Care of patients with ACS Case studies

Question 1

Single largest killer of American men and women in all ethnic groups
Broad term that includes chronic stable angina and acute coronary syndromes (unstable angina - STEMI and NSTEMI)
Affects the arteries that provide blood, oxygen, and nutrients to the myocardium (heart muscle)
Ischemia occurs when insufficient oxygen is supplied to meet the requirements
Infarction (necrosis or cell death) occurs when severe ischemia is prolonged over long-period time and decreased perfusion causes irreversible damage to tissue - can develop HF as a result; no blood flow to heart can die; need recognize early MI early and assess ASAP

Answer 1

Coronary artery disease (CAD)

Question 2

atherosclerosis is the primary factor in the development of CAD; nonmodifiable and modifiable risk factors contribute to atherosclerosis
Nonmodifiable: age, gender, family history - may need screen earlier, ethnic background
Modifiable: elevated serum lipid levels, smoking, limited physical activity, HTN, DM, obesity, excessive alcohol, excessive stress/decreased coping skills - focus on these: any meds and importance staying on med regimen

Answer 2

Etiology: CAD risk factors

Question 3

Chest pain caused by a temporary imbalance between the coronary arteries’ ability to supply oxygen and the cardiac muscle’s demand for oxygen
Ischemia (lack of oxygen) that occurs is limited in duration and does not cause permanent damage
Two types:

Answer 3

Angina pectoris

Question 4

Chronic stable angina
Unstable angina - ACS

Answer 4

Two types:- Angina pectoris

Question 5

Chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient
Frequency, duration, and intensity of symptoms remain the same over several months
Results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque
Usually relieved by nitroglycerin or rest; managed with drug therapy
Less than 15 min
Affecting daily life

Answer 5

Chronic stable angina

Question 6

Term used to describe patients who have either unstable angina or acute myocardial infarction
Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (clumping), thrombus (clot) formation, and causes vasoconstriction/totally occlude vessel and cut off vessel
ACS classified into one of three categories according to the presence or absence of ST-segment elevation on the ECG and positive serum troponin markers:

Answer 6

Acute coronary syndromes

Question 7

ST-elevation MI (STEMI), traditional manifestation
Non-ST-elevation MI (NSTEMI), common in women
Unstable angina pectoris

Answer 7

ACS classified into one of three categories according to the presence or absence of ST-segment elevation on the ECG and positive serum troponin markers:

Question 8

Chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation
Pressure may last longer than 15 minutes
Poorly relieved by rest or nitroglycerin
May present with ST changes but do not have changes in troponin or creatine kinase (CK) levels
May include:

Answer 8

Unstable angina pectoris

Question 9

New-onset angina –
Variant (Prinzmetal’s) angina –
Pre-infarction angina –

Answer 9

May include:- Unstable angina pectoris

Question 10

describes the patient who has his or her first angina symptoms, usually after exertion or other increased demands on the heart
First episode

Answer 10

New-onset angina –

Question 11

chest pain or discomfort resulting from acute coronary artery spasm and typically occurs after rest

Answer 11

Variant (Prinzmetal’s) angina –

Question 12

refers to chest pain that occurs in the days or weeks before an MI

Answer 12

Pre-infarction angina –

Question 13

Reduces peripheral vasoconstriction and oxygen demand
Relieves episodic anginal pain
Tablet or spray can be administered every 5 minutes for a total of 3 doses
Drop BP low because vasodilator
Can be given IV
Patient may experience a headache - taken a lot might not experience anymore

Answer 13

Nitroglycerin

Question 14

Occurs when myocardial tissue is abruptly and severely deprived of oxygen
When blood flow is quickly reduced by 80% to 90%, ischemia develops
Ischemia can lead to injury and necrosis of myocardial tissue if blood flow is not restored
Evolves over a period of several hours
Extent of infarction depends on collateral circulation, anaerobic metabolism, and workload demands: stents, grafting; restore blood flow: if occluded s/s of not having adequate blood flow
Physical changes do not occur in the heart until 6 hours after the infarction; evolves over sev hours; diff types heart attacks depending on location and how much occlusion
Once infarction occurs, scar tissue permanently changes the size and shape of the entire left ventricle, called ventricular remodeling - LV has irreversible damage develops HF; LV not same as was before

Answer 14

Myocardial infarction (MI/AMI)

Question 15

Pain or discomfort
Frequent associated symptoms:

Answer 15

Key features of MI

Question 16

Substernal chest pain/pressure radiating to the left arm
Pain or discomfort in jaw, back, shoulder, or abdomen
Occurring without cause, usually in the morning
Relieved only by opioids
Lasting 30 minutes or more

Answer 16

Pain or discomfort - Key features of MI

Question 17

N/V
Diaphoresis
Dyspnea
Feelings of fear or anxiety
Dysrhythmias
Fatigue
Palpitations - heart beating really fast
Epigastric distress
Anxiety
Dizziness
Disorientation/acute confusion - depending on blood flow and how much O2 getting
Feeling “short of breath”

Answer 17

Frequent associated symptoms: - Key features of MI

Question 18

NSTEMI – non-ST-segment elevation myocardial infarction
ST and T-wave changes on an ECG; not elevation
Indicates myocardial ischemia
Cardiac enzymes may be initially normal but elevate over the next 3 to 12 hours; negative troponin; always trend troponins and start going up sometimes
Causes: coronary vasospasm, spontaneous dissection, sluggish blood flow due to narrowing of the coronary artery - not total occlusion

Answer 18

NSTEMI

Question 19

STEMI – ST-elevation myocardial infarction in at least 2 leads
ST elevation in two leads on a ECG
Indicates myocardial infarction/necrosis
Attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture - completely occluding blood flow
Thrombus causes an abrupt 100% occlusion to the coronary artery - not perfusing and have s/s and need do intervention quickly

Answer 19

STEMI

Question 20

Troponin
Creatine kinase (CK)
CK-MB

Answer 20

MI Laboratory assessment

Question 21

Myocardial muscle protein released when there is injury to myocardial muscle; drawn suspect MI
Troponins T and I are not found in healthy patients
Any rise in value indicates cardiac necrosis or myocardial injury
Assess labs at 0, 3, 6 hours or until value peaks - want see how high went

Answer 21

Troponin

Question 22

Enzyme specific to cells of the brain, myocardium, and skeletal muscle
CK indicates tissue necrosis or injury

Answer 22

Creatine kinase (CK)

Question 23

Specially found in myocardial muscle
Not as quick as troponin

Answer 23

CK-MB

Question 24

Thallium scans
Contrast-enhanced cardiovascular magnetic resonance (CMR)
Echocardiogram - HF post-MI; see if any damage to muscle tissue
Computed tomography coronary angiography (CTCA)

Answer 24

Imaging assessment

Question 25

Radioactive tracers - look at cardiovascular tissue to see if functional Myocardial nuclear perfusion imaging (MNPI) Assess myocardial scarring and location and extent of an acute or chronic MI, to evaluate graft patency after CABG, and to evaluate antianginal therapy, thrombolytic therapy, or balloon angioplasty

Answer 25

Thallium scans

Question 26

Cardiovascular abnormalities can be viewed, recorded, and evaluated using radioactive tracers.

Answer 26

Myocardial nuclear perfusion imaging (MNPI)-Thallium scans

Question 27

Manage acute pain - big goals Supplemental oxygen - increase Drug therapy - nitro/morphine/aspirin Semi-Fowler’s position Quiet, calm environment

Answer 27

Acute coronary syndrome (ACS) interventions

Question 28

May complain of pain or pressure, assess according to onset, location, radiation, intensity, duration, precipitating factors, relieving factors; what doing when started Assess for associated symptoms such as N/V, diaphoresis, dizziness, weakness, palpitations, shortness of breath Assess VS: BP, heart rate, cardiac rhythm, dysrhythmias; sinus tachycardia with PVCs frequently occur in the first few hours after an MI - PVCs can lead to vtach if getting closer together Assess distal peripheral pulses and skin temperature; poor cardiac output can be manifested by cool, diaphoretic skin and diminished or absent pulse Auscultate for S3 gallop which often indicates heart failure – a serious and common complication of MI Assess the respiratory rate and breath sounds, crackles or wheezes may indicate left-sided HF - not want fluid backing up into lungs Assess for presence of jugular venous distention and peripheral edema Assess for fever, patient with MI may experience temperature elevation for several days, in response to myocardial necrosis, indicating the inflammatory response to necrosis

Answer 28

ACS - phys assessment

Question 29

For acute management of MI-MONA Beta blockers – Manage acute pain Thrombolytic therapy - Improve cardiopulmonary tissue perfusion ACE inhibitors or ARB’s – Calcium channel blockers - Statin therapy-

Answer 29

Drug therapy

Question 30

Morphine (decreases myocardial oxygen demand, relaxes smooth muscle) Oxygen therapy (if hypoxemia present) Nitroglycerin (reduces peripheral vasoconstriction and oxygen demand) Aspirin (inhibits both platelet aggregation and vasoconstriction, decreases likelihood of thrombus - not get any bigger)

Answer 30

For acute management of MI-MONA

Question 31

decreases the size of the infarct, the occurrence of ventricular dysrhythmias (so not have shock heart), and mortality rates in patients with MI (not used to acutely manage MI but often prescribed 1-2 hours post-MI if not contraindicated and for Acute Coronary Syndromes) decreases the size of the infarct, the occurrence of ventricular dysrhythmias, and mortality rates in patients with MI; slows the heart rate and decreases the force of cardiac contraction; if pulse less than 55 or systolic BP less than 100 check with provider before administering; monitor for bradycardia, hypotension, decreased LOC, chest discomfort, crackles (indicative of heart failure), wheezing (indicative of bronchospasm); carvedilol CR(Coreg CR); metoprolol XL (Toprol XL) Check HR and BP before given: bradycardia and HTN

Answer 31

Beta blockers –

Question 32

Supplemental oxygen Drug therapy: Nitroglycerin (reduces peripheral vasoconstriction and oxygen demand; relieves episodic anginal pain; tablet or spray can be administered every 5 minutes for a total of 3 doses; can be given IV – patient may experience a headache); IV Morphine Sulfate (decreases myocardial oxygen demand, relaxes smooth muscle)

Answer 32

Manage acute pain

Question 33

dissolves thrombi in the coronary arteries and restores myocardial blood flow; observe/monitor for any bleeding anywhere; tissue plasminogen activator (t-PA) given IV or intracoronary; Reteplase (Retavase) given IV or intracoronary; Tenecteplase (TNK) given IVP; contraindications exist; given in patients with indications of STEMI by ECG; not indicated for the NSTEMI patient population For STEMI pats

Answer 33

Thrombolytic therapy -

Question 34

Restoration of perfusion to injured area limits amount of extension, improves left ventricular function - descreases mortality rate Complete, sustained reperfusion of coronary arteries after an ACS has decreased mortality rates Observing for bleeding Aspirin 325 mg(antiplatelet) – P2Y12 Platelet Work Glycoprotein (GP) IIB/IIIa inhibitors –

Answer 34

Improve cardiopulmonary tissue perfusion

Question 35

inhibits both platelet aggregation and vasoconstriction, decreases likelihood of thrombosis

Answer 35

Aspirin 325 mg(antiplatelet) – Improve cardiopulmonary tissue perfusion

Question 36

to prevent platelets from aggregating together to form clots. Ex: inhibitors-Clopidogrel (Plavix) or ticagrelor (brilinta).

Answer 36

P2Y12 Platelet Work - Improve cardiopulmonary tissue perfusion

Question 37

administered IV to prevent fibrinogen from attaching to activated platelets at the site of a thrombus; observe for any bleeding

Answer 37

Glycoprotein (GP) IIB/IIIa inhibitors – Improve cardiopulmonary tissue perfusion

Question 38

usually prescribed within 48 hours of ACS if ejection fraction is equal to or less than 40% to prevent ventricular remodeling and the development of heart failure

Answer 38

ACE inhibitors or ARB’s –

Question 39

used for angina to promote vasodilation and myocardial perfusion (not indicated after a MI)

Answer 39

Calcium channel blockers -

Question 40

Reduces the risk of developing recurrent MI, mortality and stroke

Answer 40

Statin therapy-

Question 41

Patients who have recurrent discomfort despite medical therapy or who have ischemia during a stress test may require invasive correction to resolve angina or prevent MI; cardiac cath - ideal, not as invasive and easier recover from; multipl vessels occluded may need do CABG

Answer 41

Treatment for acute MI

Question 42

Tissue plasminogen activator IV (tPa, alteplase) Percutaneous Coronary Intervention (PCI) Percutaneous transluminal coronary angioplasty (PTCA) Coronary Artery Bypass Graft (CABG)

Answer 42

Patients who have recurrent discomfort despite medical therapy or who have ischemia during a stress test may require invasive correction to resolve angina or prevent MI; cardiac cath - ideal, not as invasive and easier recover from; multipl vessels occluded may need do CABG

Question 43

Thrombolytic (fibrinolytic) therapy dissolves thrombi and restores myocardial blood flow. Used in STEMI population. Ideally used within 30 min of arrival to hospital

Answer 43

Tissue plasminogen activator IV (tPa, alteplase)

Question 44

Nonsurgical method of improving arterial flow by opening the vessel lumen. Combines clot removal, angioplasty, and stent placement. Done under fluoroscopic guidance in the cardiac catheterization lab (screen for contrast dye allergy) - help with kidneys by giving extra fluid

Answer 44

Percutaneous Coronary Intervention (PCI)

Question 45

A balloon is inserted in the coronary artery and inflated to open the blood vessel.

Answer 45

Percutaneous transluminal coronary angioplasty (PTCA)

Question 46

Surgical procedure in which occluded arteries are bypassed with the patient’s own venous or arterial blood vessels or synthetic grafts. Open heart

Answer 46

Coronary Artery Bypass Graft (CABG)

Question 47

Eliminate smoking/tobacco use Diet – manage weight Have lipid levels checked regularly Increase physical activity Manage diabetes - can lead to ACS Manage hypertension - can lead to ACS Limit alcohol use Manage stress

Answer 47

CAD prevention

Question 48

The patient states that the chest discomfort occurs with moderate to prolonged exertion. He describes the pain as being “about the same over the past several months and going away with nitroglycerin or rest.” Based on the patient’s description of symptoms, what does the nurse suspect in this patient? A. Chronic Stable Angina (CSA) B. Unstable Angina C. Acute ST elevated MI D. Acute NonST elevated MI

Answer 48

answer: A Rationale: goes away with nitro/rest; about same over period of time

Question 49

Pain that is precipitated by exertion or stress Pain that lasts less than 15 minutes Pain is relieved by nitroglycerin and rest Pain that occurs in a pattern familiar to the patient

Answer 49

Chronic Stable Angina

Question 50

Pain that causes severe activity limitation Pain that is relieved only by opioids Pain may last longer than 15 minutes

Answer 50

Unstable Angina

Question 51

Pain that causes severe activity limitation Pain that is relieved only by opioids Pain may last longer than 15 minutes

Answer 51

Chronic Unstable Angina

Question 52

The patient is prescribed nitroglycerin tablets. What information does the nurse include when teaching the patient about this drug? (Select all that apply) A. If one tablet does not relieve the angina after 5 minutes, take two pills. B. You can tell the pills are active when your tongue feels a tingling sensation. C. Keep your nitroglycerin with you at all times. D. The prescription should last about 12 months before a refill is necessary. E. If pain doesn’t go away, just wait; the medication will eventually take effect. F. The medication can cause a temporary headache.

Answer 52

answer: B, C, F Take up to 3 q5min; see if can get relief; can drop BP significantly from vasodilation affect Keep with them in case experience chest pain

Question 53

Which early reaction is the most common in patients with chest discomfort associated with unstable angina or MI? A. Depression B. Anger C. Fear D. Denial

Answer 53

answer: D Psychosocial (denial is common); say probably nothing and just pulled muscle; teach recognize chest pain and if anything improving it/lasting long period time; any issues need call 911 and get to hospital; early detection is better

Question 54

The patient is admitted for Acute MI, but the nurse notes that the traditional manifestations of ST elevation myocardial infarction (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in the patient? Select all that apply. A. Positive troponin markers B. Chronic Stable Angina C. Non-ST elevation MI (non-STEMI) on ECG D. Cardiac dysrhythmia E. Pulmonary embolus F. Jugular vein distension (JVD)

Answer 54

answer: A, C Troponin – should not be present in blood typ; only in bloodstream if have injury to myocardium Since not see traditional STEMI Might have dysrhythmia, pulm embolus, JVD – but not necessarily

Question 55

A different patient the nurse is caring for starts experiencing chest pain. The patient has a PRN order to perform an ECG for any episode of chest pain. Upon obtaining an ECG there is ST elevation in leads II, III and aVF. – says having a

Answer 55

STEMI; go to cath lab and get vessel opened

Question 56

A thallium scan is scheduled for a client who had a myocardial infarction (MI). What should the nurse explain to the client regarding the reason the scan has been prescribed? A. That it will monitor the mitral and aortic valves B. That it establishes the viability of myocardial muscle C. That it can visualize the ventricular systole and diastole D. That it will determine the adequacy of electrical conductivity

Answer 56

answer: b

Question 57

What is the priority action for the nurse? A. Obtain a complete cardiac history to include a full description of the presenting symptoms B. Place the patient in Semi-Fowler’s or Fowler’s position and start supplemental oxygen C. Instruct the patient to go immediately to the closest full-service hospital D. Immediately alert the physician and establish IV access

Answer 57

answer: B

Question 58

The patient is traveling to the hospital via EMS to be admitted with AMI. He begins c/o extreme fatigue, chest pain, and shortness of breath. BP 84/59, HR 94, RR 28 and shallow. Pulse thready, skin pale and diaphoretic. These symptoms are associated with: A. Decreased lung capacity B. Increased cardiac muscle tone C. Decreased cardiac output D. Increased cardiac output

Answer 58

answer: C Not perfusing

Question 59

The patient arrives to the hospital. Which of the following are appropriate interventions for managing an Acute Coronary Syndrome? Select all that apply. A. Supplemental oxygen B. Nitroglycerin SL C. Morphine IV D. Aspirin PO E. Propanolol PO F. Nifedipine PO

Answer 59

answer: A, B, C, D, E Nifedipine – Ca channel blockers; given for chronic stable angina; not indicated after acute MI MONA – morphine, O2 therapy, nitro, aspirin Give As much O2 as possible Decreasing cardiac O2 demand

Question 60

Which of the following is considered a treatment for managing an acute myocardial infarction? Select all that apply. A. Supplemental oxygen B. Morphine IV C. Aspirin PO D. Tissue plasminogen activator IV E. PCI F. PTCA G. CABG

Answer 60

answer: D, E, F, G Opening vessels

Question 61

The patient received thrombolytic therapy for treatment of acute MI. What are post administration nursing responsibilities for this treatment? SATA A. Document the patient’s neurologic status B. Observe all IV sites for bleeding and patency C. Monitor white blood cell (WBC) count and differential D. Monitor clotting studies E. Monitor hemoglobin and hematocrit F. Test stools, urine, and emesis for occult blood G. Observe the sternal wound site

Answer 61

answer: A, B, D, E, F Following treatment for the MI, the patient is being monitored on a telemetry unit. The nurse knows that patients should be monitored for heart failure post MI.

Question 62

Which of the following is an appropriate recommendation for a patient being discharged from the hospital following an ACS episode? Select all that apply. A. You should utilize resources to help you quit smoking B. You should consume no more than 2g of sodium in 24 hours C. You can return to your usual activities right away D. You will be checking your labs regularly E. You can stop your hypertension medication F. You should find ways to manage your stress

Answer 62

answer: A, B, D, F Smoking has big impact on heart Na helps them from retaining fluid Not able return immediately – may go to cardiac rehab Labs regularly checked that not developing acute coronary syndrome Not want stop HTN med Want resources to help them find ways to manage stress