Nursing Practice Flashcards
List and describe the 4 types of acute coronary syndrome.
- Stable angina
- Vessel unable to dilate enough to allow adequate blood flow to meet the myocardial demand - Unstable angina
- Partial rupture of artery
- No/ partial occlusion of the vessel - NSTEMI
- Intermediate form of ACS
- Occlusion enough to cause tissue damage - STEMI
- “classic” heart attack
- Complete occlusion– causes extensive heart damage
How should the ECG and troponin levels of the 4 types of acute coronary syndrome look like?
- Stable angina
- Normal ECG
- Normal troponin - Unstable angina
- Normal / Inverted T waves / ST depression
- Normal troponin - NSTEMI
- Normal / Inverted T waves /. ST depression
- Elevated troponin - STEMI
- Hyperacute T waves / Hyperacute ST elevation
- Elevated troponin
What is the function of troponin?
Troponin refers to a group of proteins that help regulate the contractions of the heart and skeletal muscles.
When heart muscles become damaged, troponin is sent into the bloodstream. As heart damage increases, greater amounts of troponin are released in the blood. High levels of troponin in the blood may mean you are having or recently had a heart attack.
Intermediate nursing management for patients with STEMI
- Balance myocardial supply and demand
- O2: Aim SPO2 94-98%
- Nitroglycerin: 0.4mg every 5 mins for a total of 3 doses
- Beta-blockers: reduce BP
- Morphine: Analgesic (relief from pain) - Limit thrombus formation: Antiplatelet (aspirin) and anticoagulant (heparin)
- Restore lumen patency
- Angioplasty
- Coronary artery bypass
- Stent placement
Nursing management for patient AFTER PCI
- Monitor for recurrent myocardial ischemia
- Any chest pain?
- ECG (if needed) - Hemostasis (a process to prevent and stop bleeding) at the the catheter insertion site
- Bleeding?
- Haematoma? (localised bleeding outside of infection site)
- Infection? (POET) - Detect and prevent contrast induced renal failure
- Renal function blood test
Monitoring for more complications after PCI
- Retroperitoneal bleeding
- Vital sign: Tachycardia and increased pulse rate— Bradycardia, hypotension
- Abdominal pain, groin pain, back pain
- Diaphoresis (excessive, abnormal sweating)
- Monitor intake and output - Arrhythmias (can be brachy or tachy)
- Monitor ECG rhythm on cardiac monitor - Thrombus
- Assess limb for colour, warmth, movement, pain, etc
- Venous access site clot, affected limb will appear red, swollen
- Arterial access site clot, affected limb will appear pale, cool. have diminished pulses distal to insertion site
Routine care for patients after PCI
- Monitor behaviour:
- alert? lethargic? irritable?
- Vital signs: HR, RR, BP, SPO2, temperature - Patient to remain on bed rest for:
- 4 hrs (diagnostic catheterization)
- 6hrs (interventional catheterization)
- Ensure head of bed is no higher than 30 degrees - Assess puncture site every 30 mins for 4 hours, then hourly until ambulation.
Reassess site after 1st ambulation and then minimum of every 4 hrs prior to discharge. - Dressing should be removed 24 hrs post procedure
Non-pharmaco management for COPD
- Long term O2 therapy– for patients with severe COPD who are in chronic respiratory failure (SpO2 ≤ 88%)
- Surgical treatments
- Lung vol. reduction surgery
- Bullectomy (surgical removal of a bulla, which is a dilated air space in the lung parenchyma measuring more than 1 cm)
- Bronchoscopic lung vol. reduction
- Lung transplantation - Offer annual vaccination with seasonal inactivated influenza vaccine
Inhalation route: metered dose inhaler
Complete the steps.
- Mix _____ and _____
- _____– spray _____ puffs into the air before use
- Breathe out all the way
- Press down inhaler
- Continue breathing in slowly through mouth for _____ as deeply as they can
- Remove from mouth
- Hold breath for _____ counts
- Breathe out using __________
- Slowly exhale
- Mix active drug and propellant
- Prime MDI – spray 1 or more puffs into the air before use
- Breathe out all the way
- Press down inhaler
- Continue breathing in slowly through mouth for 2-3 seconds as deeply as they can
- Remove from mouth
- Hold breath for 10 counts
- Breathe out using pursed-lip breathing technique
- Slowly exhale
What pressure to set for oronasopharyngeal suctioning?
Usually btw 100-120mm Hg
Higher pressures can cause excessive trauma
How much to insert the catheter for oral and nasal insertions for oronasopharyngeal suctioning?
Oral: 3” to 4” (7.6cm-10.2cm)
Nasal: 5” to 6” (12.7 to 15.2cm)
General steps for applying suctioning: complete.
1) ______ for no longer than ______ seconds
2) Repeat procedure up to ______ times, until ___________.
3) Allow ______ to allow ______ and ______ in btw suctioning
- Apply suction for no longer than 10 seconds
- Repeat procedure up to 3 times, until gurgling/bubbling sounds stop and respirations are quiet
- Allow 20 sec- 1 min to allow reoxygenation and reventilation in btw suctioning
Diabetes mellitus diagnosis values
- Casual plasma glucose
- Fasting plasma glucose
- 2-hour post-challenge plasma glucose
- Casual plasma glucose–
≥ 11.1 mmol/l - Fasting plasma glucose–
≥ 7.0 mmol/l - 2-hour post-challenge plasma glucose–
≥ 11.1 mmol/l
The oral Glucose Tolerance Test (GTT), is a method which can help to diagnose instances of diabetes mellitus or insulin resistance.
When should it be performed?
Complete the steps:
- ____ patient for _______
- Collect ___________
- Administer _________ in water
- Minimal _______, no _______, no _______
- Collect a ______________ aft the test load.
When: After at least 3 days of unrestricted diet (greater than 150g of carbohydrate daily) and usual physical activity.
- Fast patient for 8-14 hrs overnight
- Collect 3mL fasting blood specimen
- Administer 75g anhydrous glucose in water
- Minimal physical activity engaged, no eating, no smoking
- Collect a 2nd blood specimen 2 hrs aft the test load
Nursing intervention for patient receiving blood transfusion (Refer to slides for ans)
Refer to slides
