Chapter 40 Acute Coronary Syndromes Flashcards
Indicators of Risk Factors of Metabolic Syndrome
Hypertension: BP 130/85 or higher, or taking antihypertensive drugs
Decreased HDL: HDLmen or 35inches or >women
Increased pro-thrombic state: increased fibrinogen or plasma activator inhibitor (blood clotting factors)
Increased pro-inflammatory state: Increased c reactive protein, a marker for inflammation
Key features of Angina
substernal chest discomfort: radiating to left arm, precipitated by exertion or stress (or rest in varaint angina), relieved by nitroglycerin or rest, lasting <15min
Few, if any, associated symptoms
Key Features of Myocardial Infarction
Pain or discomfort: substernal chest pain radiating to the left arm, pain or discomfort tin jaw, back, shoulder, abdomen, occurring without cause usually in the morning, relieved only by opioids, lasting g30 min or more
Frequent associated symptoms: n/v, diaphoresis, dyspnea, feelings of fear and anxiety, dysrhythmias, fatigue, palpitations, feelings of fear and anxiety, epigastric distress, dizziness, disorientation/acute confusion, feeling short of breath
Emergency Care of Pt. with Chest Discomfort
ABCs, defibrillate as needed
Provide continuous ECG monitoring
Obtain pt’s description of pain or discomfort
Obtain vital signs
Assess/provide vascular access
Consult chest pain protocol or notify physician or Rapid Response Team
Obtain 12 lead ECG
Provide pain relief and aspirin as prescribed
Administer oxygen therapy to maintain sat >95%
Remain calm, stay with patient
Assess pts v/s and pain intensity 5 minutes after administration of medication
Remedicate with prescribed drugs and check pt. every 5 minutes
Notify physician if v/s deteriorate
Contraindications to Thrombolytic Therapy: Absolute
prior intracrainal hemorrhage
known structural cerebral vascular lesion (arteriovenous malformations)
malignant intracranial neoplasm
ischemic stroke within 3 months except acute ischemic stroke within 3 hours
suspected aortic dissection
active bleeding or bleeding diathesis (excluding menses)
significant closed head or facial trauma within 3 months
Contraindications of Thrombolytic Therapy: Relative
hx of chronic, severe, poorly controlled HTN
severe uncontrolled HTN on presentation( >180S, >110D)
hx prior ischemic stroke within 3 months, dementia, or known intracranial pathology not covered in C/I
traumatic or prolonged CPR (>10min)or major surgery (within 3 weeks)
recent (w/in2-4wks) internal bleeding
noncompressible vascular punctures
for streptokinase/anistreplase: prior exposure (>5days ago) or prior allergic rxn to these agents
pregnancy
active peptic ulcer
current use of anticoagulants; higher INR-higher risk of bleeding
Coronary Artery Disease: Older Adult
assoc symptoms may be different: unexplained dyspnea, confusion, GI symptoms
Have greater reduction in mortality rate from MI with use of thrombolytics but have most severe SEs. monitor carefully
dysrhythmia may be normal age related change rather than complication of MI. determine if it causes significant symptoms then notify PCP.
if beta blockers are used, assess for SEs, exacerbation of depression has significant problem with beta blockade
plan slow, steady increases in activity
plan longer warm up and cool down. pulse rates may not return to baseline until 30mins or longer after exercise
Killip Classification of Heart Failure (I, II, III, IV)
absent crackles and S3
crackles in lower hal fof lung fields and possible S3
crackles more than halfway up the lung fields and frequent pulmonary edema
cardiogenic shock
Home Care Assessment: Pt who had MI
Cardiovascular function: V/S, recurrence of discomfort, indications of ht. failure, adequacy of tissue perfusion, indications serious dysrhythmia
Coping skills: denial, anger, fear, caregiver providing adequate support, pt and caregiver disagreeing?
Functional ability: activity tolerance, ADLs, household chores, does pt plan to return to work?when?
Nutritional Status: food intake (fats and cholesterol)
Pt’s understanding of illness and treatment: how to tx chest discomfort, S&S to report, meds, when to limit activity, modification of risk factors for CAD
Coronary Artery Bypass Graft Surgery: Older Adult
perioperative mortality rates are higher for adults >60.
monitor neurologic and mental status carefully, more likely to have transient neurological deficits after CABG
observe for SE of cardiac drugs because older pts more likely to develop toxic effects from positive inotropes (dobutamine) and potent antihypertensives (nitroglycerin or nitroprusside)
more likely to have dysrhythmias, afib, SVT,
recuperation is slower, hospital stay longer
first 2-5 weeks- chest discomfort, fatigue, and lack of appetite may be particularly bothersome
let someone know when they go walking
Activity for Pt. with CAD: Education
begin by walking same distance in home as in hospital (400ft 3Xs/day)
carry nitroglycerin
check pulse before, during and after
stop activity for pulse increase of >20 beats/min SOB angina or dizziness
exercise outdoors when weather is good
gradually increase distance 1/4 mile twice daily
after exercise tolerance test and with physicians approval, walk 3Xs/week increasing distance by 1/2mile every other week until total distance is 2 miles
avoid straining (lifting, pushups, pull ups, bowl movements)
Management of Chest Pain at Home
Keep fresh nitro available
At first indication of chest discomfort, cease activity, sit or lie down
place one nitro tablet or spray under tongue allowing to dissolve
wait 5 mins for relief
if no relief, repeat nitro and wait 5 more mins
if still no relief, call 911 for transportation to healthcare facility
carry medical identification card or wear alert bracelet or necklace that identifies history of heart problems
