Info To Know Mod 7

Question 1

• blood flow and oxygen is restricted or reduced in a part of the body. Cardiac ischemia is the name for decreased blood flow and oxygen to the heart muscle.
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Answer 1

Ischemia

Question 2

obstruction of the blood supply to an organ or region of tissue, typically by a thrombus or embolus, causing local death of the tissue.

Answer 2

Infarction-

Question 3

1. What are the signs and symptoms of angina pectoris?

Answer 3

• Substernal chest discomfort: • Radiating to the left arm • Precipitated by exertion or stress (or rest in variant angina) • Relieved by nitroglycerin or rest • Lasting less than 15 minutes • Few, if any, associated symptoms

Question 4

2. What are the key difference between chronic stable angina and unstable angina?

_______the discomfort is usually more intense and easily provoked, and ST-segment elevation on ECG may occur.
Symptoms may occur at rest, become more frequent, severe, or prolonged than ______angina. It also may not respond to nitroglycerin.

Answer 4

Unstable angina

Stable angina

Question 5

The term is used to describe patients who have either unstable angina or an acute myocardial infarction. In ACS, it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (“clumping”), thrombus (clot) formation, and vasoconstriction (Fig. 38-1). The amount of disruption of the atherosclerotic plaque determines the degree of coronary artery obstruction (blockage) and the specific disease process. The artery has to have at least 40% plaque accumulation before it starts to block blood flow.

Answer 5

acute coronary syndrome (ACS)

Question 6

is chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. An increase in the number of attacks and in the intensity of the pressure indicates UA. The pressure may last longer than 15 minutes or may be poorly relieved by rest or nitroglycerin. Unstable angina describes a variety of disorders, including new-onset angina, variant (Prinzmetal’s) angina, and pre-infarction angina. Patients with unstable angina may present with ST changes on a 12-lead ECG but do not have changes in troponin levels. Ischemia is present but is not severe enough to cause detectable myocardial damage or cell death. As the assays for troponins become more sensitive, the diagnosis of UA is decreasing.

Answer 6

Unstable angina (UA)

Question 7

_______comes on in response to stress, usually upon exertion, and usually predictable.
It is caused by a tight narrowing in the coronary artery limiting blood supply to the heart. As the exertion of the heart increases, the demand for oxygen and blood supply increases and can become ischemic once the demand exceeds the supply.
It usually responds to treatment such as nitroglycerin, stents, or bypass grafting depended on the location of narrowing.

Answer 7

Stable angina

Question 8

_______ is chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. The frequency, duration, and intensity of symptoms remain the same over several months. CSA results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. It is usually relieved by nitroglycerin or rest and often is managed with drug therapy. Rarely does CSA require aggressive treatment.

Answer 8

Chronic stable angina (CSA)

Question 9

a. What ECG findings are present with angina?

​The ECG should be obtained within _____of patient presentation with chest discomfort!

Answer 9

Patients with unstable angina may present with ST changes on a 12-lead ECG but do not have changes in troponin levels.
Ischemia is present but is not severe enough to cause detectable myocardial damage or cell death. As the assays for troponins become more sensitive, the diagnosis of UA is decreasing.

-10 minutes

Question 10

What are the types of Acute coronary syndrome?

Answer 10

Unstable angina, STEMI, and NSTEMI.

Question 11

What ECG change is visible in a STEMI?

Answer 11

Patients presenting with STEMI typically have ST elevation in two contiguous leads on a 12-lead ECG. This indicates MI/necrosis. STEMI is attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture.The thrombus causes an abrupt 100% occlusion to the coronary artery, is a medical emergency, and requires immediate revascularization of the blocked coronary artery.

Question 12

ECG changes in NSTEMI?

Answer 12

Patients presenting with NSTEMI typically have ST and T-wave changes on a 12-lead ECG. This indicates myocardial ischemia. Initially troponin may be normal, but it elevates over the next 3 to 12 hours. The combination of changes on the ECG and elevation in cardiac troponin indicates myocardial cell death or necrosis.

Question 13

Causes of NSTEMI include

Answer 13

coronary vasospasm, spontaneous dissection, and sluggish blood flow due to narrowing of the coronary artery. It is important to note that changes in ECG along with elevation of troponin should always be assessed in conjunction with the clinical presentation and history of the patient.

Question 14

What are possible signs and symptoms of a myocardial infarction (MI)?

Answer 14

• Pain or discomfort: • Substernal chest pain/pressure radiating to the left arm • Pain or discomfort in jaw, back, shoulder, or abdomen • Occurring without cause, usually in the morning • Relieved only by opioids • Lasting 30 minutes or more • Frequent associated symptoms: • Nausea/vomiting • Diaphoresis • Dyspnea • Feelings of fear and anxiety • Dysrhythmias • Fatigue • Palpitations • Epigastric distress • Anxiety • Dizziness • Disorientation/acute confusion • Feeling “short of breath”

Question 15

a. List at least two uncommon MI symptoms (specifically in women)

Answer 15

Many women of any age experience atypical angina.

Atypical angina manifests as indigestion, pain between the shoulders, an aching jaw, or a choking sensation that occurs with exertion.

These symptoms typically manifest during stressful circumstances or ADLs. Women may curtail activity as a result of angina, and health care providers need to ask about changes in routine.
Symptoms in women typically include chest discomfort, unusual fatigue, and dyspnea.

Question 16

6. What are the priority actions for the care of patient with chest discomfort

Answer 16

• Assess airway, breathing, and circulation (ABCs).
Defibrillate as needed.
• Provide continuous ECG monitoring.
• Obtain the patient’s description of pain or discomfort.
• Obtain the patient’s vital signs (blood pressure, pulse, respiration). • Assess/provide vascular access.
• Consult chest pain protocol or notify the health care provider or Rapid Response Team for specific intervention.
• Obtain a 12-lead ECG within 10 minutes of report of chest pain.
• Provide pain relief medication and aspirin (non–enteric coated) as prescribed.
• Administer oxygen therapy to maintain oxygen saturation ≥90%.
• Remain calm. Stay with the patient if possible.
• Assess the patient’s vital signs and intensity of pain 5 minutes after administration of medication.
• Remediate with prescribed drugs (if vital signs remain stable) and check the patient every 5 minutes.
• Notify the provider if vital signs deteriorate.

Question 17

Name the purpose for giving each med classification to a patient with an MI

Nitrates- (nitro)

Answer 17

​​Nitrates a nitrate often referred to as nitro,
increases collateral blood flow, redistributes blood flow toward the subendocardium, and dilates the coronary arteries.

In addition, it decreases myocardial oxygen demand by peripheral vasodilation, which decreases both preload and afterload.

Question 18

Purpose of giving beta blockers with MI

Answer 18

​Betablockers- beneficial effects of beta blockers in patients with acute myocardial infarction (MI) include: Decreased oxygen demand due to the reductions in heart rate, blood pressure, and contractility, and the consequent relief of ischemic chest pain.
Assess HR and BP before administration because beta blockers cause a decrease in HR and cardiac output and suppress renin activity. • Do not administer if heart rate is <50-60 beats/min. • Hold for systolic <90-100 mm Hg. Observe for signs of heart failure such as cough, edema, shortness of breath, and weight gain because this can occur with a decrease in cardiac output. Assess for wheezing and shortness of breath because beta2-blocking effects in the lungs can cause bronchoconstriction.

Question 19

Purpose of giving anti-platelets with MI patient

Answer 19

​Antiplatelets- Their main advantage is the reduction of adverse ischemic incidents and the major disadvantage is the increase in the frequency of hemorrhages.
Inform patients to report any unusual bleeding or bruising because bleeding is a side effect for all medications in this category. Avoid over-the-counter pain medications that contain additional aspirin. With aspirin therapy: • Take with food because gastric irritation may occur. • Assess for ringing in ears because this can be a sign of aspirin toxicity. • Teach patient that aspirin is an important cardiac medication that should not be stopped unless indicated by the provider as studies indicate better survival rates for patients with CAD receiving aspirin. With P2Y12 platelet inhibitors: • Take with food because drug can cause diarrhea and GI upset. • Do not confuse Plavix with Paxil.

Question 20

8. What are significant safety considerations for giving nitrates? And what are possible side effects?

Answer 20

Before administering NTG, ensure that the patient has not taken any phosphodiesterase inhibitors for erectile dysfunction such as sildenafil (Viagra, Revatio), tadalafil (Cialis), or vardenafil (Levitra) within the past 24 to 48 hours. Concomitant use of NTG with these inhibitors can cause profound hypotension. Remind patients not to take these medications within 24 to 48 hours of one another. Some phosphodiesterase inhibitors are also used in the treatment of pulmonary arterial hypertension (PAH). Patients with PAH cannot stop taking the phosphodiesterase inhibitor. As a result, NTG is contraindicated in this patient population. Teach the patient to hold the NTG tablet under the tongue and drink 5 mL (1 teaspoon) of water, if necessary, to allow the tablet to dissolve. NTG spray is also available and is more quickly absorbed. Pain relief should begin within 1 to 2 minutes and should be clearly evident in 3 to 5 minutes. After 5 minutes, recheck the patient’s pain intensity and vital signs. If the blood pressure (BP) is less than 100 mm Hg systolic or 25 mm Hg lower than the previous reading, lower the head of the bed and notify the health care provider.

If the patient is experiencing some but not complete relief and vital signs remain stable, another NTG tablet or spray may be used. In 5-minute increments, a total of three doses may be administered in an attempt to relieve angina pain. If the patient uses NTG spray instead of the tablet, teach him or her to sit upright and spray the dose under the tongue. NTG topical patches should be placed below the nipple line to decrease discomfort. Angina usually responds to NTG. The patient typically states that the pain is relieved or markedly diminished. When simple measures, such as taking three sublingual nitroglycerin tablets, in timed increments, one after the other, do not relieve chest discomfort, the patient may be experiencing an MI.

Monitor blood pressure (BP) and pay close attention to orthostatic changes because a decrease in BP occurs with vasodilation. • Dizziness can occur with drop in BP. Monitor for headache because vasodilation is generalized. Do not administer to patients taking drugs used to treat sexual dysfunction (e.g., sildenafil, tadalafil, vardenafil) because very serious, possibly fatal interactions can occur. Always assess for pain relief because additional medication may be required.

With sublingual tablets or spray: • Instruct patient to lie down when taking because the hypotensive response can be dramatic. • Tablets can be taken every 5 minutes for pain relief, up to 3 tablets. • Be sure to allow the tablet to dissolve because it is absorbed through the mucous membranes. • Check expiration date because the efficacy decreases over time and should be replaced every 3-5 months. With transdermal nitroglycerin: • Apply the patch to a clean, dry, hairless area because the medication will be better absorbed. • Rotate application sites to prevent skin irritation. • Remove the patch before defibrillation to prevent burns. • Remove patch after 12-14 hours each day to prevent drug tolerance.

Question 21

What are two treatment options for a patient with an MI?

Answer 21

Treatment ranges from lifestyle changes and cardiac rehabilitation to medications, stents, and bypass surgery.

Thrombolytics are often used to dissolve clots. Antiplatelet drugs, such as clopidogrel, can be used to prevent new clots from forming and existing clots from growing.

Nitroglycerin can be used to widen your blood vessels. Beta-blockers lower your blood pressure and relax your heart muscle.

Smoking/Tobacco Use • If you smoke or use tobacco, quit. • If you don’t smoke or use tobacco, don’t start. Diet • Consume sufficient calories for your body to include: • 5% to 6% from saturated fats • Avoiding trans fatty acids • Limit your cholesterol intake to less than 200 mg/day. • Limit your sodium intake as specified by your health care provider, or under 1500 mg/day, if possible. Cholesterol • Have your lipid levels checked regularly. • If your cholesterol and LDL-C levels are elevated, follow your health care provider’s advice, including taking statin medications as indicated.

Physical Activity • If you are middle-age or older or have a history of medical problems, check with your health care provider before starting an exercise program.

• Exercise periods should be at least 40 minutes long with 10-minute warm-up and 5-minute cool-down periods. • If you cannot exercise moderately 3 to 4 times each week, walk daily for 30 minutes at a comfortable pace. • If you cannot walk 30 minutes daily, walk any distance you can (e.g., park farther away from a site than necessary; use the stairs, not the elevator, to go one floor up or two floors down).

Diabetes Mellitus • Manage your diabetes with your health care provider.

Hypertension • Have your blood pressure checked regularly. • If your blood pressure is elevated, follow your health care provider’s advice. • Continue to monitor your blood pressure at regular intervals.

Obesity • Avoid severely restrictive or fad diets. • Restrict intake of saturated fats, sweets, sweetened beverages, and cholesterol-rich foods. • Increase your physical activity. LDL-C, Low-density lipoprotein–cholesterol.

Question 22

What are the symptoms of post-myocardial infarction heart failure?

Answer 22

Absent crackles and S3, Crackles in the lower half of the lung fields and possible S3, Crackles more than halfway up the lung fields and frequent pulmonary edema IV, Cardiogenic shock

Monitor for, report, and document manifestations of cardiogenic shock immediately.
These signs and symptoms include:

• Tachycardia • Hypotension • Systolic BP less than 90 mm Hg or 30 mm Hg less than the patient’s baseline • Urine output less than 0.5-1 mL/kg/hr • Cold, clammy skin with poor peripheral pulses • Agitation, restlessness, or confusion • Pulmonary congestion • Tachypnea • Continuing chest discomfort Early detection is essential because undiagnosed cardiogenic shock has a high mortality rate!

Question 23

The client has a sudden onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

A. Auscultate heart sounds
B. Check the blood pressure
C. Perform a 12 lead ECG
D. Determine if the pain is radiating to the jaw

Answer 23

C. Perform a 12 lead ECG *

Question 24

Which of the following questions should the nurse include when assessing for the presence of atypical chest pain in women?

A. Have you been unusually tired lately?
B. Has your urinary output increased lately?
C. How many times during the night do you urinate?
D. How many pillows do you sleep with at night?

Answer 24

A. Have you been unusually tired lately?*

Question 25

A client is complaining of chest pain that occurs during exercise. This pain is relieved when the client rests. The nurse realizes that this client is experiencing which type of angina?

A. Prinzmetal’s angina
B. Silent angina
C. Stable angina
D. Unstable angina

Answer 25

C. Stable angina*