Week 12: Coronary Vascular Disorders, Atherosclerosis, Angina, MI Flashcards
Flow of Blood from Heart to Body
IVC/SVC –> RA –> Tricuspid –> RV –> Pulmonary Valve –> Lungs –> LA –> Mitral Valve –> LV –> Aortic Valve –> Aorta
Main Coronary Arteries
RCA - Right Coronary Artery
Left Main Coronary Artery (LCA)
a. Left Circumflex Artery (LCx)
b. LAD - left anterior descending coronary artery
LAD
Left Anterior Descending Artery
Called the Widowmaker
Supplies so much blood to the left side of the heart that an acute change can cause death quickly
RCA
Right Coronary Artery
Can cause a lot of heart rate issues, so a patient with a low 50s HR would not necessarily mean anything bad it may mean they have bradycardic symptoms from RCA problems (d/t inactivity)
Leading Cause of US Death is
Heart Disease
CAD
Coronary Artery Disease
Buildup of plaque in coronary arteries - plaque buildup in the walls of coronary arteries
Blocks flow and is often unnoticed until the blockage is more than 70%
What makes up the plaque in CAD
Usually lipids, other fatty substances, fibrous material
What % of blockage of coronary arteries does it take to lead to symptoms being seen?
70% minimum usually
Could be 90-100% because of collateral circulation though
How does CAD differ in Men compared to Women
CAD manifests 10-15 years sooner
Initial cardiac event is more often an MI than angina
Higher incidence of LVH
How does CAD differ in Women compared to Men
CAD causes more death in women
Initial cardiac event more likely to be angina than MI
Complain of palpitations more frequently than men
LVH
Left ventricular hypertrophy
thicker musculature and hypertrophy of the heart causing it to get bigger and it tries to pump more blood - but it keeps getting bigger and lessens how efficient it is
Non Modifiable Risk Factors for CAD
Age
Gender
Ethnicity
Genetics and Family Hx - high risk for CAD and MI if in nuclear family
What is the gender disparity with CAD
men > women until age 60
What is the ethnicity disparity of CAD
AA > Caucasian
South Asian High - Japanese Low
Modifiable risk factors for CAD
serum lipids
HTN
tobacco
physical inactivity
obesity - waist circumference and BMI
also watch persons with DM, fasting BS > 100, psychological states
elements of metabolic syndrome
What are the 3 most common risk factors for CAD that 9/10 patients have
HTN
Hyperlipidemia
Obesity
Nursing Management of CAD Risk Factors
Health promotion - ID high risk people through risk screening and work on modifiable factors with lifestyle changes
Physical activity
nutritional therapy - lower LDL cholesterol
cholesterol lowering drug therapy
anti platelet therapy
FITT Formula of Physical Activity to counteract CAD
FITT Formula = Frequency, Intensity, Type, Time
Moderate exercise 30 min/day on 5 or more days/week - brisk walking, hikin, biking, swimming
What does following the FITT Formula lead to
Contributes to weight reduction, 10% drop in SBP, diabetics - better blood glucose
Nutrition education for CAD emphasizes what things
Decrease Sat Fat, Cholesterol, Red meat, eggs, whole milk products, alcohol, simple sugars
Increase Complex Carbs (whole grain, fruit, vegis) and Omega 3 FA
Fat intake 30% of calories - good oils (olive, canola)
What should be done if a patient with CAD has elevated serum triglycerides
alcohol intake and simple sugars should be reduced or eliminated
Where to get Omega 3 Fatty Acids
Eating fatty fish 2x a week - salmon and tuna
tofu, soybean, canola, walnuts, flaxseed
Angina
chest pain or pressure resulting from myocardial ischemia (reflects imbalance between cardiac oxygen demand and supply)
Directly related to myocardial ischemia - but not all chest pain is this (could be eating too much, gas, or somatic pain)
Types of Angina
Stable
Unstable
Intractable or Refractory
Variant (Prinzmetal’s Angina)
Silent Ischemia
Stable Angina
predictable, manageable episodes of chest pain
Relieved with rest and/or nitroglycerin
occurs with exercise
Unstable Angina
unpredictable
occurs when resting or with minimal activity or at varying levels
occurs with increasing frequency, duration, and severity
needs further workup and tx
comes and goes randomly
Interventions for Stable Angina Acute Episodes
stop all ativity and sit or rest in bed
Assess patient - VS including O2 sat, resp distress, assess pain, pain, diaphoresis?, sudden LOC change
Administer supp. O2
12 lead EKG
pain assessment and relief - nitrate then opioid
auscultate heart sounds
Unstable Angina has a high risk for…
Myocardial infarction
Prinzmetal;s Angina
occurs at night in clusters
from artery spasms
Refractory Angina
Reoccurs despite treatment
Silent Angina
No s/s
no chest pain but myocardial ischemia is occurring!
Tests pick up ischemia affecting heart and perfusion
Acute Coronary Syndrome (ACS)
Prolonged ischemia that causes DAMAGE to the heart!
An umbrella term for damage to the heart from ischemia
3 categories of ACS
unstable angina
STEMI
NSTEMI
STEMI
ACS
Complete occlusion of coronary vessel(s)
ST elevation on EKG
NSTEMI
ACS
partial occlusion of coronary vessel(s)
No ST Elevation, but other EKG changes are possible
In what ways are STEMI and NSTEMI similar
similar clinical manifestations (c/p, SOB, DOE)
similar diagnostic study cahnges (CK, troponin)
The big differece between STEMI and NSTEMI
STEMI has ST Elevation while NSTEMI does not but can have other EKG changes
Creatinine Kinase (CK)
non specific marker for ischemia and inflammation
elevation does NOT necessarily mean something cardiac is occurring, but may signift inflammation or ischemia occurring somewhere else too
What is teh gold standard diagnostic lab for cardiac studies
Troponin
Troponin
elevation in this substance can indicate dx of MI
gold standard marker for cardiac
A 53 year old male presents to the ED with complaints of 4/10 chest pain, which was previously 7/10. His vital signs are stable. What of these is the first action that the nurse should perform?
A. Start nitroglycerin drip
B. Obtain an EKG
C. Notify Physician
D. Obtain Height and Weight of Patient
B. Obtain an EKG
What is an EKG a good pic of
A good 3D pic in a 2D format of the blood vessels and such
What EKG change likely indicates an MI
ST Elevation
They are probably also going through chest pain, SOB, or maybe just a little of it but this EKG change is still occurring
*Intervene and let physician know ASAP
Clinical Signs of an MI
chest pain - not relieved by rest or position changes
heaviness, pressure, tightening
radiation to neck, jaw, arm, back
irregular heart beat
SOB
skin - clammy, cool, ashen, diaphoretic
BP and HR elevated initially but later may drop
crackles in lungs
extra heart sounds
NV
Fever (100.4-102.2F)
Elderly or DM pts may not have severe or any chest pain
R Side Problem - jugular vein distention
Presentation depends on gender too
What is the gender differences for MIs
MI PRESENTATION MAY BE DIFFERENT IN WOMEN!!!
>severe SOB > pain in abdomen > NV >Profound weakness/fatigue >anxiety and feeling "unwell" >Sweating
How Does the non specific CK marker move after an MI
rises 12 hours after MI and peaks at 24 hours, but returns to normal in 2-3 days
Troponin (T or I) is a …
myocardial muscle protein released after myocardial injury and raises faster than CK-MB
What are the levels of Troponin to know
<0.4 = normal
0.4-1.49 = ischemia
> 1.49 = Acute MI
M.O.N.A.
Nursing interventions of ACS and MI:
Morphine (for pain)
Oxygen (2-4 L)
Nitroglycerin (dilate venous system)
Aspirin (prevent clot)
Nursing Interventions for MI and ACS
Pain relief
VS/EKG Monitoring (PVCs and PACs)
Check K, Mg levels (want above 4 and below 2 respectively)
BLS/ACLS protocol
Emergent Percutaneous Coronary Intervention
Cardiac Catheterization
Goal to open affect artery within 90 minutes of pain onset and 60 minutes of arrival to ED
A balloon is inserted to open or a stent
Fibrinolytic Therapy
tPa or streptokinase
Used with STEMIs but the gold standard is cardiac catheter
Aims to stop infarction process by dissolving the thrombus in the coronary artery (ASA/Plavix)
Indications to Use Fibrinolytic Therapy
Chest Pain > 20 minute duration that is unrelieved by nitroglycerin
ST segment elevation in at least 2 leads that view the same part of the heart
Less than 6 hours from symptom onset
Contraindications of Fibrinolytic Therapy
active bleeding, hx of bleeding
hx of hemorrhagic stroke, intracranial vessel malformation
uncontrolled HTN
pregnancy
GI bleed
recent trauma, CPR, or surgery
What is important to be aware of following fibrinolytic therapy
Reperfusion Injury - Myocardial Stunning/Arrhythmia
Myocardial Stunning
Arrhythmias from ischemic heart areas being irritated after reperfusion
Nursing INterventions for Fibrinolytic Therapy
Watch for s/s of bleeding
frequent VS
LOC change
bruising
bleeding from mouth, nose, rectum, urine
be aware of increased bleeding times with any invasive procedure (IV insertion, bleed tests)
What is the EBP on aspiring/beta blockers and MI care
These two are preferred and should be given on arrival to the ER or within 24 hours of admission and Rx on discharge
EBP states that PCI (Cardiac Cath) should occur when?
Within 60 minutes of arrival for MIs with ST elevation
What does EBP say on MI care and ACEI/ARB Drugs
Rx on discharge for LVSD (left ventricular systolic dysfunction) as it lowers the EF <40%
EBP shows that patients undergoing MI care should undergo what counseling
smoking cessation
What is the best EBP to do after someone refuses MI Care and you cannot follow protocol
Any rational (contraindication) for not following the protocol for MI care msut be clearly documented in the patients progress notes
Surgical and non Surgical Therapies for ACS
LHC (L Heart Catheterization) - Carc Cath Gold Standard
PCI - Percutaneous Coronary interventions (LHC is a type of this as is RHC)
CABG - coronary artery bypass graph
Stent Placement
occurs with an angiogram
a mesh screen is place across a lesioned vessel and opened up with a balloon and keeps the vessel dilated and oepn
What nursing care aspects are done post-PCI
bed rest
watch for bleeding
watch for chest pain and VS changes
anticoagulation tx
note lyte levels and potential PACs that are normal post reperfusion
do not get them out of bed just yet
PCI Complications
Coronary Dissection
Complete Occlusion
MI
What % of PCIs restenose in 3-6 months post procedure
25-35%
at max may last 5-10 years before needing to address again
Coronary Dissection
rare post PCI complication
catheter punctures a coronary vessel
medical emergency
What needs to be done if theres a complete occlusion again post PCI
the stent cannot make the vessel patent alone so cardiac surgery with a more invasive approach must be done
CABG
coronary artery bypass grafts
surgical treatment for CAD that is done after trying to open with PCI balloon and stents priorly and it did not work
diagnosis is done by a cardiac cath, LHC is determined diagnostic for CABG and PCI wont work
How big are the lesions/occlusions to do a CABG at minimum
70% but often its 90-100% before this is done
CPB - Cardiopulmonary Bypass
Machine - the heart outside the body
takes the heart blod oxygenates it, and returns it via another catheter at a rate similar to that which teh heart pumps
The heart/lungs are stopped during invasive surgery and this takes over
What stops the heart to let the CPB take over
A high level of potassium
Complications of Longer Use of CPB
coagulopathy (have to give with anticoagulants)
pneumonia
prolonged mechanical ventilation
prolonged ICU stay
increased risk of mortality
“pump head”
Why can pneumonia occur from CPB
laying in one position between 4-8 hours and while on a ventilator
also some procedures have an ET tube further down than the carina in the right lung while the left lung is completely decompressed
Pump Head
patients with excess of 3,4,5 hours in bypass surgeyr have higher incidence of ICU delirium
They are confused, agitated, and need monitoring for a while to get back to previous neurological function
Cardioplesia
Potassium amount that stops the heart
Off Pump CABG
No CPB used, surgery is done with heart still beating
Less ‘Complete” revascularization
fewer complications than on pump
What is the big restriction on off pump CABG
it can only be done on certain vessels
it cannot replace the left circumflex before of where it is in positioning but something on the front of the heart could be replaced like this
What are some benefits of off pump CABG compared to CABG
less bleeding
shorter ICU stay
less time on mechanical ventilation
Post-Op Care of the Cardiac Surgical Patient involves..
maintain MAP goal
Manage resp status, ventilator settings
Maintain chest tube patency
Monitor urine output
Replace Lytes
monitor renal fxn, fluid status
assess rhythm changes
assess neurological status
treat pain
incentive spirometer
early mobility - work with PT and OT - important for lungs, bowels, and such
What are some less invasive surgical interventions for cardiac
MIDCABG - minimally invasive direct coronary bypass surgery
Robotic CABG
MIDCABG
minimally invasive direct coronary bypass surgery
instead of 4-5 incisions midline for open heart surgery - only a 1-2 inch incision in the rib side is done
it is for vessels easier to access and only 1-2 vessels rather than 3-4 of them
Robotic CABG
Use of Davinci Machines
Instead of 4-8 hours only takes 1-3 hours
Less complications and patients do so well they may even be off unit in 1-2 days
Education topics for Post Cardiac Event Discharge
Physical Activity (How to take pulse rate, static v isotonic activities, cardiac rehab program referral)
Avoid heavy things and exercise immediately post op for at least a week
Self concept teaching
3-4 days of torture for 10+ years of QOL
Diet
No Smoking
When to call doctor
S/s of common complications of angina, MI, postprocedural
Most have better QOL post procedureally than prior to event
A patient presents to teh ED with 5/10 chest pain…
HR 122
BP 124/62
Temp 36.8 C
SpO2 98%
Why could the nurse anticipate any of the following?
a. the patients life is in danger immeidately prepare for cath lab transfer
b. nothing; pt is stable and can be sent home
c. the patient needs to be admitted to the telemetry floor for closer monitoring
d. the patient needs open heart surgery
WITH MORE INFO:
A. if ST elevation, EKG in multiple Leads ST elevation, diaphoresis, 5/10 CP from nitro while its usually 9/10 then this could be right
B. eating too much, gas, exercise, etc could cause this
C. Troponin of 7, CP before, Troponin elevated but stable VS - does not have to be an emergency necessarily right now
D. Not something ascertained in the ED - but is done after A if it failed
A 60 year-old male client comes into the emergency department with a complaint of crushing 10/10 substernal chest pain that radiates to is left arm and shoulder. The admitting diagnosis is acute myocardial infarction (AMI). Immediate admission orders include: Oxygen @4L/min via nasal cannula, blood work, 12 lead EKG, chest radiograph, and 2 mg morphine sulfate given IV. The nurse should first:
- administer the morphine
- obtain the 12 lead EKG
- obtain the blood work
- order the chest x-ray
1.Administer Morphine
A client had driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to the EKG monitor and begins administering oxygen at 2L/min via nasal cannula. The nurse’s next action would be:
A. call the physician
B. start an IV line
C. obtain a 12 lead EKG
D. draw blood for lab studies
B. start an IV line
Fmaily hx, pt first, might be complaining of indigestion or an MI - have IV ready just incase
When monitoring a client who is receiving tissue plasminogen activator (t-Pa), the nurse understands that it is important to monitor vital signs and have resuscitation equipment available because reperfusion of the cardiac muscle can result in which of the following?
A. Cardiac Arrhythmias
B. hypotension
C. seizure
D. HTN
E. Hyperthermia
A. Cardiac Arrhythmias
