ins revision flash cards

5 immediate nursing management for ACS and its rationale

nursing management	rationale
administer iv morphine 5mg as ordered by dr	to reduce cardiac oxygen demand by relieving chest pain
administer oxygen therapy 4L/min via nasal prong as ordered by dr	to improve tissue perfusion and prevent cerebral hypoxia
administer glyceryl trinitrate as ordered by dr	it dilates main coronary artery and increase oxygen delivery to heart. it also dilates peripheral veins and arteries to reduce preload and afterload, resulting in reduction in cardiac oxygen demand
administer aspirin tablet 300mg as ordered by dr	to prevent platelet aggregation, and allow better perfusion to heart muscle
perform continuous cardiac monitoring	to detect for cardiac arrhythmia
perform PCI as ordered by dr	to re-establish coronary perfusion and minimize damage to myocardial tissue

5 complications of PCI

• damage to blood vessels from wire manipulation 

• arrhythmia caused by irritability of cardiac muscle during wire manipulation

• acute stent thrombosis (sudden blockage to new stent) causing immediate ischaemia/myocardial infarction

• plaque rupture during procedure leading to total distal occlusion

• allergic reaction to contrast medium during angiogram

pharm goals for

• aspirin, metformin

• nitroglycerin

• aspirin and prasugrel

• control future risk to prevent further episodes of ACS (antiplatelet, anticoagulant)

• decrease myocardial oxygen demand and increase oxygen supply (nitrate and morphine)

• to prevent further blockage (aspirin, prasugrel)

MOA of nitrates

it dilates the main coronary artery and increase oxygen delivery to heart. it also dilates peripheral veins and arteries to reduce preload and afterload of heart. thus, reducing cardiac oxygen demand

nursing consideration of iv nitroglycerin

nursing consideration	rationale
monitor injection site for extravasation	drug may cause irritation at site of injection
monitor bp continuously via intra-arterial line and heart rate during infusion pump	to detect adverse effects of nitroglycerin such as hypotension and reflex tachycardia. dose of drug can be titrated accordingly
monitor s/s of methaemoglobinaemia such as discoloration (grey, blue, pale) of skin	Early detection of methaemoglobinaemia is needed for prompt intervention. It can be treated with iv methylene blue

MOA and A/E of ACE inhibitor and ARB

pharm class: angiotensin converting enzyme inhibitor

drug name: lisinopril, captopril, enalapril

indication: HTN, HF

moa: inhibits conversion of angiotensin I to angiotensin II. this causes vasodilation and reduces bp. it also lowers lvl of aldosterone, thereby promoting water and sodium loss but enhancing potassium retenton. this prevents further cardiac remodelling from occuring

a/e: angioedema, coughing, hyperkalaemia, kidney insufficicnecy 

pharm class: angiotensin receptor blocker 

drug name: labetalol

indication: HTN, HF

moa: inhibits effects of angiotensin II receptor site. this causes vasodilation and reduces bp. it also lowers lvl of aldosterone, thereby promoting sodium and water loss but enhancing potassium retention. this prevents further cardiac remodelling from occurring

a/e: hyperkalemia, excessive positive, hypotension

MOA and A/E of beta blocker

pharm class: beta blockers

drug name: bisoprolol, metoprolol,  propanalol

indication: HTN, HF 

moa: it blocks beta 1 adrenergic receptor of sympathetic nervous system. this reduces hr, reduces contraction of heart, and decreases myocardial oxygen demand

a/e: bronchoconstriction, bradycardia, hypoglycemia

Immediate management for ventricular tachycardia and ventricular fibrillation 

• assist in defibrillation w 150 joules

• perform cpr immediately

• assist in endotracheal intubation 

• administer iv adrenaline 1 mg every 3-5mins. if pt does not respond after 3 or more shocks, administer iv bolus amiodarone 300mg (or lignocaine 1-1.5mg/kg)

MOA and A/E of adrenaline/epinephrine

pharm class: adrenergic agonist

drug name: adrenaline

indication: pulseless ventricular fibrillation, pulseless ventricular tachycardia 

moa: stimulates alpha 1, beta 1 and beta 2 adrenergic receptors. this causes vasoconstriction and increases bp. it also increases hr and contractability and causes bronchodilation

a/e: extravasation, hyperkalaemia, hypeglycemia, tachycardia

moa and a/e of lignocaine

pharm class: sodium channel blocker

drug name: lignocaine 

indication: ventricular fibrillation, ventricular tachycardia

moa: inhibits sodium from entering into myocardium cells. this reduces depolarization and decreases conduction velocity

a/e: headache, bradycardia, hypotension

moa and a/e of amiodarone

pharm class: potassium channel blocker

drug name: amiodarone

indication: ventricular fibrillation, ventricular tachycardia

moa: inhibits potassium efflux. this delays repolarization and prolongs refractory period

a/e: bradycardia, hypotension, hypo/hyperthyroidism, pulmonary/liver toxicity, photosensitivity

nursing consideration for amiodarone

nursing consideration of amiodarone

• monitor thyroid function test before initiation of treatment and then periodically

• monitor liver function test to look out for elevated liver enzyme

• monitor pulmonary function test and cxr regularly during therapy 

• monitor pt skin for rashes and irritation

upper gi bleeding and lower gi bleeding

upper GI bleeding (please eat good meals, get calcium)

• peptic ulcer

• esophageal and gastric varices

• gastritis and esophagitis 

• mallory weiss syndrome: bleeding from tears in mucosa at junction of stomach and esophagus, usually caused by coughing or vomiting 

• gastro-duodenal erosion

• cancer stomach

lower GI bleeding (big doctor inspect critical illnesses)

• bleeding piles/haemorrhoids

• diverticular disease

• inflammation disease and polyps 

• cancer of colon

• irritable bowel syndrome

Why does the nurse ask the pt if stools are bright red or dark red in colour during physical assignment?/ How would u educate patient about her upper gastrointestinal bleeding

Patient has been taking naproxen and is experiencing side effects of naproxen which is gastrointestinal bleeding as evidenced by her peptic ulcer and her upper gastrointestinal tract bleeding located above the duodenojejunal junction. Patient also has black tarry tools for past 2 days (might change during exam), signifying the possibility of digested blood from upper gastrointestinal tract

immediate/emergency nursing management for gi bleeding

emergency management	rationale
administer fluid resuscitation such as normal saline 0.9% 1000ml as ordered by dr	to replace fluid loss and achieve volume restoration
administer blood transfusion such as packed cells/fresh frozen blood as ordered by dr	packed cells/fresh frozen blood are used for pt who are coagulopathy and bleeding to restore clotting factors
administer oxygen therapy 2-4L/min via nasal cannula as ordered by dr	to improve tissue perfusion and prevent cerebral perfusion

moa and a/e of proton pump inhibitor (prazoles)

pharm class: proton pump inhibitor 

drug name: omeprazole, esomeprazole, pantoprazole

indication: heal ulcer/prevent bleeding 

moa: it inhibits proton pump in gastric parietal cells. this results in gastric acid secretion. This protects the ulcer clot from fibrinolysis, to prevent further bleeding

a/e: nausea and vomiting, diarrhoea, headache, hypomagnesaemia, vit b12 deficiency

pharm goals on medications:

• normal saline

• esomeprazole

• to correct shock for undynamically unstable pt using iv fluids and blood transfusion

• to stabilize pt so that further evaluation and treatment can proceed

scenario 1: if patient blood pressure is 100/60 mmhg, issit okay for to take nitroglycerin?

scenario 2: if patient blood pressure is 85/50 mmhg, issit okay to take nitroglycerin?

scenario 1: yes. the bp is above the threshold of 90/60mmhg. however, as pt bp is 100/60, the use of nitroglycerin must be closely monitored

scenario 2: no, the bp is below the threshold of 90/60 mmhg. this would worsen pt’s hypotension

moa and a/e of sodium polystyrene sulphonate

Pharm class: Cation exchange resin

Drug name: Sodium polystyrene sulphonate 

Indication: Treatment for hyperkalaemia (removes potassium from body)

MOA: it exchanges sodium ion for potassium, particularly in large intestine to enhance excretion of potassium in faeces

A/E: Hypokalaemia, hypernatraemia, hypomagnesaemia, hypocalcaemia, diarrhoea, n&v

moa and a/e of calcium carbonate/calcium chloride

Pharm class: electrolyte

Drug name: calcium carbonate/calcium chloride

Indication: prevention of cardiac toxicity

MOA: calcium regulates threshold potential, thus preventing cardiac toxicity in the presence of hyperkalaemia 

A/E: hypercalcaemia, extravasation

nursing considering of calcium injection

	Nursing consideration	Rationale
Administration	Calcium carbonate Administer bolus slowly, not exceeding 200mg/min unless in emergency situtation	Rapid administration of calcium injection may cause vasodilation, bradycardia, hypotension and arrhythmia
	Calcium chloride Administer slowly, not exceeding 100mg/min unless in emergency situation	Rapid administration of calcium injection may cause vasodilation, bradycardia, hypotension and arrhythmia
	Monitor signs of hypercalcaemia such as weakness, fatigue, headache, n&v	These may be symptoms of hypercalcaemia. Inform dr to review pt
	Monitor iv site for extravasation	Drug may cause irritation at injection/infusion site. Inform dr and administer appropriate medication (hyaluronidase /sodium thiosulphate)
	monitor ecg continuously	Normalization of ecg changes indicates effectiveness of therapy

immediate intervention for PAC 1

Immediate intervention for PAC1 (anything to do w ABC falls under this)

• High flow of o2 via non-breather ask, prepared for intubation

• Sedation and analgesics are limited due to hypotension

• Two large-bore iv started; fluid bolus of warmed crystalloid given and blood transfusion requested

• Needle decompression of left hemithorax performed

• Continuous cardiac monitoring, capnography and repeat neuro checks

nursing management for cardiogenic shock

Nursing management for cardiogenic shock

- intubate pt and place on mechanical ventilator 

• to protect her airway in view of her GCS 3 and to improve tissue perfusion and prevent cerebral hypoxia

- administer iv normal saline 0.9% 500ml over 30 mins as ordered by dr 

• to increase tissue perfusion/bp. monitor closely to prevent further overload which can worsen HF

- administer IV vasoconstrictors/inotropes such as norepinephrine (1mcg/kg/min) or dopamine (5 mcg/kg/min) as ordered by dr 

• to increase cardiac output and perfusion to vital organs by vasoconstriction and increase cardiac contractility

nursing management for septic shock

- Establish iv fluid access to administer fluid resuscitation with crystalloids such as  crystalloid iv normal saline 0.9% as ordered by dr

• fluid resuscitation is critical to restore circulating volume 

- Administer oxygen therapy to 100% via mechanical ventilation 

• To improve tissue perfusion and prevent cerebral oedema

- Administer iv vasoconstrictors such as iv norepinephrine as ordered by dr 

• vasopressors constrict blood vessels, increasing blood pressure and improving perfusion to vital organs

IV dopamine 5 mcg/kg/min, consider switching to IV dobutamine 2 mcg/kg/min when SBP > 85 mmHg.

IV sodium chloride 0.9% 1000 mL stat.

Explain why the doctor prescribed IV dopamine first and then switched to IV dobutamine when SBP > 85 mmHg

IV dobutamine has vasodilation effects, hence if given first, it will cause a further drop in systolic blood pressure initially.
When her SBP improves to > 85 mmHg, IV dobutamine is preferred as it causes less tachycardia as compared to IV dopamine

moa and a/e of norepinephrine/noradrenaline

pharm class: adrenergic agonist

drug name: noradrenaline, norepinephrine

indication: septic shock 

MOA: stimulates A1 and B1 adrenergic receptors. This causes vasoconstriction and increases bp. it also increases hr and cardiac contractility. Critically, alpha effects are stronger than beta

A/E: hypertension, reflex bradycardia, gastrointestinal&peripheral ischaemia, headache, extravasation

moa and a/e of dobutamine

pharm class: adrenergic agonist

drug name: dobutamine 

indication: cardiogenic shock

MOA: 

• stimulates B1 adrenergic receptor, resulting in positive inotropic effect. this causes increase hr and cardiac contractability

• stimulates B2 adrenergic receptor, causing vasodilation

A/E: headache, extravasation, tachycardia, hypertension, hypokalaemia

moa and a/e of dopamine

pharm class: adrenergic agonist

drug name: dopamine 

indication: cardiogenic shcok

MOA: dopamine stimulates b1 receptors, resulting in positive inotropic effect. this increases hr and cardiac contractability. it also stimulates alpha 1 adrenergic receptors at the blood vessels, resulting in vasconstriction 

A/E: extravasation, headache, tachycardia, hypertension

nursing consideration for dopamine/dobutamine

nursing consideration	rationale
monitor ecg continuously	to detect for cardiac arrhythmia, which is an a/e of drug & alert dr for intervention
monitor site for extravasation	drug can cause irritation at injection site
Administer using infusion pump for continuous infusion	To allow flow rate management and prevent drug dosage error
Monitor blood pressure via intra arterial line and central venous line during therapy	To observe for side effects of dobutamine such as hypotension

Explain why did the doctor prescribe PO enalapril 10 mg om and bisprolol 5 mg om to Ms. Kath after myocardial infarction

Both medications are prescribed to slow down cardiac remodeling by blocking neurohormonal activation and the renin-angiotensin-aldosterone (RAAS) pathway. This reduces myocardial oxygen demand and slows down the progression towards heart failure after an episode of myocardial infarction.

nursing diagnosis of heart failure

• impaired gas exchange related to pulmonary congestion and fluid accumulation in alveoli

• risk for electrolytes imbalance (hyperkalemia) related to impaired renal potassium excretion

• excess fluid volume related to impaired renal function and sodium/water retention secondary to heart failure

• activity intolerance related to imbalance between oxygen demand and supply due to cardiac output

moa and a/e of digoxin

pharm class: cardiac glycosides 

drug name: digoxin

indication: additional therapy for HF, AF

MOA: inhibits sodium/potassium ATPase pump in myocardial cells.this increases cardiac contrability but slows HR, causing a more forceful but slower heart beat  

A/E: bradycardia, GI symptoms such  as nausea and vomiting, renal toxicity

moa and a/e of furosemide

pharm class: loop diuretics

drug name: furosemide

moa: inhibits sodium and chloride reabsorption in ascending loop of henle and proximal and distal tubule. as a result, it promotes excretion of sodium, water, chloride, and potassium 

indication: edema caused by HF/renal disease, HTN,

A/E: hypotension, dehydration, renal insufficiency hyperkalemia

Compare and contrast the mechanism of action of nitroglycerin and sodium nitroprusside. Explain why nitroglycerin can be prescribed better

Both nitroglycerin and sodium nitroprusside dilate arteriolar and venous smooth muscle to produce vasodilation and bring down blood pressure.

Nitroglycerin has an additional effect of dilating the main coronary arteries and increasing oxygen delivery to the heart. Hence, it can be prescribed to patients with acute coronary symptoms such as ACS

Briefly explain two (2) nursing assessments to evaluate the effectiveness of IV furosemide

Monitor fluid status and fluid intake/output to look out for a negative fluid balance.

Monitor for reduction of body weight.

Monitor for reduction and normalization of blood pressure

goal of care for hypertensive emergency

to reduce bp to not more than 25% within minutes to hours, then towards 160/100 mmhg within 2-6 hours

moa and a/e of sodium nitroprusside

pharm class: venous and artery vasodilator

drug name: IV sodium nitroprusside 

indication: HTN

moa: it acts directly on venous and artery vascular smooth muscle to produce vasodilation and reduces bp 

a/e: hypotension, dizziness, mathaemoglobinaemia, cyanide toxicity (treatment: sodium nitrate, sodium thiosulphate), extravasation, reflex tachycardia 

nursing consideration in administering iv sodium nitroprusside

nursing consideration	rationale
administer using infusion pump for continuous infusion	to allow precise flow rate management and prevent drug dosage error
dilute w 5% dextrose in water	drug is unable to dilute with other diluents
Wrap infusion set with aluminium foil	drug should be shielded from light to prevent degradation of solution

nursing consideration for sodium nitroprusside

a/e	rationale
monitor injection/infusion site for extravasation	drug may cause irritation ate injection site
monitor bp and hr continuously via intra-arterial line during infusion	to monitor for pt’s response to drug therapy as indicated by decreasing or normalization of bp and detect a/e such as hypotension and reflex tachycardia. dose of antihypertensive drug can be titrated accordingly
monitor s/s of methaemoglobinaemia such as discoloration (grey, blue, pale) and altered mental status. standby iv methylene blue as antidote	Early detection of methaemoglobinaemia is needed for prompt intervention. It can be treated with iv methylene blue
for sodium nitroprusside monitor s/s of cyanide toxicity such as pale skin or SOB. standby cyanide antidote kit	to administer antidote such as sodium nitrate or sodium thiosulfate as ordered by dr  if cyanide toxicity is suspected

Compare and contrast between IV labetalol and IV esmolol in terms of their mechanism of action. Which medication is more effective in lowering blood pressure and explain wh

IV labetalol and IV esmolol are both beta blockers which block beta-1 receptors in the heart, resulting in decreased heart rate and decreased force of myocardial contraction. This helps to reduce blood pressure.

Additionally, IV labetalol is a non-selective beta blocker which also blocks alpha-1 receptors at the blood vessels, resulting in vasodilation. IV esmolol is a selective beta blocker and only works on beta-1 receptors in the heart.

Therefore, IV labetalol is more effective in lowering blood pressure due to additional blockade of alpha-1 receptors in the blood vessel to produce vasodilatory effects, further lowering blood pressure, as compared to IV esmolol.

moa of warfarin

Warfarin inhibits the synthesis of vitamin K-dependent clotting factors, leading to the depletion of factors II, VII, IX, and X. This prevents blood clotting, which may lead to bleeding.

moa and a/e of labetalol

pharm class: A1 and B1 adrenergic blocker

drug name: labetalol 

indication: HTN, HF

moa: blocks beta 1 adrenergic receptors at sympathetic nervous system. this reduces hr, reduces force of cardiac contractability and reduce myocardial oxygen consumption. labetalol also blocks A1 adrenergic receptor at vascular smooth muscle, resulting in vasodilation 

a/e: bronchoconstriction, hypoglycemia, bradycardia, hypotension, dizziness

patient education for hypertensive emergency

• educate patient on the importance of exercise such as brisk walking is generally preferred, swimming or cycling

• educate pt on diet control, moderate alcohol consumption, healthy lifestyle and preventing stress

• ensure that the pt take antihypertensive drug and educate pt on the importance of compliance of these medications

Identify THREE (3) adverse effects of IV furosemide and explain ONE (1) associated nursing consideration for each adverse effect

Adverse effects of furosemide	Associated nursing consideration
Hypotension	• Monitor blood pressure (BP) to look out for a sudden drop in BP and symptoms such as dizziness.
Dehydration and kidney impairment	Monitor renal function for elevated serum creatinine
Electrolyte imbalances such as hypokalaemia	Monitor serum potassium levels and look out for symptoms of hypokalaemia such as muscle weakness and fatigue.

Explain to patient on the development of renal failure, resulting from his heart failure

Heart failure reduces cardiac output, leading to decreased renal perfusion. Poor blood flow to the kidneys activates the renin-angiotensin-aldosterone system (RAAS), causing sodium and water retention. This further worsens fluid overload and renal impairment. This interaction is known as cardiorenal syndrome.

complications of hyperkalaemia

• pulseless electrical activity

• ventricular dysrrhythmia

• cardiac arrest