T5: CAD & Acute Coronary Syndrome Flashcards
Coronary Artery Disease (CAD)
disease of the arteries surrounding the heart included in the general category of atherosclerosis.
Atherosclerosis
hardening of arteries with a collection of cholesterol-like plaque
what is the major cause of coronary artery disease
atherosclerosis
collateral circulation
When plaque blocks the normal flow of blood through a coronary artery and the resulting ischemia is chronic, increased collateral circulation develops.
nursing management of coronary artery disease
if diet and exercise are ineffective;
-lipid lowering drug therapy (statin, niacin, fibric acid derivatives)
-antiplatelet therapy
Statins Inhibit…
cholesterol synthesis, decrease LDL, increase HDL
when given statins monitor
for lover damage and myopathy
niacin lowers
LDL and triglyceride by inhibiting synthesis-Increases HDL
niacin causes
Flushing, pruritus, GI side effects, orthostatic hypotension
Fibric acid derivatives (Lopid) decreases..
Decrease triglycerides and increase HDL
fibric acid derivative SE
GI SE
ASA, Clopidogrel (Plavix) monitor for
bleeding and brusing
clinical manifestations of CAD
-angina because of myocardial ischemia and decreased O2 supply
PCI and Stent placement
A stent is an expandable meshlike structure designed to keep the vessel open after balloon angioplasty.
When patients first present with chest pain, ST-elevations on the 12-lead ECG are most likely indicative of a
STEMI
For patients with chest pain who do not show ST-elevation or ST-T wave changes on the ECG..
*distinguish between UA and NSTEMI until serum cardiac biomarkers are measured.
STEMI vs NSTEMI
STEMI: Total occlusion of coronary artery, immediate intervention needed
NSTEMI: partial occlusion of coronary artery
action for STEMI
no blood flow through the artery so from the ER > cath lab > angioplasty, PCI, thrombolytic therapy
-must be opened with in 90 minutes
clinical manifestations of unstable angina
*New in onset
*Occurs at rest
*Increase in frequency, duration, or with less effort
*Pain lasting > 10 minutes
*Needs immediate treatment
*Symptoms in women often under-recognized
Unstable angina (UA)
*chest pain that is new in onset, occurs at rest, or occurs with increasing frequency, duration, or with less effort than the patient’s chronic stable angina pattern
MONA
Morphine, O2, nitro, aspirin (325mg) ask them to chew it and swallow it
-may add metoprolol to slow down the work load of the heart
clinical manifestations of MI ECG
*ST-elevation and non-ST-elevation
*Result of abrupt stoppage of blood flow through a coronary artery, causing irreversible myocardial cell death (necrosis)
myocardial infarction occurs because
abrupt stoppage of blood flow through a coronary artery from a thrombus caused by platelet aggregation
action in patients with NSTEMI
do not go to cath lab immediately, procedure usually within 12-72 hours
Thrombolytic therapy is not indicated for
*NSTEMI patients.
widow maker
left coronary artery
ECG Changes Associated With Acute Coronary Syndrome (ACS): ischemia
ST-segment depression and/or T wave inversion
ECG Changes Associated With Acute Coronary Syndrome (ACS): injury
ST-segment elevation occurs
Absence of serum cardiac markers confirms
no infarction
treatment for ACS should be
prompt and effective to help avoid or limit infarction
dramatic ST-segment elevation associated with
myocardial injury “tombstone”
complications of MI
-dysrhythmias
-HF
-cardiogenic shock
-papillary muscle dysfunction
-ventricular aneurysm
-pericarditis
-Dressler syndrome
dysrhythmias can be caused by
ischemia, electrolyte imbalances, or SNS stimulation
Cardiogenic shock occurs when
*oxygen and nutrients supplied to the tissues are inadequate because of severe LV failure, papillary muscle rupture, ventricular septal rupture, LV free wall rupture, or right ventricular infarction.
Cardiogenic shock requires aggressive management including…
*control of dysrhythmias, intraaortic balloon pump (IABP) therapy, and support of contractility with vasoactive drugs.
Papillary muscle rupture
a rare and life-threatening complication. It causes immediate and massive mitral valve regurgitation with no time for the heart to compensate
Left ventricular aneurysm
results when the infarcted heart wall is thin and bulges out during contraction
A new loud systolic murmur heard in patients with acute MI may signal
*ventricular septal wall rupture.
Serum cardiac biomarkers
*proteins released into the blood from necrotic heart muscle after an MI.
indicator of MI
troponins
negative biomarkers indicate
unstable angina
postive biomarkers indicate
NSTEMI
coronary angiography is a diagnostic study for patients with
a STEMI, NOT for patients with UA or NSTEMI
pharmacologic stress testing is used for patients with
abnormal but nondiagnostic ECG and negative biomarkers
The patient with a STEMI must undergo coronary angiography within
90 minutes of presentation or receive thrombolytic therapy within 30 minutes in agencies without PCI capability
initial intervention for ACS
-12-lead ECG
-Upright position
-Oxygen - keep O2 sat > 93%
-IV access
-MONA
-Nitroglycerin (SL) and ASA (chewable)
-Morphine
-Statin if not taking already
monitoring for ACS
-Treat dysrhythmias
-Frequent vital sign monitoring
-Bed rest/limited activity for 12-24 hours
what is recommended for patients with UA and NSTEMI
Dual antiplatelet therapy (aspirin) and heparin (UH or LMWH)
Cardiac catheterization with possible PCI is considered for both UA and NSTEMI patients once
the patient is stabilized and angina is controlled or if angina returns or increases in severity
Reperfusion therapy
treatment to re-establish perfusion to an organ for patients with STEMI
what is the first line therapy for STEMI
Emergent PCI
thrombolytic therapy is only for patients with
a STEMI, give IV within 30 minutes of arrival to ED
when initiating thrombolytic therapy
-Draw blood and start 2-3 IV sites
-Administer according to protocol
-Monitor closely for signs of bleeding
-Assess for signs of reperfusion
*Return of ST segment to baseline best sign
*IV heparin to prevent reocclusion
Coronary revascularization with CABG surgery is recommended for patients who
*Failed medical management
*Presence of left main coronary artery or three-vessel disease
arteries used for CABG
*The internal mammary artery (IMA) is most common artery used for bypass graft
-radial and saphenous are also used
Cardiopulmonary Bypass–CPB
*During CPB, blood is diverted from the patient’s heart to a machine where it is oxygenated and returned (via a pump) to the patient.
*This allows the surgeon to operate on a quiet, nonbeating, bloodless heart while perfusion to vital organs is maintained.
nutritional therapy ACS
-Initially NPO
-Progress to
*Low salt
*Low saturated fat
*Low cholesterol
clinical manifestations of MI
-Severe chest pain not relieved by rest, position change, or nitrate administration
*Heaviness, pressure, tightness, burning, constriction, crushing
*Substernal or epigastric
*May radiate to neck, lower jaw, arms, back
-Palpitations, dyspnea, dizziness, weakness
skin assessment for clients w MI
Diaphoresis, ashen, clammy, and/or cool to touch
CV manifestions for MI
-Initially, ↑ HR and BP, then ↓ BP (secondary to ↓ in CO)
-Crackles
-Jugular venous distention
*S3 or S4
*New murmur
*Ventricular Dysrhythmias-pulse deficit
management for MI
*Pain: nitroglycerin, morphine, oxygen
*Continuous monitoring
*Rest and comfort
*Balance rest and activity
*Begin cardiac rehabilitation
-anxiety reduction
The major nursing responsibilities for the care of the patient following PCI involve:
-Monitor for recurrent angina
-Frequent VS, including cardiac rhythm
-Monitor catheter insertion site for bleeding
-Neurovascular assessment
-Bed rest per institutional policy
CABG: postoperative nursing care
-Assess patient for bleeding at surgical site
-Monitor hemodynamic status
-Assess fluid status
-Replace blood and electrolytes PRN
-Restore temperature
-Monitor for atrial fibrillation (which is common)
-pain management
syncope
*lapse in consciousness
*loss in postural tone (fainting)
