Week 3C Flashcards
Management of Coronary Disease
What are the goals of nursing care for a patient with ACS?
-Ischemic pain relief
-Effective coping with illness-anxiety
-Preservation of myocardium
-Participation in rehab plan
-Immediate treatment of ischemia
-Reduction of risk factors
What signs and symptoms should be addressed immediately in collaborative care of CAD?
ABC, hemodynamic stability, preliminary history
What should be done as an acute intervention for ACS (acute coronary syndrome)
-S/S
-12-lead ECG
-BLoodwork
-oxygenation (greater than 90)
-IV access
-initial meds
-reperfusion therapy
What are the 4 initial meds we would give to an ACS patient ?
ASA/Plavix/Ticagrelor
Oxygen
Nitro
Morphine
MONA Framework
What drugs/doses should be given to prevent platelet activation and interfere with platelet adhesion?
ASA (160-325 TAB)
Plavix (600mg)
Ticagrelor (180mg)
What drugs/doses should be given to hypoxic patients in respiratory distress (SPO2 90»)
Oxygen, titrate it to SAo2
Can high flow rates (8L/min) improve the size of infarct?
No. False. High flow oxygen can actually worsen size of infarct.
What TAB is given sublingually followed by an IV when a patient is in persistent chest pain, HTN, or heart failure?
Nitro. Can give x3
What drug should you give a pt if nitro is ineffective?
Initially, you’ll have increased O2 demand, BP, HR, and contractility. Then you’ll give the patient morhpine. This will subsequently decrease all of these values.
Explain the MONA framework
Morphine, Oxygen, Nitro, Aspirin- how to treat ACS
List some additional medications you could give to a pt with ACS
B-adrenergic blockers, LMWH or IV hep, ACE-inhibitors, O2Y12 inhibitors, anti-dysrhythmic medications, cholesterol lowering, stool softeners
When would you give pt B-blockers?
Within 24h, if they’re very hypertensive or bradycardia
When do you give a pt LMWH or IV heparin?
Minimally 48hr after MI, to prevent rethrombosis or acute stent thrombosis
When and why would you give ACE inhibitors?
To lower their BP and reduce vasoconstriction and fluid retention
What are the two types of repercussion therapy?
Mechanical or pharmacologic
Mechanical reperfusion
Primary percutaneous coronary intervention
Primary PCI
Angiogram, insert STENT to re-establish perfusion distal to the occlusion. Can elect for this is there is a significant occlusion and they want to take preventative action to prevent an MI.
Pharmacologic Reperfusion
Fibrinolytic Therapy
Fibrinolytic Therapy
“systemic, risk for bleeding and/or stroke”
-Steptokinase, alterplase, reteplase, tenecteplase
-STEMI only
TIs for PCI (percutaneous coronary intervention)
-Electively for chronic, stable, angina
-Urgent for unstable angina
-Emergent for MI
-1-2 vessel disease
-Perform within 120’ of first medical contact, ideally within 90’
What are some complications of PCI ?
-Restensois
-Coronary artery spasm
-Puncture or damage
-Irritation to the heart
-Bleeding
-Risks of heparin use
What are the nursing interventions for follow-up care post-PCI?
-Angina
-Vascular site care
-Peripheral ischemia
-Renal protection
What meds are given 120’ following a PCI?
ASA 160mg
Fibrinolytic IV (STEMI only)
Plavix 300mg
UF Hep bolus 60, + cont. drip 12u/kg/hr
What meds are given immediately for a PCI?
ASA 160, Plavix 300, UF hep 70U/kg, standing by for transfer to Cath lab
Are we always worried about angina following an MI?
No. This may be caused by a transient coronary vasospasm, but it can also be a more serious complication
How do we assess for kidney function and why are we worried following a PCI?
The dye used is bad for kidneys, as is metformin. Look at hydration, fluids, D/C of some meds
Timing of fibrinolytic therapy
30’, ideally in first hour, less than 6hrs otherwise we just won’t give it because the risks are too great.
Do we treat dysrhythmias in fibrinolytic therapy ?
No, they are self limited. NO tx
What are some relative CIs for fibrinolytic therapy
-Active peptic ulcer disease
-Anticoagulant
-Pregnant
-Hx ischemic stroke not last 3month
-Dementia
-Sugery in last 3week
-Internal bleeding last 204wek
-Severe HTN
-Traruma or prolonged cardiopulmonary resuscitation
What is the major complication in fibrinolytic therapy?
Bleeding. We are looking at superficial bleeding (IV site) or internal bleeding where we would then stop the infusion and observe for stroke symptoms.
Who is eligible for fibrinolytic therapy?
-Recent onset (12hr) persistent ST-elevation, Bundle Branch blocks (BBB’s), chest pain UR Nitro, NO conditions w. predisposition to hemorrhage
Who are we NEVER giving fibrinolytic therapy to?
-Internal bleeding
-Hx cerebral aneurysm/AV malformation
-Hx cerebral hemorrhage
-Ischemic stroke Hx last 3mth
-Closed head/facial trauma 3mth
-Suspected aortic dissection
When would you elect for a coronary artery bypass graft?
When there are blockages but a stent is not appropriate. Not usually an emergency surgery.
What vein is used for a coronary bypass graft?
Saphenous from the Breast or leg. Placed into the heart to bypass the area where there is an occlusion. Allows us to re-establich perfusion distally.
TI for CABG
Left main disease, multi vessel disease, satisfactory improvement is not reached with medical management, patient is not a candidate for PCI, lifestyle limiting angina unresponsive to therapy or PCI
Post MI ongoing assessment and care
1) PAIN
2) Bleeding/skin/tubes/wires
3) catheter, extremeties
4) Monitor cardio, resp, VS, O2
5) rest/sleep
6) Anxiety
7) Efficacy
8) Psychological response
What ventricle are we US to check ejection after an MI?
Left.
How long to discharge most patients after an MI?
1 week
How would you educate your patient prior to discharge?
1-manage pain and ID PF (precipitating factors)
2-ID personal risk and lifestyle changes to make
3-Sexual activity may resume when they can climb 2 flights of stairs
4- stick to ur drug regime (duh)
Which antiplatelet will a pt be on for the rest of their lives?
Aspirin
When would you prescribe plavix in LT drug therapy?
Allergic to ASA or if they have a stent
Describe dual antipltelet therapy ?
For one year, then change in protocol. ASA + Tricagrelor//plavix
What is recommended for all patients with ACS ?
Statin therapy
What is the statin protocol for patients?
Manages cholesterol. Atorvastatin 80mg daily of Rosuvastatin 20-40mg daily.
Why do we prescribe ACE inhibitors in LT management ?
Regulare BO, prevent remodelling of Left ventricle,
ramipril, captopril
Why do we prescribe beta-blockers to pts for LT drug therapy ?
decrease: contractility, heart rate, after load, lower O2 demand and increase supply
Metoprolol, atenolol
Describe why and how you would take nitro in LT disease management
-PRN
-Before activity
Promotes peripheral vasodilation and enhances collateral flow. Increase BF to ischemic zones
When and why do we prescribe calcium channel blockers?
Coronary and peripheral vasodilation, reduced contractility,used in combination with beta boclkers,
Diltiazem, verapamil, nifedipine
What are some complications you may see in patients following an MI?
Arryhtmias, CHF, cariogenic shock, papillary muscle dysfunction, ventricular aneurysm, pericarditis, pulmonary embolism
