Week Two Flashcards
Acute Coronary Syndrome (ACS) includes….
unstable angina
NSTEMI
STEMI
NON Modifiable Risk Factors for CAD
age
gender
ethnicity
family history
genetic predisposition
Modifiable RF for CAD
HTN
smoking
exercise (lack thereof)
obesity
diabetes
metabolic syndrome
psychologic state (stress)
homocysteine level
substance abuse
Stable (chronic, exertional) Angina
blockage of coronary artery
predictable
relieved by rest
ST depression or T wave inversion
TREATMENT: rest and NTG
Prinzmetal’s Angina (Variant)
different things cause the chest pain
vasospasm of a coronary artery
smoking, alcohol, caffeine
transient ST elevation during pain episodes
cardiac cath
TREATMENT: CCB (relax coronary artery)
Silent Ischemia
ischemia without the patient reporting pain
diabetes- neuropathy
elderly
woman (present different)
Women Presentation with angina
unusual fatigue
sleep disturbances
SOB
weakness
cold sweat
lightheadness
Nausea
dizziness
indigestion
Unstable (crescendo) Angina
atherosclerotic plaque instability and possible thrombus formation
ST depression or T wave inversion
unpredictable
TREATMENT: rest, NTG, drugs affecting platelets, re-vascularization (stents and bypass)
Acute Myocardial Infarction (AMI)
ischemia with myocardial cell death (necrosis) r/t disruption or deficiency of blood supply to coronary arteries
imbalance of O2 supply and demand
CM of ACS
chest pain
diaphoretic
skin (pale/ashen, cool and clammy)
syncope
N/V
dysrhythmias
fever in the 1st 24 hours
Initially increase in HR and BP but then BP drops because of decreased CO
crackles
JVD
S3 or S4 heard
new murmur
how to classify an MI
ECG changes
depth of heart damage
location of the area of the heart affected
progression of an AMI
ischemia (lack of O2)
- ST depression, T wave inversion, tall peaked T wave
injury (occlusion with ischemia)
- ST elevation
infarction (death)
- pathological Q wave - ain’t getting fixes
Transmural
full-thickness damage of the heart
endocardium, myocardium, epicardium
pathological Q wave from scarring
Non Transmural
limited damage of the myocardium (middle layer of heart)
most frequent site of MI
left ventricle
most frequent coronary artery of a MI
left vein coronary artery (widow maker)
Anterior MI
left anterior descending
V3-V4
septal
left anterior descending
V1-V2
lateral
left circumflex
1, aVL, V5-V6
inferior MI
right coronary artery
2, 3, aVF
posterior MI
left circumflex
V1- V3
MI healing
within 24 hours, leukocytes infiltrate the area of cell death
neutrophils and macrophages remove necrotic tissue by 4th day (there is a thin wall)
10-14 days scar tissue is still weak
very vulnerable to stress
by 6 weeks, scar tissue replaced
normally, the heart will hypertrophy and dilate in an attempt to compensate for dead tissue
management of AMI
O2 supply
decrease myocardial demand (MONA)
M: morphine
O: o2
N: NTG
A: aspirin
IN THIS ORDER: ONAM
medical management of AMI
Call 911
O2
coags
decrease HR (increase ventricular filling time)
decrease preload
decrease afterload
decrease myocardial oxygen
lipid-lowering agents
thrombolytics
intensive glucose therapy
CORE MEASURES OF AMI
start ecg
ASA on arrival (and prescribed at discharge)
ACEI or ARB for LVSD (EF> 40)
smoking cessation
Beta-blockers at discharge
TBA (fibrinolytic therapy within 30 min of getting to hospital)
90 min from door to balloon
statin at dischage
nursing management of AMI
pain control
cont monitoring (ECG, ST segments, Heart and breathe sounds, VS, Pulse ox, I&O)
rest and comfort
anxiety reduction
emotional support
pt teaching
cardiac rehab
for chest pain:
- semi fowler’s
-O2
-assess VS
- 12 lead ECG
- NTG followed by opioid analgesic
- auscultate heart and breath sounds
reperfusion strategies
Fibrinolytic (Thrombolytic) therapy
-6-hour window to start from the onset of symptoms
-less than 30 with admission
-TBA
-Adjuncts: heparin and glycoprotein inhibitors
-start 2-3 IVS
Cath (90 min)
PTCA
Intracoronary artery stenting
bypass grafts
Cath/coronary angiography
visualize and open blockages
- percutaneous coronary interventions (PCI)
- balloon angioplasty
-stent
PTCA
balloon cath is inflated temporarily to open vessel
intracoronary stent
tubes placed in conjunction with angioplasty to keep vessel patent
anti coag therapy
Pre Cath Care
NPO 6-12 hours
Insulin/hypoglycemics adjusted day of procedure
Benadryl if allergic to dye
ASA, Clopidogrel or platelet inhibitor may be given
PT awake during procedure
Post Cath Care
bedrest (HOB 30)
monitor for bleeding/ hematoma
immobilize arm
monitor cardiac rhythm
encourage fluid intake (get dye to filter through kidneys)
I&O
observe for reaction to dye (angiography)
assess for chest pain, back pain, SOB
antiplatelet drugs after
go home 6-8 hours after
Nursing Management after Cath
monitor ECG and serial 12 leads
VS q15min until stable
monitor O2 stat cont
monitor serial troponin and/or cardiac biomarkers
monitor PT/APTT and observe for signs of bleeding in receiving thrombolytic therapy
manage hemodynamic compromise as ordered (Dopamine, Dobutamine)
assess for signs of HF (S3, S4, rales, edema, weight gain, decreased CO, decreased UOP)
patient education ACS
ambulatory and home care
cardiac rehab
pt and caregiver teaching
physical activity
- level of activity - METs or Borg scale
- monitor HR
- low-level stress test before discharge
- isometric vs. isotonic activities
resumption of sexual activities after 7-10 days or when you can climb two flights of stairs
do not take nitrates with ED meds
take a prophylactic nitrate before sex
CAD- symptoms (when do they need to seek help)
Diet is an AHA diet (reduces fat, total cholesterol <200, HDL > 40, LDL <100) reduces salt
smoking cessation
control HTN, diabetes
achieve ideal body weight
avoid Valsalva maneuver
med teaching
Hemodynamic Monitoring
measurement of pressure, flow, and oxygenation within the cardiovascular system
assess heart function, fluid balance, and effects of drugs on CO
Cardiac Output (CO)
volume of blood pump through heart in a min
Cardiac Index (CI)
cardiac output based on patients weight
Stroke Volume (SV)
amount ejected w each beat
this is effected by preload, afterload, and how healthy the heart is
Stroke Volume Index (SVI)
is the volume of blood pumped by the heart with each beat divided by the body surface area
Ejection Fraction (EF)
% of heart contracting (>60%)
Systemic Vascular Resistance (SVR)
How the heart has to overcome each body system
how much you are starting with and how much is left
pulmonary vascular resistance
what the heart has to overcome to pump through the lungs
preload
volume of blood within ventricle at end of diastole
PAWP: reflects left vent
CVP: reflects right vent
(what is left for the next heart beat)
afterload
forces opposing ventricular ejection
SVR and arterial pressure of left vent afterload
PVR and pulmonary pressure of right vent afterload
SVR and PVR (resistance) reflects ……
afterload
MAP
avg perfusion pressure
SBP + 2(DBP) divided by 3
> 60 mmHg
Intra-arterial Pressure monitoring
cont BP readings
components of pressure monitoring system
invasive cath
pressure tubing
transducer - level with phelbostatic axix
3 way stopcocks
pressure bag
flush solution
monitor and pressure cable
principles of invasive pressure monitoring
zeroing: calibrated to atmospheric pressure
leveling: transducer so zero reference point at level of atria of heart (phlebostatic axis)
what test do you do before entering a material pressure monitor?
allen’s test
how many mL do you flush an hour with APM?
3-6 mL
maintains line patency
limits thrombus formation
Pulmonary Artery Pressure Monitoring
guides pt with complicated cardiopulmonary problems
Pa diastolic (PAD) pressure and PAWP = cardiac function and fluid volume status
allows for precise manipulation of preload
Swan- Ganz
PA flow-directed cath
Balloon inflated to measure PAWP
Pulmonary Artery Pressure Monitoring - Insertion
trendelenberg or supine w/ towel b/w shoulder blades
sedation
inserted deflated balloon, selected inflation to float cath into PA
waveform changes as cath progression
check for proper wedging for PWP or PAOP
sheath
chest x ray
When are pulmonary artery pressure measurements obtained?
PA: at the end of expiration
PAWP: slowly inflate balloon with air until PA waveform changes to PAWP waveform
do not inflate for more than 4 RR cycles or 8-15 sec
Pulmonary Artery Pressure monitoring - nursing management
level transducer and zero arterial systems
utilize proximal lumen to measure RAP, infuse IV fluids, blood samples, and infusion of IV
distal lumen used to measure PA pressures. lumen not used for IV fluids, only irrigation fluids
balloon lumen left deflated and locked
monitor RR and Cardiac status
monitor for complications (pneumothorax, infection, sepsis, air embolus, PA infarction, or PA rupture, ventricular dysrhythmias)
Measurement parameters of PAC
PA systolic: 20-30
PA diastolic: 4-12
PA mean: 10-15
PWP/PAOP: 6-12
intermittent bolus thermodilution (TDCO)
continuous cardiac output (CCO)
inject saline or D5W into proximal lumen of PA cath
thermistor sensor detects differences in blood tempt and calculates CO
uses average of three measurements
Increase SVR
vasoconstriction (more pressure to push through)
decreases SVR
vasodilation (less pressure lower BP)
Venous Oxygen Saturation
SvO2/ScvO2 reflect balance b/w oxygenation of arterial blood, tissue perfusion, and tissue oxygen consumption
assess hemodynamic status and response to treatment/activity
normal-70%
decrease SvO2/ ScvO2
decreased arterial oxygenation
low CO
low hemoglobin level
increased oxygen consumption or extraction
increased SvO2/ ScvO2
may indicate improvement
or sepsis
CO values
4-8 L/min
SV values
60-150 mL
Cardiac Index
2.2-4.0 L/min/m^2
Systemic Vascular resistance (SVR)
left side afterload indicator
800-1200 dynes/sec/cm^5/m5
Pulmonary Vascular Resistance (PVR)
right side afterload indicator
160-380 dynes/sec/cm^5/ m2
pulmonary artery wedge pressure (PAWP)
left side
6-12 mmHg
central venous pressure (CVP)
right side
2-8 mmHg
PA systolic (PAS)
20-30 mmHg
PA diastolic (PAD)
4-12 mmHG
Mean Arterial Pressure
overall measure of tissue perfusion
70-105 mmHg (at least 60 mmHg to prevent metabolism in the peripheral tissue)
Formula: 2(DBP) + systolic BP (SBP) / 3
Cardiac Index is
cardiac output adjusted for body size
Stroke volume is
amount blood ejected by the ventricle with each heartbeat
SvO2 monitoring is
oxygen saturation of the hemoglobin in the venous return
purpose of SvO2 monitoring
early warning of an imbalance b/w oxygen supply and demand to the tissues and tissue use of oxygen (NORMAL: supply and demand match)
method of SvO2
a cath is placed in the pulmonary artery (mixed venous blood pumped out from the right ventricle) measures the amount of light reflected off the hemoglobin to determine how saturated they are with oxygen
normal SvO2 values
70%
low SvO2 means
seen in conditions that decrease O2 supple (low CO, low Hgb, and low SaO2)
or
increase in oxygen consumption (Vo2, sepsis, MODS, burns, shivering)
high SvO2
seen in conditions with low oxygen consumption such as anesthesia
