Exam 1: Cardiovascular, ECG, Shock & Sepsis Flashcards
What is angina?
Reduced blood flow to the myocardium results in inadequate oxygen delivery to heart muscles causing ischemia, which then produces chest pain
What is stable angina?
emporary, transient, reversible, predictable, and manageable most likely triggered by activity or exertion that usually lasts 3-5 minutes before relieved by rest or nitro. No permanent damage occurs if transient and relieved. Certain activities are the cause of this type of angina, such as walking to the mailbox. There will be no elevation in Troponin levels.
what is unstable angina?
(pre-infarction) unpredictable and may occur at night or at rest.
What is considered new onset angina?
First symptom that usually occurs after exertion or during periods of increased demands on the heart
What is variant angina?
(Prinzmetal) caused by coronary spasm and may occur when at rest or at night. Can cause changes in ST segments
What is preinfarction angina?
Chest pain that occurs in days or weeks before an MI Warning sign!!
What does the acronym PQRST mean for angina?
P: Precipitating events (Exercise, exertion, stress, rest, cold temps, smoking (nicotine causes vasoconstriction), heavy meals) What were you doing at the time this started?
Q: Quality of pain (Squeezing, pressure, heaviness, burning, fullness)
R: Radiation of pain (Arm, neck, shoulder, jaw, back)
S: Severity of pain
T: Timing (When it began, what activity, how long it lasted
What are the lab values that should be looked at for a patient experiencing angina?
Troponin I*
Troponin T*, CK-MB, Myoglobin
Electrolytes, Cholesterol
HDL, LDL,
C-reactive protein, homocysteine levels
What diagnostics that can be performed for a patient experiencing angina?
-ECG
-Exercise tolerance test
-Thallium Scan
-Cardiac cath
-Positron emission -5tomography (PET), —-MRI
-Transesophageal Echocardiography -Halter monitor
On an ECG what will you see for angina, MI and necrosis?
angina=ST depression means ischemia can be reversed.
MI=ST elevation means injury will occur and elevated Q wave=necrosis
What are the treatment options for angina?
Can be managed at home, stop activity and sit/lie down. If chest pain is not resolved try nitro, and if pain is not resolved in 15 minutes call 911
-Pts should have blood pressure cuff at home and be able to check BP
What are the common medications for Angina?
SL NTG
Antiplatelet agents (aspirin)
ACEI or ARB
Beta blocker
Nitrates
Calcium channel blocker
What is the protocol for nitroglycerin?
Have client sit/lie down
administer 1 SL tablet or spray under tongue
Wait 5 minutes
if unrelieved administer 2nd dose and wait 5 min
if then unrelieved administer 3rd dose. Take vital signs with each dose, but if 3 doses does not resolve pain-call 911. Use acetaminophen for headache.
What medication for angina should not be used with nitroglycerin?
Ibeuprofen
What determines an emergency in regards to angina?
If it occurs at rest, is not responsive to nitro, and lasts longer than 5min=emergency!
What are some risks to monitor for with nitro?
-Injury related to hypotension from nitro
-Syncopal events
-educate on need/reasoning for remaining seated/supine when taking nitro
-do NOT bite into nitro, ask if they have a sting-if not the nitro may have been exposed to light/heat
-appropriate technique for nitro, —–educate s/sx of MI
What are acute coronary syndromes?
Conditions characterized by excessive oxygen demand and/or inadequate supply of oxygen/nutrients to heart muscle commonly associated with plaque disruption, thrombus formation, vasoconstriction
What are the different types of acute coronary sydromes?
Unstable Angina
Non-ST segment elevation MI
ST Segment MI
What is a Non-Stemi?
Same as unstable angina w/the exception that there is actual cell death (can tell from cardiac markers), partial occlusion of coronary artery, and length of pain/symptoms are longer than unstable angina (Partial thickness damage to heart muscle)
What is a STEMI?
-Acute ST elevation MI occurs when an intracoronary plaque ruptures with thrombus formation completely occludes the vessel
-Full thickness damage to heart muscle->entire artery is blocked)
What is the goal of treatment in a STEMI?
Treatment goal of re-establishing perfusion as quickly as possible. Time is muscle (door to balloon in 90-minutes)!
What is the pathology of a myocardial infarction?
Area of tissue death will result in non-functional scar tissue, and understanding the coronary artery affected will indicate the location of necrosis (downstream of occlusion).
What is a ‘widowmaker’?
An MI in the left main descending coronary artery
On an ECG in regards to MIs, what is the difference between a Q-wave MI and a non Q wave MI?
A Q wave=entire thickness of wall is damaged
Non Q wave=Partial damage
Cardiac Enzymes:
What is the normal level of Troponin T
<0.1ng/mL
Cardiac Enzymes:
What is the onset and return to normal of Troponin T after MI?
Onset is 4-6 hours
Return to normal in 10-14 days
Cardiac Enzymes:
What is the normal range of Troponin I?
Normal=<0.03ng/mL
Cardiac Enzymes:
What is the onset and return to normal of Troponin I after MI?
Onset is 4-14 hours
Return to normal in 7-10 days
Cardiac Enzymes:
What are the normal levels of CK-MB (not cardiac specific)?
0% of total CK
Cardiac Enzymes:
What are the onset, peak and return to normal of CK-MB after MI?
Onset 3-6 hours
Peak 24 hours
Back to normal in 2-3 days
Cardiac Enzymes:
What are the normal levels of myoglobin (not cardiac specific)?
<90mcg/L
Cardiac Enzymes:
What is the onset and back to normal of myoglobin after MI?
Onset in 2 hours
Back to normal in 24 hours
In regards to monitoring Troponin levels, what is very important to remember?
We do not monitor for just one Troponin level, but successive troponin levels (q3) to monitor for the extent of damage.
What are the first-do priorities for MI?
-Initiate cardiac monitoring on 12 lead ECG (ONLY HAS 10 WIRES).
-MONA: Morphine, Oxygen, Nitroglycerin, Aspirin
-Thrombolytic Therapy: used to dissolve clots in coronary arteries that is most effective if administered under 6 hrs from symptom onset. Indicated for chest pain lasting over 30 minutes. Contraindicated in recent surgery, pregnancy, PMH of cerebral bleed, or bleeding disorders
What are the common medications used to treat MI?
Vasodilators (Nitro)
Analgesics (morphine)
Beta blockers
ACEI
Calcium Channel Blockers
Antiplatelets
Thrombolytic Agents (alteplace)
Anticoagulants
HMG CoA inhibitors
Antidysrhythmics
The ischemia from an MI leads to acidosis which leads to cardiac irritability frequently causing?
PVCs
V-tach
V-fib
Atrial Fib
What is a diagnostic cardiac catheterization?
Also known as a Cardiac Angiogram, it determines the blood flow in areas of coronary artery blockage by inserting a catheter into the radial, brachial or femoral artery and injecting an iodine based contrast dye that allows for visualization. Can be diagnostic or interventional.
What is an interventional cardiac catheterization for?
Percutaneous coronary intervention (PCI), Percutaneous transluminal coronary angioplasty (PTCA) or angioplasty
PTCA Involves balloon-tipped catheter -> balloon inflated to open stent leading to flattening of plaque and dilate artery balloon deflated and catheter removed, stent remains in place and keeps artery patent
After a cardiac catheterization, what are some of the important RN considerations?
Position supine with legs straight
Keep on telemetry
Maintain bed rest 2-6 hr
Assess q15 min x 1 hr
Assess 30 min x2 hr
Assess q1hr x 4hr
Assess Q4
Encourage PO fluids
Anticoag therapy
What are the discharge instructions for a patient post cardiac cath?
Avoid strenuous exercise/activity restrictions for prescribed period (3-12 weeks)
Report bleeding from site, chest pain, SOB, color/temp changes to extremity, changes in sensation to extremity
Restrict lifting < 10 lbs for prescribed time
What is a coronary artery bypass graph?
Also known as a CABG-
Procedure that restores perfusion to myocardium by creating a bypass using a vein (saphenous) or artery (mammary/radial) around the obstruction.
If a stent is placed, what is the anticoagulation therapy?
For drug eluting stent: 6-12 months of clopidogrel + aspirin until epithelialization
For bare metal stents: 1-3 months
What are the requirements to have a CABG?
For clients who do not respond to medical management of CAD and who are not candidates for PCI
Experience angina with ≥ 50% occlusion of the left main coronary artery that cannot be stented Have 2 or 3 vessel disease
Have ischemia with heart failure
Have an acute MI
Have signs of ischemia s/p PCI
Have coronary vessels unsuitable for PCI
A minimally invasive CABG is when?
A patient only has one area that needs to be bypassed
What are the RN considerations for pacing wires post CABG?
Need to be capped and protected
Pts cannot shower with pacing wires
Assess site and provide site care Q shift
Monitor for s/s of infection
Remove within 48-72 hours if possible
What are the sternal precautions post CABG?
6 to 10 weeks
No pushing or pulling, No lifting > 5 pounds, No lifting arms over head, No stretching arms behind back, Pace activities, Rest before and after meals, Rest before and after exercise. These patients should also be enrolled in cardiac rehab.
What is the discharge teaching for a CABG?
Incision care (Soap and water), Shower no tubs, monitor and report signs of infection, resume normal activities slowly, sternal precautions 6 to 10 weeks, sexual activity based on healthcare provider guidance, no driving for 6 to 8 weeks
What is an ART line?
A line placed in the radial (most common), brachial or femoral artery that provides continuous info about changes in BP allows withdrawal of arterial blood samples, monitors circulation in limb that has line (cap refill, temp, color but does NOT allow infusions
What is a pulmonary artery catheter?
Catheters that have multiple lumens, ports, and components that allow for different measurements such as blood sampling and infusions of IV fluids
Where is a PA catheter inserted?
Into the:
Internal jugular
Femoral
Subclavian
Brachial
then threaded through RA and RV branch of the pulmonary artery.
What is the proximal lumen used for in a PA catheter?
can be used to measure right arterial pressure (CVP), infuse IV fluids, and measure blood samples
What is the distal lumen of a PA catheter used for?
used to measure pulmonary artery pressures, but NOT used for IV admin.
What is the balloon inflation port of a PA catheter used for?
be intermittently used for PAWP measurements, but when not in use should be left deflated and in locked position unless you are taking pulmonary artery wedge
What is a central venous catheter?
Line that measures right atrial pressure and preload that is inserted into the internal jugular or subclavian vein then advanced to the superior vena cava.
How should the patient be positioned for a central venous catheter when taking measurements?
Requires client to be supine (or minimally elevated 15-30 degrees) during measurements
What are the complications of a central venous catheter?
Infection: Use transparent dressings containing chlorohexidine, sterile dressing changes (including surgical mask for RN & client)
Hemorrhage
Air Embolus: Enters through break in system or open stopcock
Position pt in Trendelenburg for insertion and removal.
Never infuse anything through a monitoring line
Occlusion
What is the normal electrical pathway through the heart?
SA Node->AV Node (between atrium and ventricles->L and R bundle branches (septum/ventricles)->Purkinje Fibers (ventricles)
What are the rates of the internal pacemakers of the heart?
**IMPORTANT***
SA Node (natural pacemaker)-intrinsic rate=60-100bpm
AV Node-intrinsic rate=40-60bpm
What does the P wave represent?
Atrial depolarizaton
What does the PR segment represent?
The time required for the impulse to travel through the AV node, where it is delayed and through the bundle of HIS, bundle branches, and Purkinje fiber network before ventricular depolarization
What does the QRS complex represent?
The ventricular depolarization and is measured from the begining of the Q (or R) wave to the end of the S wave
What does the J point represent?
The junction where the QRS complex ends and the ST segment begins
What does the ST segment represent?
Early ventricular repolarization
What does the T wave represent?
Ventricular repolarization
What does the U wave represent?
Late ventricular repolarization
What does the QT interval represent?
The total time required for ventricular depolarization and repolarization
is measured from begining of the QRS complex to the end of the T wave
What is the normal range of time for the PR interval on an ECG?
0.12-0.20 seconds (3-5 small boxes)
What is the normal time for the QRS interval on an ECG?
0.06 to 0.12 Seconds (1.5 to 3 small boxes)
What is the normal time for the QT interval on an ECG?
0.34-0.43 seconds (8.5-10.75 small boxes/1.7 to 2.5 large boxes)
Fill in the blank:
In general, the ___________ the HR, the ______________ the QT interval, and the _____________ the HR, the __________________ the QT interval.
In general, the faster the heart rate the smaller the QT interval, the slower the heart rate the longer the QT interval.
ECG waveforms are measured in ___________ and ______________.
ECG waveforms are measured in amplitude (voltage) and duration (time).
ECG:
One large box = _____ seconds=____ms=_____mm=_____mV
One large box = 0.20 seconds=20ms=5mm=0.5mV
ECG:
One small box = _____ seconds=_____mm=_____mv
One small box = 0.04 seconds=1mm=0.1mv
A pacemaker spike would be followed by?
Immediately by a QRS complex
Pacing spake seen without subsequent QRS complexes imply a?
loss of capture
You would assess vital signs and level of conciousness
Prior to cardioversion, the nurse would turn off what?
Oxygen therapy to prevent fire
What would indicate significant tachycardia on a ECG?
the P wave touching the T wave
What is the normal time range for the PR interval?
0.12-0.20 seconds
What is the normal time for the QRS interval?
0.06-0.12 seconds
What is the normal time for the QT interval?
0.34-0.43 seconds
How many boxes on an ECG are in 6 seconds?
30
What are the causes for sinus bradycardia?
Athletes
Medications (beta blockers, calcium channel blockers, digoxin)
MI
Severe hypoxia
Increased ICP
