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NSG 2202 > Stressors to Coronary Circulation Part 2/Test 2 > Flashcards

Stressors to Coronary Circulation Part 2/Test 2 Flashcards

1
Q

CAD is

A

a genetic term for many different conditions that involve obstructed blood flow through the coronary arteries

The most prevalent etiology,though, is atherosclerosis

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2
Q

Intima is

A

Lining of artery

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3
Q

Media is

A

elastic fibers, smooth muscle

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4
Q

Adventitia is

A

loose, connective tissues

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5
Q

Atherosclerosis leads to

A
  • angina, ACS (build up of plaque)
  • is the major cause of CAD
  • is characterized by a deposit of atheromas (cholesterol -and lipids) primarily within the intimal wall of the artery
  • Lumen narrows with progressive disease
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6
Q

Coronary arteries continue to

A

supply oxygen and nutrients to heart until 75% occlusion. Some are more than 75% occluded without symptoms

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7
Q

Endothelial Injury

A

by hyperlipidemia, HTN, or other chemical irritants

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8
Q

Lipid infiltration

A

From circulation

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9
Q

Aging/atherosclerosis

A

Atherosclerotic changes

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10
Q

Vascular dynamics

A

like HTN

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11
Q

Inflammation/atherosclerosis

A

believed to play a role

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12
Q

Coronary Artery Disease…the lumen

A

narrows with progressive disease

The greater the narrowing the more diminished is the blood supply to the heart

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13
Q

Coronary artery disease nursing dx

A

Ineffective tissue perfusion: coronary r/t plaque, atheroma, narrowing of the coronary vessels aeb chol 280, LDL 210, BP 160/94, 60 pk year smoke

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14
Q

Cholesterol should be

A

<200

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15
Q

Normal LDL is

A

<100

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16
Q

Normal HDL is

A

> 40

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17
Q

Normal B/P is

A

120/80

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18
Q

Treatment for CAD

A

Ineffective tissue perfusion

Prevention-rather than treat

  • Know your risk factors
  • Check lipids annually
  • keep cholesterol under 200, LDL under 160
  • Treat elevations
  • Diet-low cholesterol, modified fat (Salt content)
  • Exercise, lose weight
  • Keep HTN controlled
  • Stop smoking, moderate Etoh
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19
Q

Coronary Artery Disease: Preventions

A
  • Reduce fat content: meat fat, saturated fats, hydrogenated oils.
  • Decrease the red meat in diet
  • Increase fish, chix and turkey without skin or frying
  • Decrease the # of eggs to 3 or less q week
  • limit ETOH to 1/day
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20
Q

If detected early, first treatment for CAD may be

A

Meds that help lower blood levels

  • Cholestyramine (Questran)
  • Colestipol (Colestid)
  • Nicotinic acid (niacin)
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21
Q

Anti-lipemics

A
  • Zocor; Lipitor
  • Zetia (Ezetimibe)
  • Vytorin (Zocor + Zetia)
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22
Q

Other meds to treat coronary artery disease

A
  • ASA
  • Plavix
  • Persantine (dipyridamole)
  • Aggrenox- ASA+dipiyridamole
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23
Q

Manifestations of Coronary Artery Disease (CAD) Stable Angina

A
  • Ischemic chest pain temporary and reversible
  • refers to chest pain occurring intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms.
  • pain usually lasts only a few minutes and commonly subsides when precipitating factor is relieved
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24
Q

Stable Angina:

A 
Predictable pattern
Precipitating factors
St segment depression
Treated as outpatient with meds
Responsive to rest
Short acting 3-5 minutes
Infrequent
No elevation of Bio markers
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25
Q

Angina Pectoris

A
  • Lack of enough oxygen for the body’s demands for cellular function and metabolism
  • Cellular metabolism converts from aerobic metabolism to anaerobic
  • By product of lactic acid released instead of water
  • Nerve endings are sensitive to this and pain is the response
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26
Q

Ischemia

A

Lack of sufficient blood flow and oxygen to the tissues

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27
Q

Characteristics of angina

A
  • Chest pain

* possible areas of radiating pain; neck, jaw, upper abdomen, shoulders and arms

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28
Q

Assessment for pt with chest pain

PQRST

A
  • Chest pain or discomfort, varied descriptors, substernal?
  • Time frame less than 15 min
  • P- precipitating events
  • Q- quality- dull, aching?
  • R- radiation, where does it start? And move to?
  • S- Severity- pain scale?
  • T- time- beginning, any change, ever experience before?
  • Reversible
  • Relieved by rest or discontinuation of activity and NTG (nitroglycerin)
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29
Q

Treatment focus for stable angina

ABCD

A

Algorithm

  • A ASA/Antianginals
  • B Beta blockers/BP
  • C Cholesterol and cigarettes control
  • D Diet and diabetes
  • E Education and exercise
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30
Q

A is for

A

Aspirin: inhibits platelet aggregation

–antiaginals: Nitrates vasodilate

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31
Q

B is for

A

Beta blockers

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32
Q

C is for

A

Decreased cholesterol and smoking

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33
Q

D is for

A

Diet

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34
Q

E is for

A

Education

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35
Q

Beta blockers

A

Vessels not constricted from catacholamines, more oxygen available to the myocardium, BP and HR controlled, myocardium has to use less oxygen

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36
Q

Ca++ channel blockers-

A

diltiazem, amlodipine, Norvasc

*Blocks Ca++ entry into cells of vascular smooth muscle and myocardium

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37
Q

Ace inhibitors

A

decrease water retention and afterload, decreases workload of heart

  • enalapril
  • lisinopril
  • captopril
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38
Q

Nitroglycerin

A
  • 0.4 mg SL for chest pain-lie down, take one q 5 min x 3. If no relief, get to ER
  • In hospital, take BP, hold if <90 systolic
  • Teach- pills good only for 6 months after opening, light sensitive, heat/moisture sensitive, carry with you
39
Q

Ismo/Imdur (isosorbide dinitrate)

Isordil, Isobid (isosorbide mononitrate)

A

PO, long acting

*Topicals Nitro-Dur, Nitro Disc-Wear 12 hours/off 12 hours prevents tolerance, avoid touching

40
Q

Side effects of Nitros

A
  • decreased b/p (so don’t give it if b/p is already low)
  • pounding HA (is severe)
  • dizziness, or flushing
  • caution them to lie down when taking NTG and not to rise quickly
  • NTG can also be taken before an event known to cause angina (like climbing a flight of stairs)
41
Q

Types of Angina: Stable

A
  • New in onset
  • Unpredictable
  • Stable may progress to unstable
  • Unstable the first sign of CAD
  • Risk for total occlusion
  • HR changes, increase in b/p
  • dysrhythmias- non specific ST changes
  • Negative or positive or suspicious biomarkers
  • Symptoms longer and need intervention
  • Must have medications to relieve the pain
  • Consider acute coronary syndrome
42
Q

Associated findings of angina r/t ischemia

A
  • SOB
  • Cold sweat
  • Weakness
  • Anxiety
  • N&V
  • Indigestion
  • Dizzyness
  • ST depression-ischemic changes
  • More changes in HR or BP with unstable
43
Q

Treatment for unstable angina

A
  • Give ASA and NTG
  • EKG- shows non specific EKG changes
  • Check biomarkers in ED
  • Repeat biomarkers in AM
  • -If not elevated do nuclear studies in AM
  • If bio markers elevated-admit
  • to cath lab to identify occluded vessels
  • PTCA, stent possible
44
Q

Pts with positive biomarkers requires

A
  • immediate hospitalization with EKG monitoring and bed rest
  • If pain is caused from atherosclerotic plaque rupture, it may block the artery and progress to an MI
  • People with atherosclerosis may remain stable if the blockage does not progress beyond 70%
45
Q

Diagnostics for any chest pain

A
  • Bio markers
  • EKG
  • Stress test
  • Chest xray
  • Angiography
  • Echos
46
Q

Clinical manifestations for chest pain

A
  • Acute coronary syndrome
  • -unstable angina
  • -NSTEMI, STEMI
  • Sudden cardiac death
  • -Death occurs within 1 hr of acute symptoms
  • -25% of deaths, the death is the 1st sign of CAD
47
Q

NSG DX chest pain

A

Pain: chest r/t inadequate blood flow with O2 stimulating anaerobic metabolism and release of lactic acid

48
Q

Outcomes for chest pain

A
  • Free from chest pain
  • Free from myocardial injury
  • Will have maximal perfusion to myocardium
49
Q

Determine where pt is on the contimuum from CAD to MI

A

Pt gets an electrocardiogram–either ST elevation or No ST elevation–cardiac markers are either positive or negative. If they are positive MI if negative its unstable angina

50
Q

Stemi is

A

Q-wave MI

51
Q

NSTEMI is

A

non q wave MI

52
Q

Review-interventions for angina in general

A

VS, O2, ASA, NTG, assess for relief, Morphine IV, Do EKG, check bio-markers, if stable discharge, do cardiac workup as outpatient. If unstable, EKG shows non specific ST changes or bio-markers suspicious admit for cardiac work up

53
Q

Remember for ischemia to occur, the artery is

A

usually 70-75% stenosed

54
Q

Focus of all care

A
  • education for chronic management
  • control risk factors
  • prevent progression of disease
  • may be released within 24 hrs of PTCA and stent placement
  • Do follow up
55
Q

Acute coronary syndrome:

A
  • Atheroma has formed
  • > 70% of vessel lumen
  • Rupture of atheroma with more platelet aggregation
  • -ischemic pain is not relieved by NTG or rest
  • -pain lasts longer than 15 minutes
  • -may be first time for chest pain
  • -may have had prior episodes of angina
56
Q

Transmural or full thickness associated with

A
  • Abnormal Q wave

* ST elevation

57
Q

Subendocardial or partial thickness associated with:

A
  • Non Q wave

* ST elevation

58
Q

LAD

A

anterior myocardium LVentrical failure, cardiogenic shock, death

59
Q

RCA

A

inferior wall- conduction changes, delays, blocks

60
Q

Which is worse, LAD or RCA

A

L anterior descending b/c impacts L ventricle. No blood flow if L ventricle doesn’t work

61
Q

MI clinical manifestations: PQRST

A

Pain: P= substernal, left precordial area
Q= heavyness, pressure, tight, constricted
R= frequent, jaw, neck/shoulder, arms, back
S= most severe, viselike, immobilizing unrelieved by rest for NTG
T= lasts longer than 15 minutes

62
Q

Associated hypoxic responses to MI

A
  • VS
  • HR increased or decreased BP or decreased respirations
  • may develop a gallop, S3 or S4
  • diaphoresis
  • Dyspnea
  • Pulmonary congestion
  • Cyanosis
  • Lightheadedness
  • fainting
  • clutching chest
  • look of doom
63
Q

Differences between men and women MI

A
  • females have more GI upset
  • Often mistake MI for ulcers
  • Possible precipitating cause but not necessary
64
Q

CK CK MB

A

Test done-myocardial portion MB-muscle component If >5% rise 4-6 hrs, peak 18-24 hr, fall normal 3 days

65
Q

Cardiac troponin

A

Protein specific to myocardium- released with injury

66
Q

Troponin I

A 
>1.5 mg/ml= MI- initially more accurate
Rise- 1 to 3 hours
Peak 12 hr
Fall stays increased 7-14days 
**If T elevated on admission associated with increase in complications for MI patient
67
Q

Positive for MI if:

A
  • Biomarkers are elevated
  • CK MB >5%
  • Troponin increased
  • 12 lead shows ST elevation
  • Possible Q wave if transmural
68
Q

MI- Intervention

A
  1. reduce pain
  2. reperfuse myocardium
  3. prevent complications
  4. prevent remodeling and heart failure
  5. rehabilitate
  6. educate on control and prevention
69
Q

Acute phase management

A

Act now!! Squad or ER will;

  • assess pain, critical to know when it started
  • start oxygen 2-4 liters
  • Give ASA
  • Give NTG
  • Establish IV
  • Place on telemetry (12 lead EKG)
  • Morphine
70
Q

NTG IV 50 mg in 250 D5% W at 5-6 cc/hr-

A

dilates all vessels including collateral to better perfuse the myocardium. It does not dilate an occluded vessel

71
Q

Morphine 2-3 mg/IV Narcotic analgesia: Benefits:

A
  • Ease pain
  • Ease anxiety
  • Decrease preload
  • Decrease afterload
  • Decrease cardiac workload
  • Net result is more oxygen for myocardium
72
Q

Lidocaine: Ventricular antidysrhythmic

Can be helpful for up to 12 hours

A

*Ventricular dysrhythmias
*PVC’s, V-tach, V-fib
–caused by ischemia of the myocardium
Bolus with 75-100 mg IV lidocaine

Start IV drip at 1-4 mg/minute
500 ml D5%W with 2 GM Lidocaine at 15 ml/hour

73
Q

Clot busters

A

Fibrinolytic therapy
T-PA (Activase) “clot buster”

If the pt comes to the hospital between 4-6 hrs after pain started - Use of IV Fibrinolytic therapy to reperfuse the myocardium and save the muscle

74
Q

t-PA Criteria- Pt must meet these criteria

A
  • Chest pain no longer than 4-6 hrs
  • EKG changes consistent with MI
  • Not on coumadin
  • No recent surgery, CVA, bleeding
  • No blood dyscrasias
  • Uncontrolled HTN
  • Active PUD or bleeding
  • Recent CPR > 10 min
  • Head traumas
  • Systemic diseases- Cancer
75
Q

Side effects of t-PA

A
  • Reperfusion dysrhythmias (PVC’s)
  • Indicates the myocardium is reperfused. Treat with lidocaine-but may already be infusing
  • Bleeding- may have to stop
76
Q

Evaluation of t-PA results

ST segment-

A

returns to normal-no elevation

  • Pt denies chest pain
  • Presence of PVCs
  • -The clot has been lysed, but the atheroma is still there. Prepare for cath lab
77
Q

Heparin

A

Block extension of the clot

  • IV bolus and drip- 4-6000 units per hour
  • *follow parameters for anticoagulation
78
Q

Management:

A 
Cardiac cath
angioplasty
stents
continue to monitor patient for 24 hours
discharge
place on ABCDE program
79
Q

The Bad MI

A

-goal is to prevent death of heart muscle and complications
-treat with the same medications except
no TPA

80
Q

Nursing interventions for bad MI

A

-relieve pain initial priority
-oxygen- oximetry
-telemetry-ST changes
-Start IV’s- same meds except NO tPA
—-Ntg
—-Lidocaine
—-Heparin
—-Morphine
Admit to CCU-prevent further damage and complications

81
Q

Monitor

A
  • Activity order
  • Diet order
  • Fluid managment
  • floley and I&O orders, weights
  • DVT precautions
  • GI management
  • NO rectal temps
  • Diagnostics, enzymes, EKG
82
Q

NSG interventions:

A 
Pain
Heart rhythm
Bio markers
VS
O2 stat
Decreasing O2 needs
Improved cardiac output
Improved cardiac output
wean IV medications (ie Lidocaine, Heparin, Ntg. Dobutrex
83
Q

Recovery

A
  • Oxygen *Saline lock
  • Activity *Oral medications
  • Environment *Diagnostics
  • Telemetry *12 lead EKG
  • I&O *Echo
  • Foley *Reevaluations
  • Daily weights *Antilipemics
  • Diet *Antiplatelet aggregates
  • Ted hose *Anticoagulants
84
Q

Acute coronary syndrome: Complications

A
  • Rhythm changes with increased demands
  • DVT- Pain in calf with dorsi-flexion
  • PE- sudden, sharp, stabbing chest pain
  • -SOB, color changes, ABG changes, diaphoresis
  • Treat
  • -oxygen
  • -position/activity
  • -diagnostics-VQ
  • -Heparin IV-Coumadin
85
Q

MI preventions

A
  • Structured program to strengthen heart
  • Prevent reoccurrence
  • Exercise “good verses bad”
  • Diet
  • Lifestyle/habit changes
  • Medication compliance/knowledge
  • May need prophylactic NTG for anticipated stress, or physically demanding activity
86
Q

Complications of MI

A
  • dysrhythmias
  • pvc’s
  • v-tach
  • v-fib
  • asystole
  • atrial rhythms
  • blocks
  • Cardiac shock-extension of the MI
  • Pulmonary edema
  • Pericarditis
87
Q

Pacemaker: inserted into

A
  • give the electrical impulse when the conduction system fails as in blocks and severe bradycardia
  • Fixed- always fires at set rate, usually no underlying rhythm
  • Demand- fires only when the patient’s SA node does not function. May have mixed sinus and pacer beats
  • FYI (ICD with Pacer- internal cardioverter defibrillator)
88
Q

Pacemaker: Based on

A

Chamber paced

  • -atrial-only atrial spike
  • -ventricle- only ventricular spike
  • -Dual chamber A/V sequential -2 spikes atrial and ventricular
89
Q

For a pacemaker you will need prior to surgery:

A
  • Informed consent
  • Postop- Monitor for pacer malfunctions
  • Wound assessment
  • Immobilized shoulder for 48 hours
  • -shoulder sling, allows wires to imbed
  • -reduced shoulder movement for week
90
Q

After pacemaker teach patient to:

A
  • Pulse check
  • Report
  • -dizzyness
  • -hiccoughs
  • Check monthly with manufacturer
  • Carry card with pacer info
  • Avoid highly electrical equipment
  • -hand scanners
  • -can never have an MRI
91
Q

Pulmonary Edema

A

*Weak L ventricle
*Assess for SOB and crackles, decreased O2 sat
*Imbalanced I&O O<I
*Treat: Lasix to unload fluid
Lanoxin to strengthen muscle
Oxygen, conserve oxygen
fluid interventions
Evaluate

92
Q

Cardiogenic Shock

A
  • Failure of the circulatory system to maintain adequate perfusion
  • Leads to:
  • inadequate oxygenation at the cellular level
  • Anaerobic cellular metabolism
  • accumulation of waste products in the cells
93
Q

Cardiogenic Shock- know who

A

is at risk for developing it. Which MI. Know the early cluster of symptoms. Respond to the first signs of early shock.

NSG 2202 (22 decks)

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