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NURS3313 Adult Health > Chapter 23 Management of Patients with Coronary Vascular Diseases > Flashcards

Chapter 23 Management of Patients with Coronary Vascular Diseases Flashcards

1
Q

What is the leading cause of death in the United States?

A

Cardiovascular Disease

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2
Q

Which type of cardiovascular disease is most prevalent in disease?

A

Coronary artery disease (CAD)

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3
Q

Non-modifiable Risk Factors for CAD

A

Family Hx

Gender (Assigned at Birth): Onset of disease is earlier in males than in females

Age
Male: > 45 y.o
Female: > 55 y.o.

Race: Greater genetic risk in African-Americans than in Caucasians

Primary (genetic) Hypercholesterolemia

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4
Q

Modifiable Risk Factors for CAD

A

Hyperlipidemia (LDL) and/or Low HDL

Elevated triglycerides

Smoking/tobacco use

HTN

Diabetes mellitus

Obesity

Physical Inactivity

Metabolic Syndrome: Combo of 3 modifiable physiological factors

Chronic Inflammatory Conditions: Rheumatoid arthritis, lupus, HIV/AIDS, etc

Chronic Kidney Disease (CKD)

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5
Q

(T/F) True or False: CAD is a progressive disease process

A

True

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6
Q

Early Stages of CAD

A

Atherosclerosis & Stable Angina (pain associated w/MI)

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7
Q

Atherosclerosis

A

Abnormal accumulation of lipid deposits & fibrous tissue w/in arterial walls & lumen

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8
Q

Atherosclerosis Process

A

1) Starts w/ injured vessel

2) Injured tissue can no longer produce antithrombotics & vasodilation agents

3) Inflammatory response begins and leads to a build-up of cells and lipids in the vessel (fatty streak)

4) Decreased blood flow in vessel due to narrowed opening

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9
Q

Atheromas

A

Lipid deposits/ plaques that protrude in the arterial lumen

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10
Q

Vulnerable Plaque

A

When the fibrous cap becomes thin with ongoing inflammation

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11
Q

Myocardial Infarction (MI)

A

AKA Heart Attack

Occur when there is occlusion of the coronary artery that leads to ischemia or necrosis of the myocardium

THIS IS AN EMERGENCY!!!

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12
Q

Additional Risk Factors for Atherosclerosis

A

Diabetes Mellitus

Peripheral Artery Disease (PAD)

Abdominal Aortic Aneurysm (AAA)

Carotid Artery Disease

Presence of disease in other body arteries presents a high likelihood that there is disease in the coronary arteries as well

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13
Q

Dangers of Atherosclerosis

A

Progressive and can lead to ischemia due to narrowing in the coronary arteries

Can lead to extensive myocardial damage and scarring; later causing angina/heart failure/heart attacks, or even sudden cardiac death

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14
Q

Ischemia

A

Insufficient tissue oxygenation

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15
Q

Clinical Manifestations of Atherosclerosis

A

May be nothing/chest pain

Epigastric pain

Pain in jaw, shoulder, or arm

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16
Q

Clinical Manifestations of Atherosclerosis in Women

A

Indigestion

Nausea

Palpitations & numbness

SOB

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17
Q

Angina pectoris

A

Refers to chest pain that is brought about by myocardial ischemia
- Usually characterized by pain or pressure

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18
Q

Angina Pectoris Clinical Manifestations

A

Vice-like pain in the chest (weight on chest, crushing)

Pts w/ DM may have neuropathy & feel less pain

Older patients may not have pain due to diminishing tissue sensation from aging

Chest/neck/jaw/shoulder/arm pain

Changes in: BP, N/V, pallor, tachycardia, tachypnea, vasoconstriction

Do the symptoms improve w/ NTG?

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19
Q

Atypical Angina Clinical Manifestations in Women

A

Chest pain, discomfort, pressure or squeezing (like there’s a weight sitting on you)

Unusual upper body pain/discomfort in one or both arms, back, shoulder, neck, jaw or upper portion of stomach

Breaking out in a cold sweat

Lightheadedness or sudden dizziness

Nausea

Unusual fatigue

SOB

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20
Q

Cause of Angina Pectoris

A

Usually caused by significant coronary atherosclerosis
- ANY reduction of blood flow to the heart (coronary spasm, extreme cold, hypotension)

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21
Q

Common Causes of Angina Pectoris

A

Atherosclerotic disease-> obstruction in at least 1 of the coronary arteries

Myocardial Ischemia: Insufficient tissue oxygenation (can lead to damage)

Any reduction of blood flow to the heart (coronary spasm, hypotension, extreme cold…)

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22
Q

Stable Angina

A

Can be managed w/lifestyle changes

Predictable/constant w/exertion

Relieved by rest and/or NTG

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23
Q

Common Exacerbating Factors of Stable Angina

A

Exercise: Increases O2 demand

Extreme cold: Vasoconstriction will decrease blood flow

High-stress situation: Increase in BP, HR, & cardiac work

Substances: Tobacco, caffeine, some illicit drugs

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24
Q

Unstable Angina

A

AKA preinfarction angina or crescendo angina

Occurs w/ sudden reduction in coronary blood flow likely from a ruptured atherosclerotic plaque, the vessel is not necessarily occluded

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25
Q

Unstable Angina (Symptoms)

A

Symptoms increase in frequency/severity

Unrelieved by rest and/or NTG

Not related to usual causes, often an indicator of impending MI

HEALTH EMERGENCY! ACT QUICKLY!

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26
Q

Variant Angina (Prinmetal’s angina)

A

Pain at rest w/ reversible ST-segment elevation
- Thought to be caused by coronary artery vasospasm

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27
Q

Silent Ischemia

A

Objective evidence of ischemia (such as ECG changes w/ stress test), but patient reports no pain

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28
Q

Intractable/ Refractory Angina

A

Severe incapacitating chest pain

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29
Q

Angina Pectoris Treatment Goal

A

Balance the O2 supply & demand

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30
Q

Nitroglycerin (NTG)/Imdur Action on the Heart

A

Vasodilator to increase blood flow to the myocardium

31
Q

Patient Education on NTG Administeration

A

Instruct the patient to make sure that their mouth is moist, the tongue is still, & saliva is not swallowed until the NTG tablet dissolves
- If pain is severe: Can crush tablets between teeth to hasten sublingual absorption

Advise the patient to carry this med at ALL times
- Should be carried in its original container
- Tablets should NEVER be removed & stored in metal or plastic containers

Inactivated by heat, moisture, air, light, & time
- Instruct patient to renew every 6 months

Should be taken in anticipation of any activity that may produce pain

Recommend patient logs how much time it takes for NTG to alleviate symptoms
- If pain persists after taking 3 tablets at 5-min intervals, call 911 IMMEDIATELY!!

Discuss possible side effects: flushing, throbbing headache, hypotension, & tachycardia

Advise patient to sit down after taking a tablet to avoid hypotension & syncope

32
Q

Beta-Blocker Action on the Heart

A

Decrease O2 demand of myocardium (monitor vitals & ECG)

33
Q

Ca+2 Channel Blocker Action on the Heart

A

Decrease workload by lowering HR & systemic BP & increases O2 supply by dilating smooth muscle of coronary arteries

34
Q

Meds to Prevent Platelet Aggregation

A

PO: Aspirin, Plavix, Effient

IV - Heparin, Integrilin

35
Q

Angina Pectoris Patient Education

A

Exercise regimen

Smoking cessation if indicated

Diet changes (follow AHA/ Mediterranean Diet)

-Plant-based protein & whole grain bread/carb

  • Low saturated fat; high in fiber
  • Lower calories if indicated

Med Knowledge & Compliance

  • One of the side effects of NTG is a headache
  • Dizziness & hypotension w/BP meds
  • Take tablets 5 mins apart

ID appropriate support resources

Help clients to ID one’s individual needs

36
Q

Sudden Cardiac Death

A

Abrupt cessation of effective heart activity

37
Q

Symptoms and severity are determined by…

A

…vessel location and amount of narrowing in the vessel

38
Q

Prevention & Treatment of Atherosclerosis

A

Focus on modifiable risk factors:

-Cholesterol/triglyceride levels

-Tobacco use

-HTN: Take meds on time (low Na diet)

-Diabetes Mellitus: Take meds on time (low-carb diet)

-Activity

-Weight

39
Q

Nursing Education Considerations for Atherosclerosis

A

Education should focus on the modifiable risk factors:
 Cholesterol/triglyceride levels (see pg.
729)
 Tobacco use
 Hypertension
 DM
 Activity
 Weight

40
Q

Nursing Interventions for Atherosclerosis

A

Educate the pt

Monitor lab values/know your ranges

Encourage routine follow-up labs

Nutrition guidance

Tobacco cessation education

Encourage activity/cardiac rehab

Medication compliance and education

41
Q

Acute Coronary Syndrome

A

Spectrum includes unstable angina, NSTEMI, & STEMI

42
Q

Acute Coronary Syndrome Clinical Manifestations

A

CV: Chest pain, jugular vein distension, high/low BP, pulse changes, ECG changes

Resp: SOB, dyspnea, tachypnea

GI/GU - N/V, indigestion, decreased UO

Skin- cool, clammy, diaphoretic, pale

Neuro - Restlessness, dizziness

Psych - Fear, anxiety, denial, “impending doom”

43
Q

Order of CAD Progression

A

Atherosclerosis-> Angina-> Acute Coronary Syndrome-> MI

44
Q

Diagnostics Used in the ACS Spectrum: 12-lead ECG

A

Changes to ST segment and T wave, development of a pathologic (abnormal) Q wave

Should be obtained within 10 minutes of arrival to ED or complaint of pain

45
Q

Diagnostics Used in the ACS Spectrum: Cardiac enzymes/biomarkers

A

Troponin
- Trop T and I, “Normal” Trop range = 0 - 0.03

CK-MB is cardiac-specific and will peak within 24 hours of the MI

Myoglobin is less specific, negative MG can be used as a “rule-out”

46
Q

Normal Troponin Range

A

Normal: 0-0.03

Anything that exceeds 0.4 -> high likelihood it could be MI

47
Q

Diagnostics Used in the ACS Spectrum: Echocardiogram

A

Check ventricular function and wall function

48
Q

Diagnostics Used in the ACS Spectrum: Stress Test

A

May identify areas of CAD

49
Q

Diagnostics Used in the ACS Spectrum: Cardiac catheterization w/ PCI

A

Visually identify coronary vessels & repair blockages

50
Q

Left Heart Catheterization: Performed in Cath Lab

A

MD uses Radial or Femoral artery to insert a catheter, catheter is guided to the coronary arteries and contrast is injected
- Depends on which method the MD has been trained in
- Sometimes in patients w/ narrow shoulders, they will go femoral route

Under fluoroscopy the MD can see where the vessels narrow or are blocked

Angioplasty/stent placement vs medical management
- More than 70% occlusion = stent
- Less than 70% occlusion = medical management

51
Q

Left Heart Catheterization: Returning to the Acute Floor

A

Assess vitals, groin/wrist, extremities
- Avoid risk for infection, bleeding, excess clotting
- Hold pressure for bleeding
- Patients w/ Metformin cannot undergo this procedure (must wait at least 48 hrs after to take it-> due to interaction)

Maintain hydration to promote renal flushing
- This procedure is caustic to the kidneys
- Assess renal function BEFORE procedure

Maintain bedrest for 4-6 hours (per MD order)
- Those w/ radial catheterization have at least 30 mins of rest

52
Q

Left Heart Catheterization: Patient Education

A

Activity limitations
- Based on which body part was accessed
* Wrist = no lifting
* Groin = no bending, squatting, or stooping
- To avoid increasing pressure on procedure site

Signs of infection
- Watch out for redness, swelling, fever

53
Q

ST-segment Elevation

A

Injured myocardial cells depolarize normally but repolarize faster than normal cells, causing the ST segment to rise at least 0.04 sec (1mm) above the isoelectric line

May return to normal after reperfusion

54
Q

ST-segment Depression

A

At least 0.04 sec (1mm) below the isoelectric line

Typically associated with ischemia, not necessarily an infarct

55
Q

T-wave Inversion

A

Typically the earliest change on ECG, may be permanent

Caused when myocardial repolarization is altered/damaged

56
Q

Pathologic Q-wave

A

0.04 seconds or longer and 25% of R wave depth

Last change to occur (1-3 days after MI)

No depolarization can happen in the necrotic cells

57
Q

NSTEMI Diagnosis

A

Shows abnormal biomarker, but no changes in ECG

58
Q

STEMI Diagnosis

A

Shows abnormal biomarkers & ST changes in at least 2 leads

Highest Risk

-LAD occlusion: “Widow-maker”, anterior wall MI, person just drops dead

-RCA occlusion: Most common, inferior wall MI

59
Q

Acute Coronary Syndrome Treatment Goal

A

Reestablish blood flow & decrease ischemic damage

60
Q

Med Regiment for ACS: MONA

A

Same as angina, but also ACE-inhibitor (decrease O2 demand) & statin (help cholesterol level) should be added

Morphine

O2

Nitroglycerin

Aspirin

61
Q

Nursing Interventions for ACS

A

Position the patient safely and implement bedrest

Administer MONA if indicated/MD ordered

Call for help from charge nurse or MET/MRT/RRT

Notify primary provider as quickly as possible

Call for stat EKG per protocol/MD order

Call for stat labs per protocol/MD order

62
Q

STEMI Protocol

A

Act fast! Reperfusion needs to happen within 12 hours Preferred treatment is PCI

Door-to-balloon time is 60 minutes (arrival at ER to time PCI is performed)

-AHA suggested time is 90 mins

Thrombolytics within 12 hrs of symptom onset if PCI is not possible/indicated

-W/in 30 mins of onset shows best patient outcomes

63
Q

USA Diagnosis

A

Shows symptoms, but diagnostics are negative for acute ischemia

64
Q

The nurse is evaluating a 12-lead ECG of their patient who is experiencing an inferior wall MI. While discussing w/ the healthcare team, which of the following ECG changes has the nurse correctly identified:

A) Notched T wave & prolonged QTc
B) Inverted P wave & prolonged PR interval
C) ST segment elevation & inverted T wave
D) Irregular QRS complexes & no P wave

A

C) ST segment elevation & inverted T wave

ST elevation & T wave inversion both indicated damage to the myocardium, ST elevation indicates that it is acute (new) & this is the most life-threatening type of myocardial event

Rationale for Incorrect Choices:
A) is incorrect. These signs are more related to chronic (long-term) cardiac damage or medication use; although a prolonged QTC can be dangerous, this is not as imminently threatening as an ST elevation

B) is incorrect. These signs relate more to chronic atrial disease & are not as imminently threatening as ST elevation

D) is incorrect. These are characteristics of A-fib; while this can have dangerous complications, this is not as imminently threatening as ST elevation

65
Q

A female patient is admitted to the ED c/o indigestion & nausea, in addition to pressure in her chest & shoulder. The patient also appears to be anxious, dyspneic, & diaphoretic. Which doctor’s orders should the nurse anticipate?

A) Keep NPO; draw labs: CMP, liver enzymes, abdominal CT

B) Keep NPO; draw labs: troponin, CK-MB, myoglobin, EKG & echo

C) Chest & shoulder MRI

D) Head CT

A

B) Keep NPO; draw labs: troponin, CK-MB, myoglobin, EKG & echo
- Rationale: The symptoms of the female patient could indicate a possible cardiac event. After ruling out a cardiac event, the provider may direct the focus to the GI system.
* Address symptoms of ABC’s FIRST!!!*

66
Q

The nurse is taking care of a patient diagnosed w/ angina. Which of the following is the primary treatment goal?

A) Reversal of ischemia

B) Reversal of infarction

C) Reduction of stress & anxiety

D) Reduction of risk factors

A

A) Reversal of ischemia

Rationale: Angina is the pain associated w/ ischemic (impaired) cardiac tissue. All nursing care is aimed at reversing this damage before it becomes necrotic & is done by increasing O2 supply & decreasing O2 demand

67
Q

The nurse is caring for a patient being admitted to the cardiac telemetry floor following a LT heart catheterization w/ PCI via femoral approach. Upon initial assessment, the nurse notes there is a large amount of blood under the patient’s buttocks. What is the nurse’s priority action?

A) Call Rapid Response for help

B) Assess your patient’s vital signs & call the doctor

C) Ask the client to raise their hips so you can assess underneath

D) Assess the client’s groin site

A

D) Assess the client’s groin site

Rationale: The blood could just be from the procedure, but it could also be an active bleed. The only way to know if this is an active bleed is to assess the groin site for bleeding. The priority action in an active bleed is to hold pressure, but the nurse cannot do this until they assess (ABC’s)

68
Q

The nurse is assigned to a new patient being admitted to the cardiac telemetry floor for chest pain. The nurse assesses the patient’s medical history & current physical status. Which statement from the patient indicates a misunderstanding in the way to use nitroglycerin tablets?

A) “I can take up to 3 tablets before calling 911”

B) “I let it sit under my tongue instead of swallowing them whole”

C) “I only use them when I have chest pain”

D) “I keep a couple of the tablets in my general pill organizer for quick access”

A

D) “I keep a couple of the tablets in my general pill organizer for quick access”

Rationale: This is an INCORRECT understanding because the pills should be kept in their original pharmacy bottle (labeled for safety & dark to protect them from light exposure)

69
Q

The nurse is completing a PQRST pain assessment on a patient c/o substernal chest pain. Which patient statement would indicate this pain is most likely stable angina?

A) “The pain began while I was watching television”

B) “The pain resolved after taking my NTG tablets”

C) “The pain is radiating to my LT arm”

D) “The pain started this morning & has lasted all-day”

A

B) “The pain resolved after taking my NTG tablets”

Rationale: This is predictable & when chest pain is resolved w/ rest it is considered stable

70
Q

The nurse is caring for a 50 y.o. male patient w/ a family hx of CAD who has been prescribed Atorvastatin for the management of his cholesterol levels. The patient is concerned about the side effects of this medication, so the nurse tells him which of the following statements:

A) “This medication has no side effects; you should not worry about that”

B) “Because this medication directly impacts your normal cardiac function, the doctor will monitor your labs routinely”

C) “Because this medication directly impacts your normal liver function, the doctor will monitor your labs routinely”

D) “ A heart attack is worse than any side effect you may have, & because it is so important you should just take what the doctor ordered”

A

C) “Because this medication directly impacts your normal liver function, the doctor will monitor your labs routinely”

Rationale: The nurse should present factual information that addresses the patient’s concern & reassure the patient that care will be ongoing.

71
Q

The nurse on the telemetry unit has just finished report & is reviewing their assignment. Which patient should be seen first?

A) The patient who was admitted last night at 2100 w/ chest pain that was unrelieved by their home NTG & showed a troponin level of 0.05 (@2100) & then 0.3 (@0700)

B) The patient that had a MI 2 days ago & has questions about going home today.

C) The patient who was admitted this morning at 0500 w/ chest pain that decreases w/NTG ointment & has a troponin of 0.04 (0500)

D) The patient who had a LT heart catheterization w/ stents yesterday at 0800 & has a resolving hematoma in their LT groin.

A

A) The patient who was admitted last night at 2100 w/ chest pain that was unrelieved by their home NTG & showed a troponin level of 0.05 (@2100) & then 0.3 (@0700)

Rationale: This patient is showing clinical changes that indicate worsening cardiac damage (unrelieved chest pain & increasing troponin level)
* Unstable angina can progress into a MI!!!**

72
Q

A patient who experienced a MI received a thrombolytic agent rather than having a PCI. Which nursing intervention is most important during the next 24 hrs?

A) Assess for bleeding
B) Monitor K+ levels as ordered by the MD
C) Monitor the patient in a supine position
D) Encourage PO intake of fluid

A

A) Assess for bleeding

Rationale: A thrombolytic agent is meant to break up clots & prevent further clotting, bleeding is a SERIOUS side effect & can impact C(irculation) of the ABC’s.

73
Q

The nurse is caring for a patient in the cardiac acute care floor who was admitted yesterday for chest palpitations. The patient calls to the desk stating they are having 10/10 pain in their chest & neck. Upon assessment the nurse determines normal S1 & S2, no adventitious breath sounds, & no GI abnormalities. They check the vitals which are HR 105, RR 22, BP 140/95, O2 91%, and temp 97.8F. Which intervention should the nurse do next?

A) Call the patient’s emergency contact

B) Assist the patient to safe positioning if needed & provide MONA interventions per hospital protocol

C) Page the MD

D) Complete a full head-to-toe assessment of the patient

A

B) Assist the patient to safe positioning if needed & provide MONA interventions per hospital protocol

Rationale: There is enough assessment to determine an action

74
Q

The nurse is caring for a patient on the cardiac acute care floor. The patient was admitted overnight for recent periods of chest pain. Upon assessment of the patient, the nurse finds they are experiencing pain at a rating of 10/10. The nurse assesses the patient’s vitals & fins them to be HR 95, RR 24, BP 88/55, O2 93%, temp 98.2 F. Which intervention should the nurse do next?

A) Call the patient’s emergency contact

B) Assist the patient to safe positioning if needed & provide MONA interventions per hospital protocol

C) Page the MD

D) Complete a full head-to-toe assessment of the patient

A

C) Page the MD

Rationale: The doctor should be called since the assessment includes abnormal findings & the protocol is unsafe to proceed with. The nurse needs to communicate the findings & get new orders to work with.

NURS3313 Adult Health (27 decks)

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