which is the initial site of injury...can also spread to other layers of cardiac muscle which is termed?
How many hours does it take for obvious physical changes to occur following MI? gray with yellow streaks and why is this? 8-10 days...and what happens over 2-3 months? because scar tissue permanently changes size and shap: about 6 hours when infarcted area appears blue and swollen...what color does it appear after 48 hours?

neutrophils invade the tissue and begin to remove necrotic cells...granulation tissue forms at the edges of necrotic tissue after how many days?

necrotic area eventually develops into a shrunken, thin, firm scar..and why is this significant?

ventricular remodeling...and what does it cause?
The patient's response to an MI depends on what?: which coronary artery(s) were obstructed and which part of the LEFT ventricle was damaged:
lateral?
anterior?
septal?
inferior?
posterior?
What does the left anterior descending coronary artery perfuse? anterior or septal MIs...and accounts for what percentage of MIs? a large segment of left ventricle may have been damaged: most of the left ventricular
muscle mass and septum...so obstruction of LAD causes which kind of MI?

25% (highest mortality rate)...these patients are most likely to experience LEFT ventricular heart failure and ventricular dysrhythmias because?
What does the left circumflex coronary artery perfuse? posterior wall MI or lateral wall MI and sinus dysrhthmias: posterior wall of left
ventricle
SA node in 39% of clients
AV node in 12% of clients
Left ventricular musle in
10% of clients...these patients may experience what kind of MI?
What does the right coronary artery perfuse? inferior wall MIs...accounts for what percentage of all MIs? 10%...up to 50% of all inferior wall MIs are associated with an occlusion of right coronary artery, causing significant damage: right ventricle
inferior portion of left
ventricle
SA node in 59%
AV node in 88%...clients will most likely experience what kind of MIs?

17% and what is the mortality rate percentage?
What is the primary factor in the development of CAD?: atherosclerosis
What are nonmodifiable risk factors?: personal elements that cannot be altered or controlled
ex: age
gender
family history
ethnic background
What is the average age of a man having a first heart attack?: 66 yo
What is the average age of a woman having a first heart attack?: 70 yo
Define modifiable risk factors? (7): elevated serum cholesterol
levels
cigarette smoking
hypertension
impaired glucose tolerance
obesity
physical inactivity
stress
LDL cholesterol is good or bad cholesterol?: bad
The goal for LDL levels in patiens who have existing CAD or diabetes mellitus is?: less than 100 mg/dL
The goal for HDL levels in patients who have existing CAD or diabetes mellitus is?: more than 40 mg/dL
Cigarette smoking accounts for what percentage of mortality rate from CAD?: 30%
Nicotine initiates the release of catecholamines which results in? increased blood pressure cardiac afterload oxygen consumption... what can cigarette smoking to the vessels? clot formation vessel occlusion...smo: an increased heart rate and peripheral vasoconstriction...this results in?

cause endothelial dysfunctino and increased vessel wall thickness which increases risk for?

hypertension which increases vessel wall permeability...when smokingn stops, so does the risk
Physical inactivity may be the most important risk factor with what percentage having a greater risk of developing high BP, predisposing them to CAD: 30% to 50%
For women, what disease seriously increases risk of CAD?: diabetes (impaired glucose
tolerance)
Key features of angina?: substernal chest discomfort
radiating to left arm
precipitated by exertion
or stress
relieved by nito or rest
lasting less than 15 min

(there are few associated
symptoms)
Key features of MI?: substernal chest pressure
radiating to left arm, back
or jaw
occurring without cause,
usually in morning
relieved only by opioids
lasting 30 min or more

frequent associated symptoms:
nausea
diaphoresis
dyspnea
feelings of fear and
anxiety
dysrhythmias
fatigue
epigastric distress
feeling "short of breath"
To make a correct CV assessment, the following are crucial? (4) distal peripheral pulses skin temperature...how should the skin feel? cool diaphoretic diminished, absent pulses...all 3 of these are due to poor?: #1 IMMEDIATELY ASSESS:
blood pressure
heart rate
interpret cardiac rhythm
dysrhythmias present?
ex: sinus tachycardia
PVCs

#2 what are the NEXT conditions to assess?

warm, with all pulses palpable...what might the skin of a patient with unstable angina or MI feel like?

cardiac output

#3 auscultate for an S3 gallop which indicates?

because of anxiety and pain, but what might crackles and wheezes indicate?

previous MI
hypertension

#5 a temperature elevation for several days after MI may be as high as?
What heart abnormalities frequently occur within the first few hours after an MI?: sinus tachycardia
premature ventricular
contractions
S3 and which condition go together?: HEART FAILURE
S4 and which 2 conditions go together?: previous MI
hypertension
What psychosocial reaction is common with chest discomfort associated with angina or MI?: denial
On the average, the client with an acute MI will wait how many hours before seeking medical attention? denial...teach patient to report ANY discomfort...3 other common reactions are?: 2 hours...and this is because of?

fear, anxiety, anger
At present NO SINGLE ideal test to diagnose MI exists? troponin T and I creatinine kinase-MB (CK-MB) myoglobin A chest x-ray is not diagnostic for angina or MI unless there is?: true...what are the most common diagnositic tests for MI? (3)

associated cardiac dysfunction (e.g. valvular disease) or heart disease
What does a twelve-lead ECG show?: occurrence and location of ischemia (angina) or necrosis (infaraction)
An ischemic myocardium does not _________ normally? ST T-wave: repolarize...thus, 12-lead ECGs, obtained during an anginal episode reveals _______ depression, _________
inversion, or both.
Define variant angina? ST T old: caused by coronary vasospasm, u;sually causing elevation of ________ segment during anginal attacks...the ST- and T- wave changes usually subside when the ischemia is resolved and pain is relieved; however, the ____ wave may remain flat or inverted for a period of time. If the client is not experiencing angina at the moment of the test, the ECG for the patient with angina is normal unless the patient has evidence of an _____ MI
What 3 ECG changes are usually observed when infarction occurs? ST: ST-segment elevation
T-wave inversion
abnormal Q wave (wider than
0.04 seconds or more than
one third the height of
the QRS complex)....
women who have an MI however, may not have an ______segment elevation
With MI, the Q wave develops because? ST T Q: necrotic cells do not conduct electrical stimuli...hours to days after the MI, the ______ segment and _____wave changes will return to normal, but the _____ wave usually remains permanently
By identifying the lead in which the ECG changes are occurring, the hcp can identify the?: location and extent of infarction
Define exercise tolerance (stress test)? ECG consistent with ischemia...and evaluates medical therapy and identifies those who might benefit from referral for invasive therapy...some may use pharmcologic stress testing using agents such as?: hcp orders after acute stages of anginal episode or MI...assesses for what changes?

adenosine (Adenocard)
dobutamine (Dobutrex)...

women are better diagnosed using echocardiography stress test rather than the ______ stress test
What are myocardial perfusion imaging (MPI) or thallium scans? ischemia or necrotic muscle tissue related to what two conditions? cold spots which identify ischemia or infarction...thallium may also be used with? dipyrida: use radioisotope imaging to assess for what 2 conditions?

angina
MI...

what are the areas of decreased or absent perfusion referred to as?

exercise tolerance testing...what other type of thallium scanning may be used? HINT: DTS
What is magnetic resonance imaging (MRI)?: contrast-enhanced noninvasive approach to detect MI
What is cardiac catheterization? coronary... this study allows cardiac surgeon and cardiologist to identify clients who might benefit from which 2 types of procedures?: performed to determine extent and exact location of obstructions of which arteries?

percutaneous transluminal angioplasty (PCTA) or CABG
If MI is suspected, but can't be ruled out, where is client admitted?: telemetry unit for continuous monitoring or to a critical care unit if hemodynamically unstable
A priority nursing diagnosis for patient with CAD is? (4 total) Acute Pain related to?: biologic injury agents (imbalance between myocardial oxygen supply and demand)
A priority nursing diagnosis for patient with CAD is? (4 total) Ineffective Tissue Perfusion (Cardiopulmonary) related to?: interruption of arterial blood flow
A priority nursing diagnosis for patient with CAD is? (4 total) Activity Intolerance related to?: fatigue (caused by imbalance between oxygen supply and demand)
A priority nursing diagnosis for patient with CAD is? (4 total) Ineffective Coping related to?: effects of acute illness and major changes in lifestyle
What are the most important collaborative problems the client may be experiencing?: potential for dysrhythmias
potential for heart failure
potential for recurrent
symptoms and extension of
injury
In addition to the common nursing diagnoses and collaborative problems, patients with CAD may have one or more of the following? Ineffective Sexuality Patterns related to? Impaired Physical Mobility related to? Potential: pain and effects of illness

pain or fear of movement
How do the elders MI differ from others?: Elders don't complain of pain as much because of cognitive impairment and inability to verbalize sensations of pain...they have more collateral circulation and reduced sensitivity to pain....delay longer in seeking help...if they don't get help, it causes further problems...they should be treated aggressively with beta blockers, angiotensin converting enzymes, and statins if necessary
An expected outcome with CAD is that patient is EXPECTED to state that pain, if present, is relieved. provide pain relief modalities decrease myocardial oxygen demand (ex: using pain relief) increase myocardial oxy: okay...what are 3 interventions for this?
When assessing patient for pain management, what is the correct procedure?: evaluate chest or other
complaints of pain
obtain vital signs
ensure patency of IV accesses
notify hcp of patient's
condition
How does relieving pain help? morphine sulfate and oxygen asprin 325 mg orally nitroglycerin for anginal pain: increases oxygen supply
decreases myocardial oxygen
demand...
what are several strategies?
What does nitroglycerin do for blood flow and coronary arteries?: increases collateral blood
flow
redistributes blood flow
toward subendocardium
causes dilation of coronary
arteries
What should the nurse instruct the patient to do when taking nitro?: hold tablet under tongue, then
drink 5 mL of water if necessary to dissolve

there is also a nitro spray which is absorbed more rapidly
How fast is nitro pain relief? blood pressure pulse respiration pain intensity possible 12 lead EKG possible pain relief med stay with patient if possible If the blood pressure is less than 100 mmHg sy: begins within 1 or 2 minutes and should be clearly evident in 3 to 5 minutes

What should the nurse check after 5 minutes?

lower head of bed, call hcp

if the client is experiencing some but not complete relief and vital signs remain stable, another NTG tablet or spray may be given to relieve ANGINA
If the patient has correctly taken 3 NTG tabs or spray and is not responding well, what might he be experiencing? IMMEDIATELY inform hcp and prepare client for transfer to a specialized unit where close monitoring and appropriate management ca: MI...and what should nurse do?
If a nitro patient not getting good medication response is transferred to a special unit, what might hcp prescribe and how is it prescribed?: IV NTG...the infusion is begun slowly, checking BP, and pain level every 3 to 5 minutes...increase NTG until pain relieved, BP falls excessively, or maximum dose is reached
MONITOR BP CONTINUOUSLY!
Angina scenario: Patient doesn't respond to 3 treatments of nitro within 15 minutes Patient gets transferred to a special unit for IV NTG After pain has subsided and client stabilized, hcp might chang: oral or topical nitrate...during administration of long-term oral and topical nitrates, how many hours of nitrate-free time should be maintained to prevent tolerance?

headache for which the hcp may prescribe?
<Meds to promote oxygenation and circulation for myocardial infarctions... name the coronary vasodilators needed?>: <NTG, nitrates>
<Meds to promote oxygenation and circulation for myocardial infarctions?> What is MOA for beta beta blockers?>: <increases heart rate
decreases work>
<Meds to promote oxygenation and circulation for myocardial infarctions?> <MOA of calcium channel blockers?>: <decrease myocardial O2
demands>
<Meds to promote oxygenation and circulation for myocardial infarctions... <MOA of ACE inhibitors?>: <decrease preload and
decrease afterload...
(SVR) decreases work>
<Meds to promote oxygenation and circulation for myocardial infarctions... <what is the purpose of anti- coagulants when treating MI?>: <prevents new clots>
<Three thrombolytic agents used for treatment of MI?>: <Reteplase
Tenecteplase (TNPase)
Streptokinase>
<Follow along here...the anticoagulants (coagulation modifier agents) are? Reteplase (Retavase) Tenecteplase (TNPase) Streptokinase (Kabbikinase)... what do these do? they BREAK UP existing clots or thrombi or emboli...s: <aspirin
enoxaparin (Lovenox)
dalteparin (Fragmin)
warfarin (Coumadin)
protomine sulfate...
these agents thin the blood and PREVENT clot formation, thrombi, emboli...now, what are the thrombolytic agents?>
<What are the nursing responsibilities during and following administration of fibrinolytic agents such as reteplase (Retavase)? First of all, monitor for possibility of coronary thrombosis every 4 hours: temperature blood pressu: <if systolic blood pressure is greater than 180mmHg or
diastolic blood pressure is greater than 110mmHg>...this is important when consideration medications because?

hypotension and this may result from?
<Patient with MI has angioplasty and is discharged to go home on which meds?>: <aspirin 81 mg po daily
atromid 500mg qid
cardizem cd 12mg daily
NTG paste qd
NTG 4 mg SL 1 q5min x3 prn
for chest pain>
Thrombolytic agents can be administered ____ to ____ hrs following MI?: 4-6 h
Thrombolytic agents can be infused into coronary vessels during which procedure?: heart catheterization
If patient is suffering from nausea and vomiting, then give?: antiemetics
Find out if the patient has Strep throat before giving Streptokinase because?: can increase resistance to Streptokinase...Streptokinase is produced from beta-
hemolytic Streptococci
<Rapid acting nitro includes?: Nitrostat..used for rapid relief of angina.
<Prolonged acting nitro meds include?: Nitrobid
Isordil

(there is also a longer acting nitro-paste and ointment and usually used in chronic nitrate therapy)
<Nitroglycerin is usually taken sublingually because?: of the many blood vessels in mouth and it's readily absorbed.
<After an MI, a patient may be instructed to ____ aspirin because it's more readily absorbed in the mouth. Swallowing takes too long.: chew
<Try not to expose nitro to _____ or _____ and keep in dark place: light
air
<Nitro can cause headaches.: okay
<What are the actions or indications of a nitro drip?: causes venodilation which decreases preload and decreases workload of heart...potent coronary artery vasodilator...decreases pain...give in glass container..plastic absorbs medication
<How many liters per hour should the nurse regulate IV nitro to assure that patient receives dose as ordered at 10 mcg/min?> 50 mg in 250 cc D5W at 10 mcg/min Answer 3 ml/hr: <see powerpoint>
<What nursing precautions are needed with nitro?: blood pressure
monitor pain level every
3 to 5 miniutes
titrate nitro until pain is
relieved...monitor for
headaches....then patient
will ultimately be switched
to an oral or topical
nitro
<Why is morphine usually the choice choice for the management of pain associated with MI?: decreases myocardial oxygen
demand
relieves pain unresponsive to
nitro
decreases circulating
catecholemines...e and ne
<Streptokinase is an antigen so it can cause?: an allergic reaction...if patient has had Strep throat infection recently, they may be resistant to Streptokinase
Since Reteplase and Tenecteplase aren't antigenic, the patient has less chance for?: allergic reaction
<Streptokinase...not fibrin specific, so it can cause?: systemic bleeding...watch for bleeding
<What are some of the nursing responsiblilties during and following administration of fibrinolytic agents? cerebrovascular accident...look for neural changes: bleeding in other locations...bleeding in the brain is serious...so monitor for?
<If patient is have bleeding from Streptokinase, nurse needs to monitor?: coagulation studies including
PT and PTT...assess all IV SITES for BLEEDING...monitor lab, coagulation studies and other possible bleeding sites
<Lidocaine is used for? 1 mg/kg IV push and maintained at about 1 to 4 mg per minute and again it's used to treat ventricular arrhythmias.: arrhythmias and usually given in a bolus dose of?
<Premix: 1 Gm in 250 cc D5W Dosage ordered: 2mg/minute How many cc/min? answer: 0.5 cc/min: see powerpoint
<After angioplasty, the patient may be transferred to which unit?: telemetry
<What are some other diagnostic tests that the doctor may order to determine the extent of cardiac damage?: MUGA
stress test
thallium scan
arteriography
echo
transesophageal TEE
nuclear perfusion imaging
MRI
<ASA (aspirin) is a blood thinner. It's not for?: pain
Aspirin is rough on stomach lining, so take with?: food or take enteric coated aspirin...alcohol has an additive effect on aspirin and can increase anti-platelet aggregation
What should be included when teaching about Atromid clofibrate...a lipid-lowering agent? anticoagulant...that probably why ASA is prescribed instead of a more potent anticoagulant: will decrease lipids in blood
bleeding may be a side
effect..
so watch for bleeding
clofibrate is usually not
given with someone who's
taking an?
What should be included in the teaching regarding Cardizem?: calcium channel blocker
used to prevent angina and
control blood pressure
check blood pressure
regularly and report any
episodes of angina or
increased blood pressure
notify doctor if there's any
shortness of breath or
tachycardia or bradycardia
which are signs of
heart failure
What should be included in teaching with nitroglycerin?: used to reduce pain because
it's a vasodilator for coronary vessels...increases blood flow to heart and gives
it more oxygen and that's what relieves pain. One of the main side effects
they'll have are headaches, and tell them a headache is a problem that lessens over time as they become accustomed to taken NTG.

nitro usually taken SL and call dr. after 15 minutes and 3 pills if it doesn't relieve pain

if patient has paste, let them know that it's for continual use
What should be taught about diet?: low sodium
low fat
low cholesterol
weight reduction
restrict caffeine because
it increases heart rate
What should be included in discharge teaching regarding physical activity and exercise?: moderation...what can be tolerated without pain
T<ake pulse before, during and after excercise. If increase in pulse is greater than ______: 20 bpm is not good...decrease exercise level...if patient has shortness of breath or chest pain...teach them to have nitro handy in case they do have chest pain.>
<Regarding sexual activity, an MI patient should be able to climb: two flights of stairs with
no chest pain
don't participate in sexual
activity after a heavy
meal
talk to spouse or therapist
report chest pain during
activity to doctor>
<CAD is the leading cause of death in men and women in the US.: okay
<How do symptoms of stable angina differ from symptoms of unstable angina?: Unstable
attacks can be repeated
occur at rest
poorly relieved by nitro
and rest
lasts longer than 15
minutes
Stable
occurs on exertion
can usually be relieved by
nitro or rest
<What is the etiology of acute coronary syndrome vs atherosclerotic plaque?: !
<Define atherosclerosis?: okay
<What tests will physician order to determine risk of CAD?: lipid profile
cholesterol (HDL, LDL,
triglycerides)
C-reactive protein
indicates actual damage
to heart

EKG..shows necrosis
stress test looking for EKG
changes during exercise
CXR looking for heart
enlargement
thallium scan which is a
radioisotope image process
where cold spots are
determined and where
blood flow is not good
MUGA..multigated acquisition
scan..used to evaluate left
ventricular ejection and
velocity of that injection
....so it measures left
ventricular strength
ultrasound
echocardiogram
transesophageal endocardio-
graphy...transducer is put
down esophagus so it's
taking a view from behind
the heart...posterior view
phonography...records heart
sounds
myocardial nuclear perfusion
imaging and this detects
cardiovascular
abnormaliites using radio-
active substances, but
amount of radiation dose
is so small that there's
very little risk from the
radiation
MRIs
<Concerning metoprolol, the patient should know that Lopressor?: decreases blood pressure and
heart rate
monitor before adminisitra-
tion
notify doctor if there's
shortness of breath or
wheezing
<What should patient know about nitro?: store in dark place
may have headaches
vasodilator may cause
hypotension...may also
raise heart rate
she may have tachycardia
takes 5-10 minutes to
relieve pain
can take one every 5 minutes
for 15 minutes
if it's relieved after taking
one, don't take anymore
<What is discharge teaching for someone with angina?: lower stress levels
control diet with low fat,
low sodium
monitor exercise
medication teaching (nitro)
<Define C-reactive protein?: first acute phase protein
identified...
binds with phospholipids on foreign substances, activates
complement system, stimulates production of cytokines, and inhibits production of oxygen radicals by neutrophils

INCREASED blood levels of C-reactive protein (CRP) are present in many infectious and inflammatory diseases

CRP levels are sometimes followed to determine whether these diseases have been effectively treated
<Inflammation and thromobosis are measured by CRP (C-reactive protein) which increases with atherosclerotic formation, thrombus formation. CRP can be lowered by giving?: -statin drug
ASA
quit smoking
low fat, low cholesterol
diet
exercise
<A CRP with a lipid profile gives a STRONG indication of coronary risk.: okay
<What is the pathophysiology of CAD?: atherosclerosis...lumen becomes narrowed and blood flow is obstructed by lipids...when it's partially occluded then collateral circulation may develop...
a partially occluded artery for a prolonged time...the body will compensate by developing new circulation

arteriosclerosis which is thickening of the walls

coronary artery spasms which may cause MI...cocaine use exacerabates spasms

embolism
<What is the pathophysiology of an MI?: complete occlusion of a coronary artery resulting in ischemia, injury, and necrosis
<What are some of the manifestations that are seen with a heart attack or MI?: severe chest pain unrelieved
by nitro...
radiation down left arm and
other places as well..
not relieved by rest..
can be associated with dyspnea, diaphoresis, apprehension, nausea...
silent MI may occur where
there are no symptoms,
feels like heartburn or
indigestion
elders may not have acute pain, may feel discomfort,
feel sleep...
<The peak time to have an MI is?: 4 am...stress hormones begin to rise...chest pain may wake them
<How does the nurse differentiate between anginal pain and chest pain associated with acute myocardial infarction?: STABLE ANGINA?...radiates to left arm usually..relieved by nitro...precipitated by exertion just like MI

ACUTE MI? very severe pain which can last longer than 30 minutes...unrelieved by nitro and can occur for no reason...CAN be relieve by opioids...associated symptoms are dyspnea, light-headedness, denial, anxiety, short of breath, irregular heartbeat
<What might a doctor order for an admit that has the following signs? VS T100.2 P122 R24 BP 180/110 Chest pain 8/10 LOC x 3 c/o: dizziness nausea SOB has ashen mucus membranes diaphoretic sinus r: stat ECG
stat cardiac enzymes and
troponins
CBC
O2 at 4L per NC
bedrest
VS q 1 hr
IV D5%W at TKO
NPO
I&O
MS 2 mg IV stat
continuous cardiac monitoring
nitro 50 mg in 250 cc D5W
at 10 mcg/min
lidocaine 2 gm in 250 cc
D5W 2-4 mg/min for
symptomatic PVCs

Which of the patient's manifestations are consistent with acute MI?
<Temperature can be how high with acute MI?: as high as 102...due to reaction from necrosis
<Mmost patients with MI and are not hospitalized will die of ________: dysrhythmias
<What percentage with MI event have some abnormality of cardiac rhythm?: 70-90%
<Cardiac nurse can do 3 things with MI patient?: identify dysrhythmia
assess patient's hemodynamic
status
ABGs
vital signs
oxygenation
evaluates patient for chest
discomfort
<ALL dysrhythmias are NOT treated...they're treated when they're?: life-threatening
<What tests comprise serum/caradiac markers?: creatinine kinase
CK-MB
<What is a CK-MB?: usually rises within 3-6 hours after an MI...usually peaks at 12, but can go up to 18 hours after infarction...usually returns to normal within 3 to 4 days
<What happens to troponin with an MI occurs?: Troponin is an inhibitory muscle contraction protein that is released by damaged heart muscle (but not skeletal muscle) and is a highly sensitive and specific indicator of recent MI...it rises EARLIER than a CK-MB...rises within 3 hours of an MI and it persists up to 7 days
<What is an LDH 1?: lactate dehydrogenase...and it's also specific for heart muscle damage...useful in using with a client who's delayed seeking treatment which happens a lot because of denial...if they get to the hospital too late, then the CK-MB and troponin studies are not valid tests to run anymore....LDH is as it starts to rise within 12 to 24 hours and it peaks between 48 and 72 hours and then it returns to normal in about 7 days
<With MI diagnosis, look for: chest pain abnormal EKG biochemical cardiac monitors...there's not a lab test that can establish that an anginal attack is occurring, but if EKG and lab tests are NEGATIVE, then that constitutes an?: anginal attack and NOT an MI(heart attack)
<What is the significance of an EKG that shows frequent PVCs and ischemic changes consistent with an MI?: <it's been about 3-6 hours since the MI occurred, but it was less than probably 12 hours ago
<What is the significance of an elevated CK-MB test?: ! check previous flashcards
for time lapse
<What is the significance of an elevated troponin test?: !check previous flashcards for time lapse
<What is the significance of a WBC that is elevated for 3-7 days?: !
<What is the significance of an ESR (Sed rate) that rises the first week and remains elevated for several weeks?: First of all, a sedimentation rate refers to the amount of time that it takes for rbcs to settle either in plasma or saline and this is an indication of the inflammation occurring after the infarction...so it will be elevated.
<What EKG changes indicate ischemia?: an inverted T wave...a T wave normally points up...with ischemia, then there's an inverted T wave...T wave shows repolarization...so there's a conduction problem when ischemia occurs which inhibits proper repolarization...the T wave changes usually subside when ischemia is resolved and pain is relieved...

also with ischemia, there may a very elevated T wave...this may be one of the first symptoms seen with an ischemic patient
<As second semester students, we'll be looking at 2nd and 3rd leads: !
<Patient with hyperkalemia may also have a very elevated?: T-wave...so hyperkalemia can lead to some of the ischemia...important to monitor potassium level, esp if giving potassium
<very elevated may also be referred to as?: hyper-acute or peaked
<there'll be an elevated ST segment, so PQRS and then before it gets to the P, it's elevated, and that's an indication of injury and then when there's a pathological acute wave...right before the QRS there's a little bit of a dip in a normal EKG as yo: !
<How long can EKG changes be seen on an EKG?: The T wave and ST changes reverse as soon as ischemia or injury is gone...and Q wave stays FOREVER! once heart muscle has been necrosed...if patient has a Q wave on EKG then nurse knows they've had a myocardial infarction in the past.
<What are treatment goals for an acute MI?: maximize tissue perfusion
minimize tissue demands
<How is tissue perfusion maximized?: thrombolytic therapy to
break up clot
give them more oxygen
offer surgical procedures
<How is myocardial tissue demand reduced?: <Meds to promote oxygenation and circulation for myocardial infarctions?>
relieve pain
rest
take smaller meals to
decrease metabolism
quiet environment, turn
lights low, speak softly
eliminate chest discomfort
nitro
other pain meds

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