NUR 546 EXAM I ACS & Delegation questions with complete verified solutions + rationales

Describe the underlying pathophysiology and clinical manifestations of stable angina

Pathophysiology:

- pain usually occurs during activity which results in ischemia (increased O2 demand, decreased supply), and it's relieved by rest or nitrates.

Clinical manifestations of chronic stable angina:

- EKG: possible ST-depression and/or T-wave inversion= ischemia

- EKG returns to normal when symptoms subside

- "The usual chest pain"

- Negative cardiac enzymes

Describe the underlying pathophysiology and clinical manifestations of unstable angina

Pathophysiology:

- Unstable angina is ACS and it results from ischemia. Stable atherosclerotic plaques rupture. This causes platelet aggregation and the formation of a thrombus, manifesting as a UA. There is an imbalance between myocardial oxygen supply and demand due to ischemia.

Clinical manifestations of unstable angina:

- Unpredictable. Chest pain that is new in onset, occurs at rest, or occurs with increased frequency, duration, or less effort than the patient's chronic stable angina pattern. In patients with chronic stable angina, they describe a significant change in pattern of angina, which occurs with increased frequency and with less exertion than previously.

- "squeezing," "burning," "heavy," "tight," "smothering," "choking," "pressure."

- Frequently substernal, left pectoral, or epigastric; may radiate to jaw, L shoulder or L arm.

- May also have dyspnea, lightheadedness, diaphoresis

- Women may feel SOB, anxiety, fatigue

- Diabetics may be asymptomatic due to neuropathy

- Often more severe pain requiring more frequent nitrate therapy, may occur at rest.

- Crescendo nature

- ECG may show ST depression, T-wave inversion, or no changes

- Increased risk of MI

- Negative cardiac enzymes

Define Acute Coronary Syndrome (ACS)

ACS includes the spectrum of UA, NSTEMI, & STEMI. ACS develops when chest pain from ischemia is prolonged and not immediately reversible.

Describe the clinical manifestations and related pathophysiology of NSTEMI (Non-ST Segment Elevation Myocardial Infarction)

Patho:

- Partial occlusion of coronary artery causing cell death

- No ST elevation (possible ST depression & T-wave inversion)

- Positive cardiac enzymes troponin

Manifestations:

- Chest pain, Unstable angina related clinical manifestations. Sympathetic NS stimulation (diaphoresis, increased HR & BP, ashen skin, cool & clammy skin), cardiovascular manifestations (high BP & HR initially, decreased BP due to decreased CO, edema and fluid overload due to impaired LV dysfunction, & abnormal heart sounds), Nausea and vomiting, and fever.

Describe the clinical manifestations and related pathophysiology of STEMI (ST-Elevation Myocardial Infarction)

Patho:

- Total occlusion of coronary artery causing cell death

- ST elevation

- Pathologic Q-wave

- Positive cardiac enzymes troponin

Manifestations Similar to NSTEMI

- Chest pain, Unstable angina related clinical manifestations. Sympathetic NS stimulation (diaphoresis, increased HR & BP, ashen skin, cool & clammy skin), cardiovascular manifestations (high BP & HR initially, decreased BP due to decreased CO, edema and fluid overload due to impaired LV dysfunction, & abnormal heart sounds), Nausea and vomiting, and fever.

List priority collaborative care of the patient with an AMI

Collaborative care

- Sit patient up (if indicated),

- oxygen via NC,

- obtain IV access

- 12 lead EKG & Continuous EKG monitoring

- SL nitro + chew ASA (162-325mg)

- Morphine if nitrates are ineffective

- High dose statin

- ST-elevation: take directly to cath lab within 90 minutes (PCI or thrombolytics- if unable to do PCI)

- ST-depression: take to the cath lab ASAP... if not able.. transfer to ICU, telemetry monitoring, heparin, cardiac biomarkers, Glycoprotein IIb/IIIa inhibitors

Other Meds:

- Beta blockers (-lol): decrease myocardial demand

- ACE inhibitors/ARBs: started within 24h if no contraindications, can prevent HF and ventricular remodeling

- Antidysrhythmic drugs

- Stool softeners

List priority nursing care of the patient with an AMI

- Sit patient upright (if indicated)

- Oxygen

- IV access

- Assess VS

- 12 lead EKG

- Continuous EKG monitoring

- Pain relief (Nitrates first, morphine if needed, continuous evaluation)

- Auscultate heart and breath sounds

- Assess for other manifestations: restlessness, EKG changes, tachycardia, anxiety.

- Provide support: Remain calm, provide realistic reassurance, reduce patient anxiety

- Assessment findings: (midsternal chest pain, sympathetic nervous response, dyspnea/tachypnea, vasovagal response, fever, dysrhythmias, s/s of failing pump)

Describe safe nursing care for the patient with a ventricular assist device

Emergency Management

Potential Complications

Clinical Assessment

Emergency Management

- Seek immediate medical assistance/ VAD Coordinator

- EKG monitoring

- How do we know if they need BLS/ACLS?: Unresponsive, absence of mechanical hum, apnea

- CPR is Controversial (risk of dislodging LVAD) & No mechanical CPR devices

- May Defibrillate or Cardiovert, use code drugs if patient unstable (do not place pads over LVAD)

- Assess for unresponsiveness and apnea before CPR (remember: absent pulse is often normal)

Potential Complications:

- Blood clots, infection, bleeding, tamponade, loss of power, disconnection

Clinical Assessment:

- LVAD model, alarm history, equipment/driveline concerns

- Pulse and BP may not be obtainable manually

- PulseOx may be inaccurate

- Mechanical hum auscultated from LVAD

- Monitoring MAP with doppler

- Monitor: Pump Flow (L/min), INR, fluid status, infection

Describe safe nursing education for the patient with a ventricular assist device

- No baths,

- daily exit site/driveline care

- Sterile dressing changes,

- anticoagulants,

- lab work (INR) if on anticoagulants

- Maintaining power source to device

- Emergency management, ensuring adequate hydration

Delegate tasks that:

Frequently occur

Are considered to be technical by nature

Are considered standard and unchanging

Have predictable results

Have minimal potential for risks

5 rights of delegation

Right task

Right circumstances

Right person

Right direction/communication

Right supervision

General considerations of delegation

- Be understanding, know your delegatee and what their limits are, consider the patient, communicate, and give feedback to the delegatee..

- RN cannot delegate the Nursing Process

What can delegatees do? (indirect vs direct patient care)

- Direct patient care= Meeting the patient's basic needs and associated documentation

- Indirect patient care= Providing for safe and efficient environment - usually in the home