Stressors to Coronary Circulation Part 2/Test 2 Flashcards
(93 cards)
1
Q
CAD is
A
a genetic term for many different conditions that involve obstructed blood flow through the coronary arteries
The most prevalent etiology,though, is atherosclerosis
2
Q
Intima is
A
Lining of artery
3
Q
Media is
A
elastic fibers, smooth muscle
4
Q
Adventitia is
A
loose, connective tissues
5
Q
Atherosclerosis leads to
A
- angina, ACS (build up of plaque)
- is the major cause of CAD
- is characterized by a deposit of atheromas (cholesterol -and lipids) primarily within the intimal wall of the artery
- Lumen narrows with progressive disease
6
Q
Coronary arteries continue to
A
supply oxygen and nutrients to heart until 75% occlusion. Some are more than 75% occluded without symptoms
7
Q
Endothelial Injury
A
by hyperlipidemia, HTN, or other chemical irritants
8
Q
Lipid infiltration
A
From circulation
9
Q
Aging/atherosclerosis
A
Atherosclerotic changes
10
Q
Vascular dynamics
A
like HTN
11
Q
Inflammation/atherosclerosis
A
believed to play a role
12
Q
Coronary Artery Disease…the lumen
A
narrows with progressive disease
The greater the narrowing the more diminished is the blood supply to the heart
13
Q
Coronary artery disease nursing dx
A
Ineffective tissue perfusion: coronary r/t plaque, atheroma, narrowing of the coronary vessels aeb chol 280, LDL 210, BP 160/94, 60 pk year smoke
14
Q
Cholesterol should be
A
<200
15
Q
Normal LDL is
A
<100
16
Q
Normal HDL is
A
> 40
17
Q
Normal B/P is
A
120/80
18
Q
Treatment for CAD
A
Ineffective tissue perfusion
Prevention-rather than treat
- Know your risk factors
- Check lipids annually
- keep cholesterol under 200, LDL under 160
- Treat elevations
- Diet-low cholesterol, modified fat (Salt content)
- Exercise, lose weight
- Keep HTN controlled
- Stop smoking, moderate Etoh
19
Q
Coronary Artery Disease: Preventions
A
- Reduce fat content: meat fat, saturated fats, hydrogenated oils.
- Decrease the red meat in diet
- Increase fish, chix and turkey without skin or frying
- Decrease the # of eggs to 3 or less q week
- limit ETOH to 1/day
20
Q
If detected early, first treatment for CAD may be
A
Meds that help lower blood levels
- Cholestyramine (Questran)
- Colestipol (Colestid)
- Nicotinic acid (niacin)
21
Q
Anti-lipemics
A
- Zocor; Lipitor
- Zetia (Ezetimibe)
- Vytorin (Zocor + Zetia)
22
Q
Other meds to treat coronary artery disease
A
- ASA
- Plavix
- Persantine (dipyridamole)
- Aggrenox- ASA+dipiyridamole
23
Q
Manifestations of Coronary Artery Disease (CAD) Stable Angina
A
- Ischemic chest pain temporary and reversible
- refers to chest pain occurring intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms.
- pain usually lasts only a few minutes and commonly subsides when precipitating factor is relieved
24
Q
Stable Angina:
A
Predictable pattern Precipitating factors St segment depression Treated as outpatient with meds Responsive to rest Short acting 3-5 minutes Infrequent No elevation of Bio markers
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Angina Pectoris
* Lack of enough oxygen for the body's demands for cellular function and metabolism
* Cellular metabolism converts from aerobic metabolism to anaerobic
* By product of lactic acid released instead of water
* Nerve endings are sensitive to this and pain is the response
26
Ischemia
Lack of sufficient blood flow and oxygen to the tissues
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Characteristics of angina
* Chest pain
| * possible areas of radiating pain; neck, jaw, upper abdomen, shoulders and arms
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Assessment for pt with chest pain
PQRST
* Chest pain or discomfort, varied descriptors, substernal?
* Time frame less than 15 min
* P- precipitating events
* Q- quality- dull, aching?
* R- radiation, where does it start? And move to?
* S- Severity- pain scale?
* T- time- beginning, any change, ever experience before?
* Reversible
* Relieved by rest or discontinuation of activity and NTG (nitroglycerin)
29
Treatment focus for stable angina
ABCD
Algorithm
* A ASA/Antianginals
* B Beta blockers/BP
* C Cholesterol and cigarettes control
* D Diet and diabetes
* E Education and exercise
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A is for
Aspirin: inhibits platelet aggregation
| --antiaginals: Nitrates vasodilate
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B is for
Beta blockers
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C is for
Decreased cholesterol and smoking
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D is for
Diet
34
E is for
Education
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Beta blockers
Vessels not constricted from catacholamines, more oxygen available to the myocardium, BP and HR controlled, myocardium has to use less oxygen
36
Ca++ channel blockers-
diltiazem, amlodipine, Norvasc
| *Blocks Ca++ entry into cells of vascular smooth muscle and myocardium
37
Ace inhibitors
decrease water retention and afterload, decreases workload of heart
* enalapril
* lisinopril
* captopril
38
Nitroglycerin
* 0.4 mg SL for chest pain-lie down, take one q 5 min x 3. If no relief, get to ER
* In hospital, take BP, hold if <90 systolic
* Teach- pills good only for 6 months after opening, light sensitive, heat/moisture sensitive, carry with you
39
Ismo/Imdur (isosorbide dinitrate)
| Isordil, Isobid (isosorbide mononitrate)
PO, long acting
| *Topicals Nitro-Dur, Nitro Disc-Wear 12 hours/off 12 hours prevents tolerance, avoid touching
40
Side effects of Nitros
* decreased b/p (so don't give it if b/p is already low)
* pounding HA (is severe)
* dizziness, or flushing
- caution them to lie down when taking NTG and not to rise quickly
- NTG can also be taken before an event known to cause angina (like climbing a flight of stairs)
41
Types of Angina: Stable
* New in onset
* Unpredictable
* Stable may progress to unstable
* Unstable the first sign of CAD
* Risk for total occlusion
* HR changes, increase in b/p
* dysrhythmias- non specific ST changes
* Negative or positive or suspicious biomarkers
* Symptoms longer and need intervention
* Must have medications to relieve the pain
* Consider acute coronary syndrome
42
Associated findings of angina r/t ischemia
* SOB
* Cold sweat
* Weakness
* Anxiety
* N&V
* Indigestion
* Dizzyness
* ST depression-ischemic changes
* More changes in HR or BP with unstable
43
Treatment for unstable angina
* Give ASA and NTG
* EKG- shows non specific EKG changes
* Check biomarkers in ED
* Repeat biomarkers in AM
- -If not elevated do nuclear studies in AM
* If bio markers elevated-admit
* to cath lab to identify occluded vessels
* PTCA, stent possible
44
Pts with positive biomarkers requires
* immediate hospitalization with EKG monitoring and bed rest
* If pain is caused from atherosclerotic plaque rupture, it may block the artery and progress to an MI
* People with atherosclerosis may remain stable if the blockage does not progress beyond 70%
45
Diagnostics for any chest pain
* Bio markers
* EKG
* Stress test
* Chest xray
* Angiography
* Echos
46
Clinical manifestations for chest pain
* Acute coronary syndrome
- -unstable angina
- -NSTEMI, STEMI
* Sudden cardiac death
- -Death occurs within 1 hr of acute symptoms
- -25% of deaths, the death is the 1st sign of CAD
47
NSG DX chest pain
Pain: chest r/t inadequate blood flow with O2 stimulating anaerobic metabolism and release of lactic acid
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Outcomes for chest pain
* Free from chest pain
* Free from myocardial injury
* Will have maximal perfusion to myocardium
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Determine where pt is on the contimuum from CAD to MI
Pt gets an electrocardiogram--either ST elevation or No ST elevation--cardiac markers are either positive or negative. If they are positive MI if negative its unstable angina
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Stemi is
Q-wave MI
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NSTEMI is
non q wave MI
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Review-interventions for angina in general
VS, O2, ASA, NTG, assess for relief, Morphine IV, Do EKG, check bio-markers, if stable discharge, do cardiac workup as outpatient. If unstable, EKG shows non specific ST changes or bio-markers suspicious admit for cardiac work up
53
Remember for ischemia to occur, the artery is
usually 70-75% stenosed
54
Focus of all care
* education for chronic management
* control risk factors
* prevent progression of disease
* may be released within 24 hrs of PTCA and stent placement
* Do follow up
55
Acute coronary syndrome:
* Atheroma has formed
* >70% of vessel lumen
* Rupture of atheroma with more platelet aggregation
- -ischemic pain is not relieved by NTG or rest
- -pain lasts longer than 15 minutes
- -may be first time for chest pain
- -may have had prior episodes of angina
56
Transmural or full thickness associated with
* Abnormal Q wave
| * ST elevation
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Subendocardial or partial thickness associated with:
* Non Q wave
| * ST elevation
58
LAD
anterior myocardium LVentrical failure, cardiogenic shock, death
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RCA
inferior wall- conduction changes, delays, blocks
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Which is worse, LAD or RCA
L anterior descending b/c impacts L ventricle. No blood flow if L ventricle doesn't work
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MI clinical manifestations: PQRST
Pain: P= substernal, left precordial area
Q= heavyness, pressure, tight, constricted
R= frequent, jaw, neck/shoulder, arms, back
S= most severe, viselike, immobilizing unrelieved by rest for NTG
T= lasts longer than 15 minutes
62
Associated hypoxic responses to MI
* VS
- HR increased or decreased BP or decreased respirations
- may develop a gallop, S3 or S4
* diaphoresis
* Dyspnea
* Pulmonary congestion
* Cyanosis
* Lightheadedness
* fainting
* clutching chest
* look of doom
63
Differences between men and women MI
* females have more GI upset
* Often mistake MI for ulcers
* Possible precipitating cause but not necessary
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CK CK MB
Test done-myocardial portion MB-muscle component If >5% rise 4-6 hrs, peak 18-24 hr, fall normal 3 days
65
Cardiac troponin
Protein specific to myocardium- released with injury
66
Troponin I
```
>1.5 mg/ml= MI- initially more accurate
Rise- 1 to 3 hours
Peak 12 hr
Fall stays increased 7-14days
**If T elevated on admission associated with increase in complications for MI patient
```
67
Positive for MI if:
* Biomarkers are elevated
- CK MB >5%
- Troponin increased
* 12 lead shows ST elevation
* Possible Q wave if transmural
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MI- Intervention
1. reduce pain
2. reperfuse myocardium
3. prevent complications
4. prevent remodeling and heart failure
5. rehabilitate
6. educate on control and prevention
69
Acute phase management
Act now!! Squad or ER will;
- assess pain, critical to know when it started
- start oxygen 2-4 liters
- Give ASA
- Give NTG
- Establish IV
- Place on telemetry (12 lead EKG)
- Morphine
70
NTG IV 50 mg in 250 D5% W at 5-6 cc/hr-
dilates all vessels including collateral to better perfuse the myocardium. It does not dilate an occluded vessel
71
Morphine 2-3 mg/IV Narcotic analgesia: Benefits:
* Ease pain
* Ease anxiety
* Decrease preload
* Decrease afterload
* Decrease cardiac workload
* Net result is more oxygen for myocardium
72
Lidocaine: Ventricular antidysrhythmic
Can be helpful for up to 12 hours
*Ventricular dysrhythmias
*PVC's, V-tach, V-fib
--caused by ischemia of the myocardium
Bolus with 75-100 mg IV lidocaine
Start IV drip at 1-4 mg/minute
500 ml D5%W with 2 GM Lidocaine at 15 ml/hour
73
Clot busters
Fibrinolytic therapy
T-PA (Activase) "clot buster"
If the pt comes to the hospital between 4-6 hrs after pain started - Use of IV Fibrinolytic therapy to reperfuse the myocardium and save the muscle
74
t-PA Criteria- Pt must meet these criteria
* Chest pain no longer than 4-6 hrs
* EKG changes consistent with MI
* Not on coumadin
* No recent surgery, CVA, bleeding
* No blood dyscrasias
* Uncontrolled HTN
* Active PUD or bleeding
* Recent CPR > 10 min
* Head traumas
* Systemic diseases- Cancer
75
Side effects of t-PA
* Reperfusion dysrhythmias (PVC's)
- Indicates the myocardium is reperfused. Treat with lidocaine-but may already be infusing
* Bleeding- may have to stop
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Evaluation of t-PA results
| ST segment-
returns to normal-no elevation
* Pt denies chest pain
* Presence of PVCs
- -The clot has been lysed, but the atheroma is still there. Prepare for cath lab
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Heparin
Block extension of the clot
- IV bolus and drip- 4-6000 units per hour
* *follow parameters for anticoagulation
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Management:
```
Cardiac cath
angioplasty
stents
continue to monitor patient for 24 hours
discharge
place on ABCDE program
```
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The Bad MI
-goal is to prevent death of heart muscle and complications
-treat with the same medications except
no TPA
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Nursing interventions for bad MI
-relieve pain initial priority
-oxygen- oximetry
-telemetry-ST changes
-Start IV's- same meds except NO tPA
----Ntg
----Lidocaine
----Heparin
----Morphine
Admit to CCU-prevent further damage and complications
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Monitor
* Activity order
* Diet order
* Fluid managment
* floley and I&O orders, weights
* DVT precautions
* GI management
* NO rectal temps
* Diagnostics, enzymes, EKG
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NSG interventions:
```
Pain
Heart rhythm
Bio markers
VS
O2 stat
Decreasing O2 needs
Improved cardiac output
Improved cardiac output
wean IV medications (ie Lidocaine, Heparin, Ntg. Dobutrex
```
83
Recovery
* Oxygen *Saline lock
* Activity *Oral medications
* Environment *Diagnostics
* Telemetry *12 lead EKG
* I&O *Echo
* Foley *Reevaluations
* Daily weights *Antilipemics
* Diet *Antiplatelet aggregates
* Ted hose *Anticoagulants
84
Acute coronary syndrome: Complications
* Rhythm changes with increased demands
* DVT- Pain in calf with dorsi-flexion
* PE- sudden, sharp, stabbing chest pain
- -SOB, color changes, ABG changes, diaphoresis
* Treat
- -oxygen
- -position/activity
- -diagnostics-VQ
- -Heparin IV-Coumadin
85
MI preventions
* Structured program to strengthen heart
* Prevent reoccurrence
* Exercise "good verses bad"
* Diet
* Lifestyle/habit changes
* Medication compliance/knowledge
* May need prophylactic NTG for anticipated stress, or physically demanding activity
86
Complications of MI
* dysrhythmias
- pvc's
- v-tach
- v-fib
- asystole
- atrial rhythms
- blocks
* Cardiac shock-extension of the MI
* Pulmonary edema
* Pericarditis
87
Pacemaker: inserted into
- give the electrical impulse when the conduction system fails as in blocks and severe bradycardia
- Fixed- always fires at set rate, usually no underlying rhythm
- Demand- fires only when the patient's SA node does not function. May have mixed sinus and pacer beats
- FYI (ICD with Pacer- internal cardioverter defibrillator)
88
Pacemaker: Based on
Chamber paced
- -atrial-only atrial spike
- -ventricle- only ventricular spike
- -Dual chamber A/V sequential -2 spikes atrial and ventricular
89
For a pacemaker you will need prior to surgery:
* Informed consent
* Postop- Monitor for pacer malfunctions
* Wound assessment
* Immobilized shoulder for 48 hours
- -shoulder sling, allows wires to imbed
- -reduced shoulder movement for week
90
After pacemaker teach patient to:
* Pulse check
* Report
- -dizzyness
- -hiccoughs
* Check monthly with manufacturer
* Carry card with pacer info
* Avoid highly electrical equipment
- -hand scanners
- -can never have an MRI
91
Pulmonary Edema
*Weak L ventricle
*Assess for SOB and crackles, decreased O2 sat
*Imbalanced I&O O
92
Cardiogenic Shock
* Failure of the circulatory system to maintain adequate perfusion
* Leads to:
- inadequate oxygenation at the cellular level
- Anaerobic cellular metabolism
- accumulation of waste products in the cells
93
Cardiogenic Shock- know who
is at risk for developing it. Which MI. Know the early cluster of symptoms. Respond to the first signs of early shock.
