ED Care PT w/ ACS Flashcards
Exam 2
1
Q
What labs do you get for chest pain?
A
CBC CMP BMP and Troponin
Maybe a PT PTT and INR
2
Q
What should the total ischemia time for chest pain be? Should the patient be taken to a hospital with PCI [Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat the blockages in a coronary artery] capabilities?
A
under 120 min
Yes
3
Q
What are pulsus alternans
A
change in pulse amplitude every other beat
4
Q
What does T stand for in chest pain assessment?
A
Timing
5
Q
ECG and ischemia, injury, and infraction
A
- Ischemia - causes depressed ST segment
- Injury - ST elevation on ECG
- Infarction - Q wave on ECG
6
Q
What occurs when a pt has an mi?
A
- Within minutes of hypoxia to an area, the cells lose their contractility.
- If o2 isn’t restored to the area, mi occurs.
- Infarcted cells can’t help the heart contract.
- Scar tissue builds up and ventricular remodeling can occur, changing the shape of the heart muscle.
7
Q
What condition is increased in heart disease that presents with these clinical manifestations?
>40(men) or >35(women) inch waists, high triglyceride levels, high ldl, low hdl
A
Metabolic syndrome
changing lifestyle can help
8
Q
What determines blood pressure?
A
Flow through the vessels and vessel resistance
9
Q
How does oxygen-rich blood enter the heart?
A
From the lungs and goes out to the body
10
Q
What does ACS stand for?
A
acute coronary syndrome insufficient blood supply to heart muscle causing chest pain
11
Q
What is the main cause of development of fatty plaques in coronary arteries?
A
Atherosclerosis
12
Q
What is atherosclerosis?
A
Accumulation of lipids/fatty substance/fibrous in vessel wall
13
Q
What is stable angina?
A
- is the accumulation of plaque in coronary arteries
- occurs with exertion and is relieved by rest
14
Q
What are nonmodifiable risk factors for atherosclerosis and ACS?
A
Family history, increasing age, gender, race
15
Q
What are some modifiable risk factors for atherosclerosis and ACS?
A
High blood cholesterol levels, smoking tobacco use, HTN, diabetes mellitus, lack of estrogen in women, physical inactivity, obesity, behavior patterns
16
Q
What does LDL stand for?
A
below 130 mg/dl want it LOWWW to the ground
17
Q
What is metabolic syndrome also known as?
A
Insulin resistance syndrome
18
Q
Which is most severe injury, ischemia, infarct?
A
Infarct
Injury
then ischemia
19
Q
What is infarct
A
An absence of blood flow to the myocardial tissue, leading to necrosis.
20
Q
What is the manifestation associated with myocardial oxygen demand exceeding supply?
A
Chest pain
21
Q
What does I see all leads stand for?
A
Inferior II , II , avf
Septal v 1 v2
Anterior v3 v4
Lateral v5 v6
22
Q
Angina can be…
A
stable angina, unstable angina, and variant
Stable angina occurs with exertion and is relieved by rest.
Unstable angina pain is often more severe, may occur at rest, and requires more frequent nitrate therapy.
Variant angina caused by coronary artery spasms.
23
Q
What route and med would you not giving if you have an st elevation in the leads II, III, and AVF?
A
Inferior Stemi – ST elevation in II, III, AVF
Nitro sublingual because you cannot adequately control how much and how fast you are giving nitro?
24
Q
What shows the septal view of the heart?
A
V1 and V2
25
What shows the lateral view of the heart?
V5 and V6
26
What is angina?
Chest pain caused by myocardial ischemia
27
What are concerning signs for angina?
Radiation to left hand, elbow, arm, shoulder, neck, head, jaw, tooth
When it lasts longer than 20 mins and us unrelieved by rest or nitro
28
What is stable angina?
Chest pain with exercise, it is predictable and relived by rest or nitro
29
What is unstable angina?
More severe form of chest pain
Can be an indication of impending MI
30
What is the possible cause of Variant or Prinzmetal's Angina?
Vasospasms with minimal plaque causing chest pain at rest
31
What is a myocardial infarction?
Abrupt deprivation of oxygen to the heart
32
What are the three stages of an acute myocardial infarction?
Ischemia, Injury, Infarction
33
What leads are considered inferior?
II, III, AVF
34
What are the leads that show ST-segment elevations suggestive of septal myocardial infarction?
Septal V1, V2
35
n/v shob, dizziness, diaphoresis – associated symptoms
Increase in mi oxygen demand when they get up
left pain arm mean mi
Coughing – respiratory
Is movement the problem increase mi oxygen
Chest pain assessment s/s
36
What does the 'R' in chest pain assessment stand for?
Radiation – move to chest
37
Color of skin and mucous membranes.
Pallor of lower extremities with legs raised may be indicative of arterial insufficiency.
Pale upper plate can tell a lot by what occurs in month
Cyanosis may be indicative of low PaO2 or Right to Left shunting.
Edema: may be indicative of Right Vent Failure.
Varicosities: Predisposition to thrombophlebitis.
Clubbing: Indicative of chronic O2 deficiency.
Position of comfort: Orthopnea may be indicative of Left Vent. Failure.
What do you look for in cardia assessment in terms of perfusion?
38
Skin temperature: does temperature reflect good circulation? Why? Why not? – it can help indicate – signs pt is not getting good refill
LOC: How alert is my patient?
Breathing: Is my patient SHOB?
Heart tones
Skin color
Extremities
Pulses
What do each of these things tell me about my patient?
Cardiac Assessment: Palpation & Percussion
39
What should be assessed in the cardiovascular examination?
Rate, rhythm, presence of murmurs
40
What is the anatomical location of the carotid pulse?
Neck
41
What are the points on the chest to auscultate for the heart?
Aortic pulmonic tricuspid and mitral
APE TO MAN
42
What is the normal range for pulse pressure?
30-40 mm Hg
43
What should you assess in the neck veins during a cardiac inspection?
RIJ distention and pulsation
HOB 30 to 45 degrees to check
44
What should be evaluated during cardiac assessment of neck veins?
RIJ distention, pulsation, Jugular Venous pressure, Hepato-jugular reflux
45
What is the recommended O2 level for patients with indicated spo2 <94%?
2-4L
46
What should be done when a patient presents with chest pain?
O2 - 2-4L if indicated spo2 <94%
IV line(s)
12 - Lead EKG
Continuous cardiac monitoring
Lab Tests
Patient Position
47
- EKG confirms ST elevation in any group of leads
- There will be ST elevation + (eventually if not already present) the release of troponin I, which is a protein that is specific to the heart muscle when damage occurs.
- Reperfusion therapy should be administered to all eligible patients with a STEMI (Tenecteplase)
- PCI is the recommended method (Percutaneous Coronary Intervention)
- Fibrinolytics after STEMI: Check PT/PTT/INR
STEMI
48
What should you always check before giving Nitro?
Blood pressure
49
Angina v MI
ANGINA
Occurs with exertion (physical or emotional)
Is relieved by rest
Is relieved by nitroglycerin
Last for minutes
50
What are s/s you'll see in an MI
Pian radiating to back necj jaw shoulder arm
Dyspnea
Syncope
N/V
Weakness
Diaphoresis
Tachy
Are you having any nausea/vomiting/shob/dizziness/diaphoresis/radiation to left side?
51
What is the recommended frequency for monitoring vital signs while titrating NTG?
Q 5 min
52
What high risk monitoring should you do?
Assess LOC - sensitive indicator – decrease bloodflow causes confusion
Cardiogenic Shock – not able to perfuse enough blood – low bp – inferior stemi – 60/90 is cardiogenic shock
53
What is the effect of hyperkalemia on the T wave?
T wave elevated
54
What is a high sensitivity troponin flowsheet?
Documentation tool for monitoring high sensitivity troponin levels
Less than or equal to 15
55
What are signs of cardiogenic shock?
Decreased LOC
Tachycardia
SBP < 80
Narrowed pulse pressure – top number and bottom are getting closer together
Pale, cool, clammy skin – might give levophed
56
What is afterload?
Resistance against which the ventricle has to pump to eject blood
(resistance) – all the blood outside of the venous system
57
What does HDL stand for?
High Density Liproprotein want above 45 mg/dl for a client to feel HIGGHHH and HEALTHY
58
What happens to insulin levels in metabolic syndrome?
Elevated insulin levels because the pancreases overreacts to make more insulin
59
How does nitroglycerin help relieve pain?
vasodilates the vessels
60
How does Variant or Prinzmetal's Angina present?
With normal findings and the area where it the vasospasm occurred will cause the most pain
61
What are the phases of tissue injury in a myocardial infarction?
1. Ischemia - no damage as long as MI doesn't extend as circulation is compensated/(causes depressed ST segment)
2. Injury - Tissue may be saved if O2 is increase in area/(ST elevation on ECG)
3. Infarction - O2 deprived/irreversible damage/(Q wave on ECG)
62
What is represented by tissue death and Q waves?
Infarction
63
What is an inferior MI?
Damage to the inferior wall of the heart
64
What can jugular venous distention indicate?
Right sided failure
65
MI v Angina
MI
Can occur at rest
Is not relieved by rest
Is relieved by morphine rather
than NTG
Lasts for at least 20 minutes
66
What medications are indicate for MI?
ASA - asprin
Oxygen
NTG - sublingual
Morphine – decrease oxygen demand and cardio work load
NTG - IV drip
Thrombolytic (Tnkase/T-pA)\
Heparin
67
How often should vital signs be assessed once stable?
Q 15 min
68
What is released when there is damage to the heart?
Tropin
69
What is the effect of hypokalemia on the T wave?
T wave depressed
70
If dysrhythmias occur due to MI...
Antiarhythmic
Amiodorone
Lidocaine
Atropine – increase HR
Pacemaker
Cardioversion
71
How does oxygen-poor blood enter the heart?
From the body and goes out to the lungs
72
Left side v right side
Left is lungs – shob, hypoxia, confusion, anxiety – not pumping as much blood as we are supposed to
Right for rest of body edmea, jvd, anything that is not resp is probably right
73
What does clubbing of the nails indicate?
Chronic low oxygen saturation
74
Where is the point of maximal impulse usually visible? Anterior chest appearance
4th to 6th I.C. space medial to left midclavicular line
75
What should be done immediately for a patient with chest pain?
1. Arrive to ED
2. Nurses immediately notified
3. Call for ECG immediately/placement of monitors (cardiac and vitals)
4. IV access/with simultaneous lab draw-CBC, CMP, TROP, CXR, maybe BNP
5. Aspirin 162-324mg depending on facility (chewed)
6. Nitro if not contraindicated (inferior STEMI)
76
What is a desirable quality of IV Nitro that SL Nitro does not have?
IV Nitro can be titrated with a drip
77
What is the use of NTG IV drip?
Used for continuous relief of angina
78
What is the recommended dosage of aspirin for a patient experiencing chest pain?
Chew and take 81-325 mg of asprin
79
What should be checked in the legs, ankles, and feet?
Edema, pulses, sensation, pressure areas
80
What are the most common side effects? What should you educate your patient on?
Dizziness and headache.
1. Warn them it may and probably will happen.
2. Recline their head of bed and discourage standing up.
3. Consider making your patient a “fall risk”
81
What is preload?
Stretch on the ventricular myocardium at the end of diastole
(filling pressures) – the blood that has not completely returned to the heart
82
What does a clot indicate?
Congestion and no traffic meaning the body cannot perfuse to that part of the cardiovascular system
83
What are the three levels of acute coronary syndrome?
ischemia, injury, and infract
84
What are the two types of ACS?
STEMI and non-STEMI
85
What happens when the vasculature supplying oxygen to the coronary muscle narrows?
Limited blood flow
86
What are atherosclerosis symptoms and complication based on?
the location and degree of narrowing of arterial lumen
87
When does stable angina become unstable and dangerous?
when the plaque ruptures or becomes unstable in the vasculature
88
What is the fasting glucose level in metabolic syndrome?
Fasting glucose >110
89
Which tissues become unresponsive to insulin in metabolic syndrome?
Skeletal muscle, fat, and liver
90
What is ischemia?
Temporary interruption of myocardial blood supply
91
What is injury in the context of myocardial blood flow?
Prolonged interruption of blood flow
92
What does angina pectoris mean?
Strangling of the chest
93
What is the effect of nitro on blood pressure?
lowers blood pressure and vasodilates
94
Which leads show the anterior view of the heart?
V3 and V4
95
When should an ECG be obtained for toothaches?
One-sided toothaches in absence of poor dentition
96
How do you tx variant angina?
Cardizem
Treated with calcium channel blockers.
97
What is St depression?
Ischemia indicator
98
What is represented by ST segment depression, T wave inversion, or both?
Ischemia
99
What is represented by ST segment elevation?
Injury
100
P wave represents?
atrial contractions
101
QRS represents?
Atrial contraction of the ventricles
102
T wave represents?
Relaxation of the ventricles
103
What does the 'P' in chest pain assessment stand for?
Provoke
104
What does the 'Q' in chest pain assessment stand for?
Quality – sharp stabbing aching
105
What does the 'S' in chest pain assessment stand for?
Severity
106
What is the anatomical location of the dorsalis pedis pulse?
top of foot
107
What is the anatomical location of the femoral pulse?
Groin
108
What is the anatomical location of the posterior tibial pulse?
Ankle
109
Why is it important to know what you are listening to when you listen to the heart?
To provide accurate clinical information
110
What abnormalities should be noted during heart tone assessment?
S1 & S2 abnormalities, S3, S4, and/or murmurs
111
Pulsus alternans – change in pulse amplitude every other beat
Paradoxic pulse – decreased systolic blood pressure during inspiration
Blood pressure difference > 10 mm Hg between left and right arm (may indicate aneurysm, aortic dissection, obstruction, or arterial compression.
Orthostatic hypotension - significant if > than 20 mm Hg.
Bruits: caused by arterial narrowing (plaque), aortic murmur, patency of fistula.
Abnormal findings?
112
What is paradoxic pulse?
Decreased systolic blood pressure during inspiration
