ACS part 2

57問 • 1年前

問題一覧

What is cardiac output

The amount of blood pumped from the left ventricle/min, Adult CO range is 4-7 L/min, IS dependent on the relationship of the HR and SV (stroke volume), CO= HR x SV

Heart Rate is?

The number of times the ventricles contract per minute, Normal adult resting HR is 60-100 bpm, Is controlled by automnomic nervous system, Adjusts rapidly to regulate cardiac output

What is stroke volume?

The amount of volume ejected by the LEFT ventricle during SYTOLE, IS influence by HR, preload, and afterload, and contractility

What is Ejection fraction?

The amount of blood ejected blood ejected by the Left ventricle expressed in a percentage, Normal is 50-70%

The pressure the ventricle must over come to eject blood is…

Afterload

What is preload?

The degree of myocardial fiber stretch at the end of diastole AND its ability to “shrink to squeeze” back, Determined by left ventricular end-diastolic volume (LVEDV), Starling’s law: the more the heart is filled during diastole the more forcefully it contracts (up to a point), Excessive filling = excessive LVDEV = overstretched = decreased CO

What is afterload?

The pressure ventricles must overcome to eject blood into the peripheral blood vessels, Is influenced by the condition of the aortic valve, Is also influenced by pressure and distensibility of the vascular system

What is contractility?

Force of cardiac contraction independent of preload, How well does it “squeeze”

What is STEMI?

ST-elevation myocardial infarction, ST segment elevation greater than 1mm or more in 2 or more contiguous ECG leads

What are the priority interventions for STEMI?

O2 @ 4L/min if O2<94%, Aspirin 160mg to 325mg chew, Nitroglycerin SL or spray x3, Give morphine for pain

What are morphine sulfates action, dosing, adverse effects, cantraindications.

Action binds with mu and kappa pain receptors to produce analgesia, is a venodilator, Dosing 2-4mg IV q5-15min (up to 8mg can be used), Adverse effects respiratory depression, Contratindicated in hypotension or hypovolemia

ECG changes for STEMI

ST segment elevation greater than 1mm or more in 2 or more contiguous ECG leads, Large occlusion, Rapid reperfusion required

What is the quality emergency center care for impaired tissue perfusion?

Targeted H&P, Blood work, CXR, Total ED time should be <30mins, Timely reperfusion: Percutaneous coronary intervention -within 90 minutes first contact -within 30 minutes of EC door, Fibroinolytics -within 30 minutes of EC door

Cardiac cath lab:

Is superior to fibronolytics if performed by skilled providers (40 facilities in MI), Door to balloon time should be less than or equal to 90 mins, Preferred if heart failure or cardiog, Caution if: Allergy to contrast, metformin hydrochloride, renal impairment, anticoagulants. (keep in mind this isn’t a contraindication but a caution!)

What is the process of Percutaneous Coronary Intervention (PCI) and how does the balloon catheter restore blood flow in an artery?

A balloon-tipped catheter is inserted into a blood vessel and guided to the narrowed section of the coronary artery., The uninflated balloon is positioned at the site of the blockage or plaque build-up., The balloon is then inflated, which compresses the plaque against the artery wall, effectively widening the artery., After the artery is widened, the balloon is deflated and removed, leaving the artery open to restore proper blood flow.

What is fibrinolytic therapy, and what is it used for?

A type of reperfusion therapy, Used to dissolve blood clots in the coronary arteries and restore blood flow during conditions like ST-elevation MI STEMI.

What are the action and indications of fibrinolytic therapy?

Action: dissolves clots in coronary arteries to restore blood flow helping reduce damage to the heart muscle, Indications: Primarily used for STEMI if onset of symptoms is less than 12 hours, Indications: Early treatment is ideal, Indicaitons: The goal is to administe fibrinolyticsa within 30 minutes of the pt arriving at the hospital (door-to-needle time)

What are the contraindications to fibrinolytics?

Absolute contraindications: Recent major bleeding, pregnancy, Relative contraindications: HTN with SBP>180 or DBP>110

What are examples of fibrinolytics? And what are the side effects?

rtPA (activase), Retelplase (Retavase), Tenecteplase (TNKase), SE: bleeding

What are P2Y12 aka ADP inhibitors used for, and what is their action?

Action: Binds to P2Y12 receptors blocking ADP thus reducing platelet function, Uses: Decreases sudden cardiac death due to thrombus

What are the cautions and and alert for P2Y12 aka ADP inhibitors?

Cautions: Age>75, hx CVA, stop 7 days before surgery, ALERT: Cardiologist approval is needed to stop therapy.

What are examples and SE of P2Y12 at ADP inhibitors?

Examples: Clopidogrel (Plavix) -on for 2 yrs Prasugrel (Effient) Tricagrelor (brilinta) -is newer less SE, pricey, off in a year sometimes months Cangrelor (Kangreal), SE: Bleeding, Stroke

What factor do the new anticoagulants work on?

Facto xa

What is therapeutic hypothermia?

Deliberate reduction of the core body temperature usually around 32-34C in pts who don’t regain consciousness after ROSC following a cardiac arrest, Only intervention shown to improve neurological outcome and decrease mortality, Adverse effects: F&E imbalance, arrhythmias, insulin resistance, shivering, coagulation problems, pain & sedation concerns

What is NSTEMI?

Non st elevation myocardial infarction, Chest pain, ST depression ≥ 0.5mm, T wave inversion, Transient (<20 min) ST elevation, Cardiac markers (Troponin) determine diagnosis

What the initial NSTEMI treatment: Acute pain

911- EMS, Aspirin 162-325mg,, Antiplatelet (clopidogrel), Nitroglycerin sublingual, O2, IV, Heart monitor, morning, ECG, H&P, Blood draw: cardiac biomarker

Tissue perfusion interventions: What are anti-ischemic therapy interventions?

Bedrest, Oxygen, Nitroglycerin, Beta blocker, Calcium channel blocker, ACE inhibitor or angiotensin receptor blocker

What are continuous nitroglycerin infusion indications, and parameters?

Chest pain, Hypertension, Pulmonary edema, Titrate to response parameters: SBP >100 (with IV, without would be 120), Titrate to response parameters: Limit BP drop 20-30mmhg

Continuous nitroglycerin paste.

Slow release, Squeeze a ribbon of ointment onto measuring paper, Apply to upper torso

What is Heparin.

Indirectly inhibits thrombin, Bolus IV then continuous infusion to maintain a therapeutic PTT/aPTT (2-3x normal), Low intensity 55-75 seconds/60-80, High intensity 80-100, Normal PTT 25-30 (3x norm for heparin) Critical >120, Normal aPTT 22-31 (3x normal for heparin? Critcial >120, Monitor platelets - risk of HIT

What other anticoagulants options?

Enoxaparin (Lovenox), Bivalrudin (Angiomax), Argatroban (Acova), Fondaparinus (Arixta)

What is NSTEMI treatment PCI (percutaneous catheter insertion

Next day or earlier if:, :Persistent pain, :Ventricular dysrythmias, :Intermittent ST changes, :Symptoms of heart failure

More Antiplatelet agents: Glycoprotein (GP) IIb/IIa inhibitors action?

Inhibits platelet aggregation by preventing fibrin binding with platelets

More Antiplatelet agents: Glycoprotein (GP) IIb/IIa inhibitors indications?

UA/NSTEMI, STEMI abciximab only, In combination with aspirin herparin and clopidogrel before PCI, Not indicated if PCI not planned

More Antiplatelet agents: Glycoprotein (GP) IIb/IIa inhibitors examples and advers effects/

Eptifibatide (Integrilin), Abciximab (ReoPro, Tirofibran (Aggrastat), Bleeding

What are some nursing diagnoses related to ACS, STEMI, NSTEMI, etc.

Acute pain, Ineffective cardiopulmonary tissue perfusion, Ineffective coping, Activty intolerance, RC dysthymias, RC heart failure, RC Reccurrent chest discomfort and extension of injury.

Ineffective coping::

Related to effect of acute illness, major changes in lifestyle &/or loss of control over body part, Outcomes: Patient will indicate a reduction in anxiety and recognize the beginning of control over life, General interventions: Assess level of anxiety Allow expression of feelings Repeat explanations in simple terms Anxiolytic

Ineffective coping interventions:

Deinal: Avoids discussing what happened, may or may not comply with treatment, Denial nursing interventions: Remain calm, avoid threats while indicating harmful behavior, Anger: an attempt to regain control, Anger Nursing interventions: Allow verbalizaiton, allow opportunities to make decisions, Depression: Grief response, Depression nursing interventions: listen no false reassurances, encourage ADL, teaching

Optimism:

Patients with high levels of optimism experience better long term (>12 months) physical health and psychological well being, Significantly less readmisssions, More l healthy lifestyle changes: Smoking cessation More fruits and veggies

Activity Intolerance:

Planned cardiac rehabilitation:, :Phase 1: hospitalization -Nursing & Physical therapy supervised progressive ambulation, :Phase 2: Convalescense -Outpatient cardiac rehab, :Phase 3: Long term conditioning -Independent, Studies have shown 12 sessions ⬆️ survival 24 sessions has the greatest impact decreasing risk of death by 50% and risk of MI BY 33%!!, every person who has a heart attack should have cardiac rehab!

RC Dysrhythmias:

Inferior -Bradcardias -Blocks, Anterior -Ventricular irritability -BBB

RC heart failure:

B blockers, Inotropes, ACE-I or ARBs, Balloon pump

RC: Recurrent symptoms and extension of injury:

Smoking cessation, Cardiac diet, Statin, Risk factor modification, Exercise, Sexual activity, Blood pressure control, Blood glide control, Manage angina, Rest, Nitrates, Beta Blockers, Ca channel blockers, Revascularization

Coronary Artery Bypass Graft Surgery:

Postop care:, Manage F&E balance, Complications- hypotension, hypothermia, hypertension, bleeding, cardiac tamponade, change LOC

ACS: Care coordination and transition management:

Home care management (support groups), Self-management education: Risk factor modification Complementary and integrative health Sexual activity Drug therapy Seeking medical assistance, Healthare resources: American heart association Mended hearts

ACS: Evaluate out comes. Expected outcome are that the patient will:

State pain is alleviated, Have adequate myocardial perfusion, Be free of complications such as dysthymias and heart failure, Sexual activity is an important component of patient and partner quality of life, and it is reasonable for most patients with CVD to engage in sexual activity.

Just look at picture!

Ok great thanks!

Performance measures:

Aspirin -at arrival -RX at d/c, Statin, LV function evaluation, ACE-I or ARB, Reperfusion therapy -Fibrinolytics in 30 mins -PCI in 90 mins, Transfer for PCI in 24 hrs, Smoking cessation, Cardiace rehab referral, Cholesterol assessment, Appropriate anticoagulant dosin, Appriopraite fibrinolytic dosing, Clopidogrel or prasurgel or ticagrelor

What are the challenges associated with caring for patients with ACS?

Deaths occur in pts with non-critical disease, -Unstable plaque, -Abnormal coronary flow reserve

WHAT IS THE LEADING CAUSE OF CORONARY ARTERY DISEASE?

Atheroscelrosis

THE LOCATION OF AN MI ASSOCIATED WITH THE HIGHEST MORTALITY RATE IS..?

Anterior wall

A 56-year-old man had chest pain, elevated Troponin levels and ST segment depression. What is the nurse’s interpretation of these findings?

The patient is experiencing an NTSEMI

Paramedics arrive at the ED with a 74-year-old client with severe chest pain rated at an 8 on a 0-10 scale. He says he has had chest pain for a few hours which got bad enough that he called 911. He takes ”heart medications” but does not recall their names. The electronic health record shows a history of CAD and a myocardial infarction 5 years ago with stent placement in the LAD and the circumflex artery. He says, “my doctor said I also have heart failure”. 1. What diagnostic tests do you anticipate the provider will order for this client?

12 lead EKD, Echo, Troponin

Two hours later, the client is admitted to the cardiac stepdown unit. Orders include: • Saline lock • Cardiac diet • Oxygen at 2 L per nasal cannula • Follow-up cardiac enzymes • 12-lead ECG in 6 hours. One hour later, the client reports severe shortness of breath and mild chest pain. Oxygen saturation is 88%, BP is 96/54, and the monitor shows sinus tachycardia with a rate of 116. 2a. What do you suspect is happening to the client? 2b. The client’s laboratory values include troponin T 0.6 mg/mL. What is your interpretation of this finding?

2a - Heart failure, 2b- Cardiac muscle damage acute mi necrosis

You immediately notify the provider and within 45 minutes, the client is transferred to the CCU in serious condition. He has developed crackles bilaterally, and his chest pain level has increased. 3. Which drugs do you anticipate will be ordered? (Select all that apply.)

Atenolol, Morphine, Furosemide

The next morning, the client is taken to the cardiac catheterization laboratory. The cardiologist finds that there is an 80% blockage in the proximal LAD coronary artery. 4. Which procedure is most likely to be performed to correct this condition?

PTCA percutaneous transluminal coronary angioplasty with coronary artery stent placement

The client’s condition improves, and he is returned to the cardiac stepdown unit. He is to be discharged after 6 days in the hospital. 5. What client teaching will you provide before he is discharged?

Diet changes, exercise, smoking cessation, medication therapy

Health assessment questions

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Health assessment questions