Care of Patients with Acute Coronary Syndromes Flashcards
coronary artery disease
single largest killer of American men and women ion all ethnic groups, Broad term that includes chronic stable angina and acute coronary syndromes. Affects the arteries that provide blood, oxygen, and nutrients to the myocardium. Ischemia occurs when insufficient oxygen is supplied to meet the requirements. Infarction occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue.
angina pectoris
chest pain caused by temporary imbalance between the coronary arteries’ ability to supply oxygen and the cardiac muscle’s demand for oxygen. ischemia that occurs is limited in duration and does not cause permanent damage.
Two types: chronic stable angina and unstable angina
chronic stable angina
chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. Frequency, duration, and intensity of symptoms remain the same over several months. Results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. Usually relieved by nitroglycerin or rest; managed with drug therapy.
acute coronary syndrome
term used to describe patients who have either unstable angina or acute myocardial infarction. Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (clumping), thrombus (clot) formation and vasoconstriction. ACS classified into one of three categories according to the presence or absence of ST- segment elevation on the ECG and positive serum troponin markers:
- STEMI: ST elevated MI (traditional manifestation)
- NSTEMI: Non ST elevated MI (common in women)
- unstable angina pectoris
unstable angina pectoris
chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. Pressure may last longer than 15 min. Poorly relieved by rest or nitroglycerin. May present with ST changes but do not have changes in troponin or creatine kinase levels.
New onset angina
variant Prinzmetal’s angina
Pre-infarction angina
new onset angina
describes the patient who has his or her first angina symptoms, usually after exertion or other increased demands on the heart.
variant Prinzmetal’s angina
chest pain or discomfort resulting form coronary artery spasm and typically occurs after rest.
pre-infarction angina
refers to chest pain that occurs in the days or weeks before an MI
Myocardial Infarction (MI or AMI)
occurs when myocardial tissue is abruptly and severely deprived of oxygen. When blood flow is quickly reduced by 80% to 90%, ischemia develops. Ischemia can lead to injury and necrosis of myocardial tissue if blood flow is not restored. Evolves over a period of several hours. Extent of infarction depends on collateral circulation, anaerobic metabolism and workload demands. Physical changes do not occur in the heart until 6 hours after the infarction. Once infarction occurs, scare tissue permanently changes the size and shape of the entire left ventricle, called ventricular remodeling.
NSTEMI
Non ST segment elevation myocardial infarction. ST and T-wave changes on ECG. Indicates myocardial ischemia. Cardiac enzymes may be initially normal but elevate over the next 3-12 hours.
causes of a NSTEMI
coronary vasospasm, spontaneous dissection, sluggish blood flow due to narrowing of the coronary artery.
STEMI
ST elevated myocardial infarction. ST elevation in two leads on a ECG. Indicates myocardial infarction/necrosis. Attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture. Thrombus causes an abrupt 100% occlusion to the coronary artery.
CAD/ ACS Etiology
atherosclerosis is the primary factor in the development of CAD; non-modifiable and modifiable risk factors contribute to atherosclerosis
non-modifiable risk factors of atherosclerosis
age, gender, family history, ethnic background
modifiable risk factors of atherosclerosis
elevated serum lipid levels, smoking, limited physical activity, HTN, DM, obesity, excessive alcohol, excessive stress/ decrease coping skills.
CAD/ACS incidence
average age for first MI, 65.1 years in men, 72 for women, postmenopausal women have lower incidence than men, postmenopausal women in their 70s or older have an equal chance.
CAD/ACS health promotion
control or alter modifiable risk factors for CAD
CAD Prevention
eliminate smoking and tobacco use, diet, have lipid levels checked regularly, increase physical activity, manage diabetes, manage HTN, manage weight, limit alcohol use, manage stress
Physical assessment of ACS
may complain of pain or pressure, assess according to onset, location, radiation, intensity, duration, precipitating factors, relieving factors.
assess for associated symptoms such as NV, diaphoresis, dizziness, weakness, palpitations, SOB
assess BP, HR, Cardiac rhythm, dysrhythmias; sinus tach with PVC frequently occur in the first few hours after an MI
assess distal peripheral pulses and skin temp; poor cardiac output can be manifested by cool, diaphoretic skin and diminished or absent pulses.
auscultate for S3 gallop which often indicates HF (complication of MI)
assess resp rate and breath sounds, crackles and wheezes may indicate LSHF
assess for presence of JVD and peripheral edema.
Assess for fever, patient with MI may experience temperature elevation for several days, in response to myocardial necrosis, indicating the inflammatory response.
key features of angina
substernal chest discomfort: radiating to the left arm, precipitated by exertion or stress (or rest in variant angina) relieved by nitroglycerin or rest, lasting less than 15 min.
key features of MI
pain or discomfort: substernal chest pain/pressure radiating to the left arm, pain discomfort in jaw, back, shoulder, or abdomen, occurring without cause usually in the morning, relieved by opioids, lasting 30 min or more.
frequent associated symptoms of MI
N/V, diaphoresis, dyspnea, feelings of fear and anxiety, dysrhythmias, fatigue, palpitations, epigastric distress, anxiety dizziness, disorientation/ acute confusion, feeling SOB
ACS psychosocial assessment
denial is common
ACS lab assessment
Troponin’s- T&I criterion stnadard use today; can be elevated within 3-4 hours and may remain elevated for 10-14 days.
CK-MB (creatine kinase MB)
ACS imaging assessment
thallium scans, contrast enhanced cardiovascular magnetic resonance, echocardiogram, computed tomography coronary angiography
Other tests performed for ACS
12 lead ECG, stress test, cardiac catheterization
Interventions for ACS to manage acute pain
supplemental oxygen, drug therapy, semi fowler position, quiet, calm environment
Interventions for ACS to improve cardiopulmonary tissue perfusion
restoration of perfusion to injured area limits amount od extension, improves left ventricular function. complete, sustained reperfusion of coronary arteries after an ACS has decreased mortality rates.
Interventions for ACS to increase activity intolerance
phase 1: patients progress at their own rate to increase levels of activity
phase 2: cardiac rehab (all patients with MI should be referred)
Interventions for ACS to promote effective coping
denial, anger, depression
other examples of intervention for ACS
identify and manage dysrhythmias
monitor for and manage HF
monitor for and manage recurrent symptoms and extension of injury
Invasive corrections to resolve angina or prevent MI
percutaneous coronary intervention (PCI)
coronary artery bypass graft (CABG)
The patient states that the chest discomfort occurs
with moderate to prolonged exertion. He describes
the pain as being “about the same over the past
several months and going away with nitroglycerin
or rest.” Based on the patient’s description of
symptoms, what does the nurse suspect in this
patient?
A. Chronic stable angina (CSA)
B. Unstable angina
C. Acute ST elevated MI
D. Acute Non ST elevated MI
A
The patient is prescribed nitroglycerin tablets. What information does the nurse include when teaching the patient about this drug? (Select all that apply)
A. If one tablet does not relieve the angina after 5 minutes, take two pills.
B. You can tell the pills are active when your tongue feels a tingling sensation.
C. Keep your nitroglycerin with you at all times.
D. The prescription should last about 12 months before a refill is necessary.
E. If pain doesn’t go away, just wait; the medication will eventually take effect.
F. The medication can cause a temporary headache.
BCF
A 71-year-old female presents to the ED
via EMS with pain in her upper back and
shoulders that started 2 hours ago. She
has been experiencing nausea,
dizziness, shortness of breath, and
diaphoresis. She reports that she has
had more frequent indigestion over the
past week and has been unusually
fatigued
Which of the following is the most likely
diagnosis at this time?
a. Acute Myocardial Infarction
b. Chronic Stable Angina
c. Congestive Heart Failure
d. Deep Vein Thrombosis
A
Which early reaction is most common in
patients with the chest discomfort associated
with unstable angina or MI?
A. Depression
B. Anger
C. Fear
D. Denial
D
The patient is admitted for acute MI, but the nurse notes that the traditional manifestation of ST elevation myocardial infarction (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in this patient? (Select all that apply)
A. Positive troponin markers
B. Chronic stable angina
C. Non-ST elevation MI (non-STEMI) on ECG
D. Cardiac dysrhythmia
E. Pulmonary embolus
F. Jugular vein distension (JVD)
AC
A thallium scan is scheduled for a client who had a
myocardial infarction (MI). What should the nurse
explain to the client regarding the reason the scan
has been prescribed?
A. That it will monitor the mitral and aortic valves
B. That it establishes the viability of myocardial
muscle
C. That it can visualize the ventricular systole
and diastole
D. That it will determine the adequacy of
electrical conductivity
B
A 55 male patient comes to the walk in
clinic reporting left anterior chest
discomfort with mild shortness of breath.
The patient is alert, oriented, diaphoretic,
and anxious.
What is the priority action for the nurse?
A. Obtain a complete cardiac history to include
a full description of the presenting symptoms
B. Place the patient in Semi-Fowler’s or
Fowler’s position and start supplemental
oxygen
C. Instruct the patient to go immediately to the
closest full-service hospital
D. Immediately alert the physician and establish
IV access
B
The patient is traveling to the hospital via EMS to
be admitted with AMI. He begins c/o extreme
fatigue, chest pain, and shortness of breath. BP
84/59, HR 94, RR 28 and shallow, pulse
thready, skin pale and diaphoretic. These
symptoms are associated with:
A. Decreased lung capacity
B. Increased cardiac muscle tone
C. Decreased cardiac output
D. Increased cardiac output
C
The patient arrives to the hospital. Which of the following are appropriate interventions for managing an Acute Coronary Syndrome? (Select all that apply)
A. Supplemental oxygen
B. Nitroglycerin SL
C. Morphine IV
D. Aspirin PO
E. Propranolol PO
F. Nifedipine PO
ABCDE
Which of the following is considered a
treatment for acute myocardial infarction?
(Select all that apply)
A. Supplemental oxygen
B. Morphine IV
C. Aspirin PO
D. Tissue plasminogen activator IV
E. PCI (Percutaneous Coronary Intervention)
F. PTCA (Percutaneous transluminal coronary angioplasty)
G. CABG (Coronary Artery Bypass Graft)
DEFG
The patient received thrombolytic therapy for treatment of acute MI. What are post administration nursing responsibilities for this treatment? (Select all that apply)
A. Document the patient’s neurologic status
B. Observe all IV sites for bleeding and patency
C. Monitor white blood cell (WBC) count and differential
D. Monitor clotting studies
E. Monitor hemoglobin and hematocrit
F. Test stools, urine, and emesis for occult blood
G. Observe the sternal wound site
ABDEF
Which of the following is an appropriate recommendation for a patient being discharged from the hospital following an ACS episode? (Select all that apply)
A. You should utilize resources to help you quit smoking
B. You should consume no more than 2 g of sodium in 24 hours
C. You can return to your usual activities right away
D. You will be checking your labs regularly
E. You can stop your hypertension medication
F. You should find ways to manage your stress
ABDF
What are characteristics of chronic stable angina? (Select all that apply)
A. Pain is precipitated by exertion or stress
B. Pain occurs without cause, usually in the morning
C. Pain is relieved only by opioids
D. Pain is relieved by nitroglycerin and rest
E. Nausea, diaphoresis, feelings of fear, and dyspnea may occur
F. Pain lasts less than 15 minutes
ABDF
Which of the following may contribute to a
patient’s risk for coronary artery disease
(CAD)? (Select all that apply)
A. Smokes one pack cigarettes daily
B. Exercises rarely
C. Drinks a few glasses of wine on the
weekends
D. Has high cholesterol level
E. Father and brother have coronary artery
disease
ABDE
Within 4 to 6 hours after a client has a
myocardial infarction, the nurse expects which
blood level to increase?
A. Lactate dehydrogenase (LDH-1)
B. Creatine kinase-MB band (CK-MB)
C. Erythrocyte sedimentation rate (ESR)
D. Serum aspartate aminotransferase (AST)
B
A patient is admitted with AMI and c/o moderate
chest discomfort. The nurse asks about which
associated symptoms? (Select all that apply)
A. Nausea
B. Diarrhea
C. Diaphoresis
D. Dizziness
E. Joint pain
F. Shortness of breath
ACDF
Which of the following are appropriate
interventions for managing stable angina?
(Select all that apply)
A. Supplemental oxygen
B. Nitroglycerin SL
C. Morphine IV
D. Aspirin PO
E. Propranolol PO
F. Nifedipine PO
BDEF
A client is admitted to the hospital with the
diagnosis of myocardial infarction. The nurse
should monitor this client for which signs and
symptoms associated with heart failure?
(Select all that apply)
A. Weight loss
B. Unusual fatigue
C. Dependent edema
D. Nocturnal dyspnea
E. Increased urinary output
BCD
Four patients are admitted with an Acute MI.
Which one of them is least likely to be developing
a complication?
A. Pt c/o of increasing chest pain after
receiving Morphine IV
B. Pt with c/o increased need for urination
C. Pt with multiple multifocal PVCs on EKG
D. Pt with decreased level of consciousness
and thready pulse
B
After receiving change of shift report, which client does
the nurse assess first?
A. The client with percutaneous coronary angioplasty
who has a dose of heparin scheduled
B. A client admitted for a NSTEMI myocardial
infarction who reports dyspnea after ambulating to the
bathroom
C. A client on telemetry who has a PR interval of 0.14
and QRS complex of 0.10 and noted PVCs
D. A client who has received thrombolytic therapy for
a myocardial infarction (STEMI) who has facial
drooping
D
