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Acute Care Exam 2 > CH 14 and 15: Patients with Coronary Vascular Disorders > Flashcards

CH 14 and 15: Patients with Coronary Vascular Disorders Flashcards

1
Q

patho of coronary atherosclerosis

A
  • Abnormal accumulation of lipid or fatty substances and fibrous tissue in arterial blood vessel walls
    *** Create blockages and narrow coronary vessels  reduced blood flow
  • Ruptured plaque can cause thrombus formation
  • Can lead to ischemia (lack of oxygen) and infarction (tissue death)
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2
Q

**uncontrollable (nonmodifiable) risk factors for coronary atherosclerosis

A
  • Age (men >45, women >55)
  • Gender (<55 men, >both, women <55 with early
    menopause)
  • Race (Blacks, Mexican Americans, Native
    Americans)
  • Family history of first degree relative
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3
Q

**controllable (modifiable) risk factors for coronary atherosclerosis

A
  • Diabetes and prediabetes
  • HTN
  • Smoking
  • Obesity
  • Physical inactivity
  • High blood cholesterol
  • Unhealthy diet
  • Stress
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4
Q

additional risk factors for coronary atherosclerosis

A
  • Sleep apnea
  • Increased BMI
  • CKD
  • Chronic infection
  • Flu
  • Nonalcoholic fatty liver
  • Metabolic syndrome
  • Cluster of metabolic abnormalities
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5
Q

clinical manifestations and assessment of coronary atherosclerosis

A
  • Progressive buildup
  • Symptoms are based on location and degree of occlusion
  • Can lead to ischemia
  • Causing angina
  • Significant damage can cause low cardiac output
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6
Q

controlling cholesterol to prevent coronary atherosclerosis

A

*total cholesterol less than 200
* Have a fasting lipid profile every 5 years or more often if abnormal
* HDL >40 mg/dL (preferably more than 60) - take away LDL
* LDL - fat - less than 100
* triglycerides - less than 150
* Primary prevention with status reduces mortality
* Monitory for myopathy, liver disease; contraindication  pregnancy
* Diet and physical activity
* Use meds in conjunction with diet and exercise

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7
Q

ways to prevent coronary atherosclerosis

A

control cholesterol
treat hyperlipidemia
manage HTN
manage DM

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8
Q

treating hyperlipidemia to prevent coronary atherosclerosis

A

Lipid-lowering meds
Lifestyle changes:
** Heart-healthy diet
** Increase physical activity  150 min of mod exercise or 75 min of vigorous activity
** Smoking cessation
** Stress management
** HTN and DM management

recheck labs 4-12 weeks
check liver enzymes

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9
Q

managing HTN to prevent coronary atherosclerosis

A
  • Elevated BP can increase
    stiffness in vessel walls  vessel injury
  • Therapeutic regimen
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10
Q

managing DM to prevent atherosclerosis

A
  • Hyperglycemia fosters
    dyslipidemia and increased
    platelet aggregation
  • Antihyperglycemic agents
    and diet

A1C less than 7

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11
Q

patho of angina pectoris

A
  • Insufficient coronary blood flow decreased 02 supply with
    increased 02 demand
  • Significant obstruction of amajor coronary artery 
    decreased blood flow ischemia
  • Similar risk factors as coronary atherosclerosis
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12
Q

assessing angina

A

P - position - where does it hurt
Q - quality - type of pain
R - radiating
S - severity 1-10
T - timing - how long

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13
Q

**characteristics of stable angina

A
  • Chest pain/discomfort associated with physical activity
  • Alleviated with rest and/or medications
  • Associated with plaque build up
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14
Q

**characteristics of variant/prinzmetals angina

A
  • Form of chest pain
  • Blockage of blood flow due to coronary artery spasm
  • Occurs at rest
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15
Q

**characteristics of unstable angina

A
  • Chest pain that occurs at rest
  • Considered initial phase of acute coronary syndrome
    (ACS)
  • Precursor to MI
  • Medical emergency
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16
Q

clinical manifestations of angina pectoris

A
  • Pain
  • Feeling of impending death
  • Pain/discomfort is poorly localized and can radiate to neck, jaw, shoulders, inner aspects of upper (left) arm
  • Tightness
  • Women have varying symptoms
  • Unusual fatigue, weakness or numbness in arms, SOB, pallor, diaphoresis, anxiety, dizziness, headache, N/V
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17
Q

assessment to diagnose angina pectoris

A
  • Clinical manifestations of ischemia
  • 12 lead ECG - ST elevation
  • Echo - working valves? blood leaking
  • Nuclear scan or invasive procedure
    **stress test- medication to see how heart reacts to accelerated HR
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18
Q

goal of angina pectoris

A

decreased 02 demand and increase 02 supply

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19
Q

pharmacologic management of angina pectoris

A

Positive inotropes (increase contractility), negative inotrope,(decrease contractility)
positive chronotrope (increase HR) , negative chronotrope (decrease HR)
Beta-Adrenergic Blockers (lol) (negative chronotrope and inotrope)
** Reduce myocardial 02 consumption by blocking sympathetic stimulation
** Don’t stop taking abruptly; cautious of admin with low heart rate, monitor resp. rate - rebound hypertension
Calcium channel blockers (amlodipine (Norvasc) and diltiazem (Cardizem))
** Decrease HR, decrease workload of the heart (LV), vasodilate (negative chronotrope and inotrope)
**check BP and HR before administration
Oxygen therapy - start on 2L

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20
Q

nitrates in management of angina**

A
  • Reduce myocardial 02 consumption to relieve pain, VASODILATES
  • SL (tablet or spray) administration under tongue
  • Always carry med in original container
  • Renew supply every 6 months
  • Taken in anticipation of any activity that can cause pain; take BEFORE pain develops for stable
  • If pain persists after 5 minutes of first administration, call EMS. Two more doses in 5 min intervals
    (PUT PT IN TRENDELENBUG IF BP DROPS - LESS THAN 90)
  • Side effects: flushing, throbbing, headache, hypotension, and tachycardia
  • Precautions for side effects
    **Do not give if patient is on ED drugs
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21
Q

antiplatelets (aspirin, clopidogrel (Plavix), glycoprotein IIb/IIIa inhibitors) management of angina

A
  • Prevent platelet aggregation
  • Monitor for bleeding
  • Takes a few days for clopidogrel to start working
  • Monitor for s/s of aspirin toxicity (abd pain, seizures, SOB, stroke signs)
  • Prevention for GI upset
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22
Q

Anticoagulant (heparin, enoxaparin) management of angina

A
  • Prevent thrombosis
  • Monitor for s/s of bleeding; monitor coag studies
  • Place on bleeding precautions
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23
Q

patho of MI

A
  • Area of myocardium is permanently destroyed due to reduced blood flow from ruptured
    plaque and occlusion of an artery by a thrombus
  • Profound imbalance b/w 02 supply and demand
  • As cells are deprived of 02  ischemia  cellular injury  infarction (death of cells)
  • Acute coronary syndrome = continuum from unstable angina to acute MI
  • Classified by type (NSTEMI or STEMI), location of injury (anterior, inferior, posterior,
    lateral wall), point of time (acute, old) and extent of damage (partial or full)
  • Risk factors similar as atherosclerosis and angina
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24
Q

clinical manifestations of MI

A
  • Cardiac: Chest pain continues despite rest and meds, increased BP, JVD
  • Resp: SOB, Dyspnea, tachypnea, crackles
  • Neuro: Fatigue, syncope, lightheadedness, restlessness, anxiety; fear of impending doom
  • GI: N/V
  • GU: decreased U/O
  • Skin: cool, clammy, diaphoresis
  • Women have atypical symptoms = fatigue, shoulder blade discomfort, indigestion, and/or
    SOB
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25
Q

assessment of MI

A
  • Patient history
  • ECG
    ** Obtained within 10 minutes!! of report of
    pain or arrival to ED
    **     Assess for ST elevation
    ** STEMI: ECG evidence of acute MI;
    significant damage to myocardium
    **     NSTEMI: Elevated biomarkers but not
    definite ECG evidence of acute MI
    ** Echocardiogram
    **     Labs
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26
Q

Creatinine kinase- myocardial band (CK-MB)
purpose:
normal value:
significance:
peak, return, normal:

A

Determine damage to cardiac cells
0-3 ng/mL or 1-3 μg/L
increases with damage to cells
peaks around 24 hours, no longer evident after 3 days

27
Q

Myoglobin serum test
purpose:
normal value:
significance:
peak, return to normal

A

Helps transport 02 found in cardiac and skeletal muscle
5-70 ng/mL or 5-70 μg/L
Increases, but not specific to cardiac event
Peaks in 12 hours, no longer evident after 24 hours

28
Q

Troponin I and Troponin T
purpose
normal value
significance
peak, return to normal

A

Regulates myocardial contraction;
Determines damage to cardiac cells, most sensitive for MI
< 0.5 ng/mL
Increases indicate MI; levels >1.5
ng/mL are critical
Increases within a few hours of MI; no longer evident after 1-3 weeks

29
Q

medical treatment guidelines for acute MI

A

Rapid transit to hospital 12 lead ECG read within 10
minutes of arrival Labs for cardiac biomarkers Other diagnostics
Medical interventions
* Supplemental 02
* Nitro
* Morphine
* Aspirin 162-325 mg
* Beta blocker
* ACE or ARB within 24 hours
Evaluate for reperfusion therapy (percutaneous
coronary intervention or thrombolytic therapy)
Continue therapy as indicated
* IV hep or enoxaparin
* Clopidogrel or antiplatelet
* Glycoprotein
How would YOU prioritize???

30
Q

pharmacological treatment for MI

A

MONA
(start on statin, ACE or ARB, BB, aspirin)
* Aspirin
** Give prior to arrival to ED unless absolute contraindication
** Che the tablet to increase absorption faster
* Nitro
* Morphine
** Reduces preload and afterload; promotes vasodilation, decreases workload of
heart
** Monitor BP and resp rate
* Beta blocker
* Documentation of ARB or ACE AND aspirin upon D/C
(SAAB)

31
Q

thrombolytic therapy for MI

A
  • Used when there is no PCI capable center within 120 minutes; with < 6 hours of chest pain; ST-elevation; chest pain >20 min with no relief
  • Used to dissolve clots and lyse thrombus in coronary artery  increased blood flow
  • Must administer with 30 minutes of arrival to ED!
32
Q

nursing considerations for thrombolytic therapy

A
  • Avoid punctures to skin and continuous BP measurement
  • Start access before therapy
  • Monitor for bleeding, arrythmias, and hypotension
  • Treat major bleeding with D/C and applying pressure; immediately call provider!
  • Be aware of absolute contraindications
33
Q

patho of percutaneous coronary intervention (PCI) or stent

A
  • The occluded artery is opened and reperfusion to the area is re-established to improve blood flow
  • Used for angina and acute MI
  • PCI should be performed with !!60 minutes!! of arrival to ED
  • Includes balloon angioplasty with intracoronary stent placement
  • Can be done in combination with a cardiac catheterization
    ** Procedure where a vascular catheter is inserted, and dye is injected for visualization
    ** Used for diagnosis
34
Q

complication of percutaneous coronary intervention

A

-Bleeding or hematoma
**Suture line leak, increased intraabdominal pressure
**Apply manual pressure, outline hematoma, monitor H/H, blood transfusion, keep bedrest or site immobile
-Lost/weakened pulse on extremity
**Arterial thrombus/embolus
**Asses perfusion and circulation, notify provider; anticipate surgery or thrombolytic therapy
-Retroperitoneal bleeding
**Blood accumulates in retroperitoneal space; tearing in flank from femoral access
**Notify provider, anticipate surgery or ultrasound guided compression, keep leg straight
-Acute kidney failure
**Nephrotoxic dye
**Monitor U/O, BUN, creatinine; ensure adequate hydration (IV/PO)
-Allergic reaction
**Reaction to dye
**Prepare for epi, prednisone, antihistamines, H2 blockers depending on severity
-Cardiac tamponade
**Bleeding into pericardial space from mediastinal tubes; reduces CO
**Monitor for JVD, pulsus paradoxus, cessation of previous heavy drainage, cardiovascular collapse, muffled heart sounds; emergency sternotomy with
drainage and volume expansion
-Chest pain/acute event/spasm
**Vasospasms, acute stent thrombosis, occlusion, abrupt vessel closure
**Notify provider of chest pain; monitor VS, 02 sat, perfusion, ECG, serial markers; prepare for cardiac cath

35
Q

acute post-pocedure care of percutaneous coronary intervention

A
  • Monitor for bleeding, changes in sensation, hematoma, absence of pulse, variance in VS
  • Hemostasis achieved after sheath removal with direct manual pressure, mechanical compression device, or pneumatic compression device
    ** Sheaths removed when heparin is not active and clotting times are normal
    ** Removal can cause bradycardia  have atropine ready; have patient in sitting/lying position
    ** Place occlusive dressing (keep for 24 hours)
  • Remain in bed and avoid bending affected limb
    ** Remain in bed for 3-6 hours
  • VS and Neurovascular checks Q15 min x4, Q30 min x4, Q1hr x4, then Q4hrs**
36
Q

discharge teaching after percutaneous coronary intervention

A

*Report any abnormalities or complications
*For 24 hours, minimalize movement of extremity (no weight bearing)
*Do not drive for 24 hours or operate heavy machinery
*No heavy lifting (over 5 lbs.)
*Plan for follow up appointment
*Remove dressing after 24 hours and leave OTA; avoid submersion in water
*If bleeding occurs hold pressure; if >10 minutes call 911

37
Q

Coronary Artery Revascularization: Coronary Artery Bypass Graft (CABG)

A
  • Blood vessel is grafted to bypass occlusion for 70% occlusion
  • Indications: alleviation of angina
    uncontrolled by meds, treatment of CAD, prevention/treatment of MI or HF, treatment of complications from unsuccessful PCI
  • Can be elective or emergent
  • D/C within 3-5 days without complications
38
Q

pre-op care for Coronary Artery Bypass Graft (CABG)

A

Informed consent
CXR, ECG, labs, baseline assessment
* Preop antibiotic prophylaxis
* Anticholinergics to decrease secretions
* Anxiolytics
Administer meds
Continuous monitoring
Post-op education and expectations
Verbalize fears and feelings with client and family
D/C meds that cause bleeding

39
Q

intraop care of Coronary Artery Bypass Graft (CABG)

A
  • Padding bony prominences
  • Communicate surgical progress to family/loved ones
  • Continuous monitoring
  • Arrange ICU placement after surgery
40
Q

postop care assessment of CABG

A

*neuro assessement
*NG tube to decompress stomach
*ETT provide vent support, suction, end-tidal CO2
*central venous or Swan-Ganz catheter for monitoring central venous pressure, etc.
* ECG monitoring
* SpO2 monitoring
* assess skin color and temp
* epicardial pacing electrodes
* mediastinal and pleural chest tubes
* radial arterial line - blood pressure
* indwelling catheter
* assess pulses

41
Q

postop cardiac care - restoring cardiac output

A
  • Evaluate cardiac status and kidney
    function
  • Monitor for Afib, decreased cardiac output
  • Stabilize rhythm as necessary
  • Check patency of mediastinal tube
  • Diuretics, dig, and IV inotropics
    for cardiac failure
  • Treatment for tachycardia and/or bradycardia
  • Monitor for cardiac tamponade
42
Q

postop cardiac care - maintaining adequate perfusion

A

Report s/s of emboli/thrombus
Prevent venous stasis
* Compression wraps, elastic
stocking, discourage
crossing legs, early
frequent ambulation
Report U/O < 30 ml/hr Monitor kidney function
Fluids replacement with colloids, PRBCs, or crystalloids
Change dosage of vasopressors (reduce blood flow to kidneys) CRRT or dialysis if necessary

43
Q

Postop cardiac Care ~ Maintaining Normal Body Temperature

A
  • Warm to temperature gradually (98.6)
    ** Warm ventilator air
    ** Warming system, blankets, heated lamps
  • Prevent hypothermia
    ** Makes clotting less efficient, prone to arrhythmias, oxygen doesn’t readily transfer from hemoglobin to tissues, and causes vasoconstriction
44
Q

Postop cardiac Care ~ Monitoring and Managing Potential Complications (infection control and F&E balance)

A

Infection Control
* Hand hygiene
* Antibiotics
* Remove all invasive equipment ASAP
* Aseptic technique with wound care and dressing changes
F&E imbalance
* Nursing assessment of I&O, weight, hemodynamics, hematocrit, neck veins,
edema, breath sounds, electrolytes, glucose
* Administer insulin if necessary
(regardless of dx of DM)
* Potassium, mag, sodium, and calcium treatment (high or low)

45
Q

Postop cardiac Care ~ Monitoring and Managing Potential Complications (impaired gas exchange)

A
  • Impaired gas exchange
    ** ETT with ventilator assistance initially
    ** Maintain patency of ETT
    ** Suction
    **     Secure the tube
    *** Extubated as soon as possible
  • Pulmonary interventions
    ** Turning
    **     Coughing and deep breathing
    *** IS
46
Q

Postop Cardiac Care ~ Monitoring and Managing Potential Complications
* Impaired Cerebral Circulation

A
  • Observe for s/s of hypoxia
  • Assess neuro status
  • Note any immediate change to the provider
  • Monitor for s/s of stroke
47
Q

Postop Cardiac Care ~ Minimizing Sensory-Perception Imbalance

A

Prevention and treatment of delirium
* Treat cause
Be aware of sleep deprivation in ICU
Careful explanation of procedures
Continuity of care Welcome family at bedside
Won’t get back to baseline for 3-12 months

48
Q

Postop Cardiac Care ~ Relieving
Pain

A

NO IV and oral NSAIDs
* To decrease opioid use
Administer analgesics as
necessary
Splinting with increased intra-
abdominal pressure
Improvement in pain after removal of mediastinal tubes

49
Q

what is the purpose of cardiac rehab

A
  • Active rehab program to reduce cardiac risk through education, individual and group support,
    and physical activity
  • Assist patient with cardiac disease to achieving a productive life while remaining within the limits of their heart’s ability to respond to increases in activity and stress
50
Q

3 phases of cardiac rehab

A

Phase 1
* Starts with acute illness
* Consist of low-level activities and initial education
Phase 2
* After discharge into a cardiac rehab program at home
* Supervised exercise training
Phase 3
* Long-term conditioning and maintaining cardiovascular stability

51
Q

nursing management during cardiac rehab

A

Implement orders to relief pain and other s/s of ischemia
Assess VS frequently
Physical rest with semi-Fowler’s position to decrease 02 demand
*If hypotensive, place in supine position with legs elevated
Health promotion activities after an MI/ACS
Alleviate fears and anxiety
Closely report and monitor changes

52
Q

patho of acute HF

A

*Inability of the heart to pump sufficient blood to meet the needs of the tissues for 02 and nutrients
*Issue with contraction of the heart (systolic dysfunction) or filling of heart (diastolic dysfunction)

53
Q

medical management of Chronic HF

A
  • Lifestyle changes - decrease weight, exercise, decrease sodium, decrease fluid, no alcohol or smoking,
    –report fluid weight gain
  • Pharm (diuretics, inotropes, ACE inhibitors, ARBs, beta blockers, nesiritide, digoxin, vasodilators)
54
Q

nursing management of chronic HF

A

medication effects
assess emotional response
resources
assess health history
assess ADLS
daily weights
making urine?
pitting edema

55
Q

digitalis toxicity

A
56
Q

Risk factors for chronic HF

A

HTN
dm
abd obesity
high cholesterol
CAD
previous stroke
PVD
increased fasting glucose
atherosclerosis

57
Q

Right sided heart failure

A

ventricle pump fails leading to cengestion in peripheral tissues
enlarge liver
JVD
edema in LE
ascites
anorexia
N
fluid retetnion
weight gain
decrease in perfusion to systemic organs
fatigue from decreased CO

58
Q

Left sided HF

A

left ventricle can no longer pump blood into the aorta and systemic circulation
leads to pulmonary congestion
dyspnea
orthopnea - lying down - pt has to sit up when sleeping (how many pillows?)
crackles
decreased O2 sats
S3
cough
tachypnea
weak thready pulse
fatigue a
activity intolorence

59
Q

NSTEMI vs STEMI

A

NSTEMI - ST not elevated or depressure - partial occlusion of vessel
STEMI - ST elevated
get

60
Q

abnormal accumulation of fluid in lungs
* Increased resistance to left ventricular filling  blood to backup
fluid accumulates in alveoli

A

pulmonary edema

61
Q

cause of acute HF/pulmonary edema

A
  • Cardiogenic or noncardiogenic (AKI, liver failure, rapid admin of IVF, oncologic disorders)
  • Leads to impaired gas exchange and hypoxemia (HA, confusion, SOB, restlessness)
62
Q

clinical manifestations of pulmonary edema

A
  • Restless, anxious
  • Sudden onset of breathlessness, sense of suffocation, persistent cough with pink-tinged frothy
    sputum, pulmonary crackles, expiratory wheezing, tachypnea, orthopnea
  • Cold moist skin, cyanotic nail beds
  • Weak and rapid pulse, JVD
  • Reduced U/O
63
Q

medical and nursing management of pulmonary edema

A
  • Oxygen
  • Diuretics
  • Hemodynamic monitoring - decrease pre and after load
  • Noninvasive mask ventilation
  • Bronchodilator therapy with albuterol
  • High fowlers position with dependent position (decrease preload)
  • Morphine
  • Inotropes (dig, dobutamine)
  • Check ABGs, CXR, Sa02, electrolytes
  • Restrict fluid intake
64
Q

treatment for pulmonary edema (MAD DOG)

A

Morphine
Airway
Digitalis
Diuretics
Oxygen
Blood gases

Acute Care Exam 2 (5 decks)

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