ACS - medsurg 2 Flashcards
what are the 2 conditions that follow under acute coronary syndrome (ACS)
unstable angina & acute MI
when comparing angina pain to MI pain, characteristics of MI would include
-w/o a cause & usually in the early morning d/t cortisol surge
-relieved only by opioids
->20mins
-Sx: diaphoresis, dyspnea, anxiety, dysrhythmias
if someone “drops dead” bc of a heart attack, what was the cause
dysrhythmia
during an MI, how long can cells stand ischemia before cell death occurs
20 minutes
during an MI, how long does it take for the entire thickness of heart muscle to necrose
4-6 hrs
what layer of the heart is affected first during an MI
subendocardium
MI’s are described based on
location of damage (anterior, inferior, lateral, septal or posterior)
what does MI pain feel like
severe, immobilizing chest pain not relieved by rest, position change or nitrates
what is the hallmark sign of a MI
non responsive to nitrates
how might a pt describe their sx during an MI
-persistent
-heaviness, pressure, tightness
-burning
-constriction, crushing
complications of MI
-dysrhythmias
-HF
-cardiogenic shock
-papillary muscle dysfunction
-pericarditis
complications of MI: dysrhythmias
get on tele immediately
-most common comp
-causes pre hospital death
complications of MI: HF
occurs because of reduced pumping action of the heart
complications of MI: cardiogenic shock
loss of BP d/t severe left ventricular failure
complications of MI: papillary muscle dysfunction
leads to new murmur noted
complications of MI: pericarditis
-occurs 2-3 days after acute MI
-new pericardial friction rub
dx testing for ACS
EKG (serial order)
-look for change in QRS, ST seg & T wave
-elevated or non elevated ST determined STEMI or NSTEMI
ischemia characteristics
-ST depression
-temporary damage
-reduced blood flow
infraction characteristics
-ST elevation
-permanent damage
-complete blockage
-death of tissue
STEMI: ST, QRS, T wave, Troponin, size, outcome
ST: elevation
QRS: wide (over hours)
T wave: peaked then inverted
Troponin: elevated
size: larger
outcome: poor
ST elevated in two anatomically contiguous leads
NSTEMI: ST, QRS, T wave, Troponin, size, outcome
ST: depression or normal
QRS: normal
T wave: inverted
Troponin: elevated
size: smaller
outcome: better
initial assessment for ACS
-consider MI if pt comes in with expected sx or if women, older or diabetic w/ atypical sx
-12 lead EKG within 10 mins of arrival
initial interventions
-assess/stabilize ABC’s
-position pt upright, admin O2, obtain VS, PQRST
-attach tele
-establish IV access
-ASA 325mg
-lab work
-monitor heart & lung sounds
what lab work should be obtained for ACS admission
-cardiac markers
-electrolytes
-H&H
-coags
what heart & lung sounds are we monitoring for w/ a ACS admit
murmur, gallup, rub, crackles
what are the 3 reperfusion strategies for ACS blockage
1) emergent PCI (for STEMI & NSTEMI)
2) thrombolytic therapy (STEMI)
3) CABG (DM &/or 3 vessel disease)
PCI
-1st line treatment for confirmed MI
-goal: open w/n 90mins of ED arrival
-do cardiac cath prior to locate & evaluate
-post cath: guide wire through artery, inflate balloon within plaque to separate, deflate and pull out (can add stent)
PCI advantages
-percutaneous (do not crack chest)
-local anesthesia
-pt is ambulatory shortly after procedure
-shorter hospital days (1 to 3 days)
-return to work sooner
PCI nursing care
-similar to cardiac cath
-monitor for ischemia, pain, EKG changes, & hemodynamic instability
-mindful that pt is on dual anti platelet therapy
-sheath removed 4-6hrs post op
thrombolytic therapy
clot busters
-fibrinolytic used to dissolve thrombi & restore myocardial blood flow
-can be administered during cardiac cath
-most effective when given within 6hrs of coronary event, goal within 30 mins of admission
-monitor for bleeding
example of fibrinolytic drugs
-tissue plasminogen activator (T-PA)
-reteplase (retavase)
thrombolytic therapy contraindications
-hx of intracranial hemorrhage
-recent abdominal surgery or stroke
-any active bleed (excluding menses)
what is an example of an elective CABG
pt goes for heart cath and more blockages were found so CABG scheduled for the next day
where is the saphenous vein
long vein from groin to ankle
when used for CABG, people w/ peripheral vascular disease do not heal as well
potential comps post CABG
-stroke or MI
-infection
-dysrhythmias (be on tele)
-pleural effusion
-cardiac tamponade
-renal failure
continuous care post CABG
-monitor
-rest & comfort (w/ activity restriction)
-help deal w/ anxiety & emotions
-pt teaching (include sexual activity)
-send home w/ referral to cardiac rehabilitation
