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N362: Practice of Nursing III > Week 12: Coronary Vascular Disorders, Atherosclerosis, Angina, MI > Flashcards

Week 12: Coronary Vascular Disorders, Atherosclerosis, Angina, MI Flashcards

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1
Q

Flow of Blood from Heart to Body

A

IVC/SVC –> RA –> Tricuspid –> RV –> Pulmonary Valve –> Lungs –> LA –> Mitral Valve –> LV –> Aortic Valve –> Aorta

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2
Q

Main Coronary Arteries

A

RCA - Right Coronary Artery

Left Main Coronary Artery (LCA)

a. Left Circumflex Artery (LCx)

b. LAD - left anterior descending coronary artery

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3
Q

LAD

A

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

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4
Q

RCA

A

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)

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5
Q

Leading Cause of US Death is

A

Heart Disease

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6
Q

CAD

A

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%

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7
Q

What makes up the plaque in CAD

A

Usually lipids, other fatty substances, fibrous material

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8
Q

What % of blockage of coronary arteries does it take to lead to symptoms being seen?

A

70% minimum usually

Could be 90-100% because of collateral circulation though

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9
Q

How does CAD differ in Men compared to Women

A

CAD manifests 10-15 years sooner

Initial cardiac event is more often an MI than angina

Higher incidence of LVH

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10
Q

How does CAD differ in Women compared to Men

A

CAD causes more death in women

Initial cardiac event more likely to be angina than MI

Complain of palpitations more frequently than men

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11
Q

LVH

A

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

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12
Q

Non Modifiable Risk Factors for CAD

A

Age

Gender

Ethnicity

Genetics and Family Hx - high risk for CAD and MI if in nuclear family

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13
Q

What is the gender disparity with CAD

A

men > women until age 60

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14
Q

What is the ethnicity disparity of CAD

A

AA > Caucasian

South Asian High - Japanese Low

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15
Q

Modifiable risk factors for CAD

A

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

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16
Q

What are the 3 most common risk factors for CAD that 9/10 patients have

A

HTN

Hyperlipidemia

Obesity

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17
Q

Nursing Management of CAD Risk Factors

A

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

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18
Q

FITT Formula of Physical Activity to counteract CAD

A

FITT Formula = Frequency, Intensity, Type, Time

Moderate exercise 30 min/day on 5 or more days/week - brisk walking, hikin, biking, swimming

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19
Q

What does following the FITT Formula lead to

A

Contributes to weight reduction, 10% drop in SBP, diabetics - better blood glucose

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20
Q

Nutrition education for CAD emphasizes what things

A

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)

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21
Q

What should be done if a patient with CAD has elevated serum triglycerides

A

alcohol intake and simple sugars should be reduced or eliminated

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22
Q

Where to get Omega 3 Fatty Acids

A

Eating fatty fish 2x a week - salmon and tuna

tofu, soybean, canola, walnuts, flaxseed

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23
Q

Angina

A

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)

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24
Q

Types of Angina

A

Stable

Unstable

Intractable or Refractory

Variant (Prinzmetal’s Angina)

Silent Ischemia

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25
Q

Stable Angina

A

predictable, manageable episodes of chest pain

Relieved with rest and/or nitroglycerin

occurs with exercise

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26
Q

Unstable Angina

A

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

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27
Q

Interventions for Stable Angina Acute Episodes

A

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

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28
Q

Unstable Angina has a high risk for…

A

Myocardial infarction

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29
Q

Prinzmetal;s Angina

A

occurs at night in clusters

from artery spasms

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30
Q

Refractory Angina

A

Reoccurs despite treatment

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31
Q

Silent Angina

A

No s/s

no chest pain but myocardial ischemia is occurring!

Tests pick up ischemia affecting heart and perfusion

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32
Q

Acute Coronary Syndrome (ACS)

A

Prolonged ischemia that causes DAMAGE to the heart!

An umbrella term for damage to the heart from ischemia

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33
Q

3 categories of ACS

A

unstable angina

STEMI

NSTEMI

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34
Q

STEMI

A

ACS

Complete occlusion of coronary vessel(s)

ST elevation on EKG

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35
Q

NSTEMI

A

ACS

partial occlusion of coronary vessel(s)

No ST Elevation, but other EKG changes are possible

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36
Q

In what ways are STEMI and NSTEMI similar

A

similar clinical manifestations (c/p, SOB, DOE)

similar diagnostic study cahnges (CK, troponin)

37
Q

The big differece between STEMI and NSTEMI

A

STEMI has ST Elevation while NSTEMI does not but can have other EKG changes

38
Q

Creatinine Kinase (CK)

A

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

39
Q

What is teh gold standard diagnostic lab for cardiac studies

A

Troponin

40
Q

Troponin

A

elevation in this substance can indicate dx of MI

gold standard marker for cardiac

41
Q

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

A

B. Obtain an EKG

42
Q

What is an EKG a good pic of

A

A good 3D pic in a 2D format of the blood vessels and such

43
Q

What EKG change likely indicates an MI

A

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

44
Q

Clinical Signs of an MI

A

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

45
Q

What is the gender differences for MIs

A

MI PRESENTATION MAY BE DIFFERENT IN WOMEN!!!

> severe SOB
pain in abdomen
NV
Profound weakness/fatigue
anxiety and feeling “unwell”
Sweating

46
Q

How Does the non specific CK marker move after an MI

A

rises 12 hours after MI and peaks at 24 hours, but returns to normal in 2-3 days

47
Q

Troponin (T or I) is a …

A

myocardial muscle protein released after myocardial injury and raises faster than CK-MB

48
Q

What are the levels of Troponin to know

A

<0.4 = normal

0.4-1.49 = ischemia

> 1.49 = Acute MI

49
Q

M.O.N.A.

A

Nursing interventions of ACS and MI:

Morphine (for pain)

Oxygen (2-4 L)

Nitroglycerin (dilate venous system)

Aspirin (prevent clot)

50
Q

Nursing Interventions for MI and ACS

A

Pain relief

VS/EKG Monitoring (PVCs and PACs)

Check K, Mg levels (want above 4 and below 2 respectively)

BLS/ACLS protocol

51
Q

Emergent Percutaneous Coronary Intervention

A

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

52
Q

Fibrinolytic Therapy

A

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)

53
Q

Indications to Use Fibrinolytic Therapy

A

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

54
Q

Contraindications of Fibrinolytic Therapy

A

active bleeding, hx of bleeding

hx of hemorrhagic stroke, intracranial vessel malformation

uncontrolled HTN

pregnancy

GI bleed

recent trauma, CPR, or surgery

55
Q

What is important to be aware of following fibrinolytic therapy

A

Reperfusion Injury - Myocardial Stunning/Arrhythmia

56
Q

Myocardial Stunning

A

Arrhythmias from ischemic heart areas being irritated after reperfusion

57
Q

Nursing INterventions for Fibrinolytic Therapy

A

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)

58
Q

What is the EBP on aspiring/beta blockers and MI care

A

These two are preferred and should be given on arrival to the ER or within 24 hours of admission and Rx on discharge

59
Q

EBP states that PCI (Cardiac Cath) should occur when?

A

Within 60 minutes of arrival for MIs with ST elevation

60
Q

What does EBP say on MI care and ACEI/ARB Drugs

A

Rx on discharge for LVSD (left ventricular systolic dysfunction) as it lowers the EF <40%

61
Q

EBP shows that patients undergoing MI care should undergo what counseling

A

smoking cessation

62
Q

What is the best EBP to do after someone refuses MI Care and you cannot follow protocol

A

Any rational (contraindication) for not following the protocol for MI care msut be clearly documented in the patients progress notes

63
Q

Surgical and non Surgical Therapies for ACS

A

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

64
Q

Stent Placement

A

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

65
Q

What nursing care aspects are done post-PCI

A

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

66
Q

PCI Complications

A

Coronary Dissection

Complete Occlusion

MI

67
Q

What % of PCIs restenose in 3-6 months post procedure

A

25-35%

at max may last 5-10 years before needing to address again

68
Q

Coronary Dissection

A

rare post PCI complication

catheter punctures a coronary vessel

medical emergency

69
Q

What needs to be done if theres a complete occlusion again post PCI

A

the stent cannot make the vessel patent alone so cardiac surgery with a more invasive approach must be done

70
Q

CABG

A

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

71
Q

How big are the lesions/occlusions to do a CABG at minimum

A

70% but often its 90-100% before this is done

72
Q

CPB - Cardiopulmonary Bypass

A

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

73
Q

What stops the heart to let the CPB take over

A

A high level of potassium

74
Q

Complications of Longer Use of CPB

A

coagulopathy (have to give with anticoagulants)

pneumonia

prolonged mechanical ventilation

prolonged ICU stay

increased risk of mortality

“pump head”

75
Q

Why can pneumonia occur from CPB

A

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

76
Q

Pump Head

A

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

77
Q

Cardioplesia

A

Potassium amount that stops the heart

78
Q

Off Pump CABG

A

No CPB used, surgery is done with heart still beating

Less ‘Complete” revascularization

fewer complications than on pump

79
Q

What is the big restriction on off pump CABG

A

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

80
Q

What are some benefits of off pump CABG compared to CABG

A

less bleeding

shorter ICU stay

less time on mechanical ventilation

81
Q

Post-Op Care of the Cardiac Surgical Patient involves..

A

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

82
Q

What are some less invasive surgical interventions for cardiac

A

MIDCABG - minimally invasive direct coronary bypass surgery

Robotic CABG

83
Q

MIDCABG

A

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

84
Q

Robotic CABG

A

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

85
Q

Education topics for Post Cardiac Event Discharge

A

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

86
Q

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

A

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

87
Q

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:

  1. administer the morphine
  2. obtain the 12 lead EKG
  3. obtain the blood work
  4. order the chest x-ray
A

1.Administer Morphine

88
Q

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

A

B. start an IV line

Fmaily hx, pt first, might be complaining of indigestion or an MI - have IV ready just incase

89
Q

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

A. Cardiac Arrhythmias

N362: Practice of Nursing III (15 decks)

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