ADH3 Exam 2 Combined

CAD clinical manifestations: (3)

1. stable angina

2. unstable angina

3. prinzmetal’s angina

what distinguishes stable (3) from unstable angina (4)?

stable: (3)

1. CP with activity

2. linked to fixed plaque

3. relieved by meds and rest

unstable: (4)

1. CP at rest (and activity)

2. most concerning

3. marks the start of ACS

4. treated as emergency

what causes Prinsmetal’s angina?

• when does it typically occur?

a variant of unstable angina caused by coronary spasms rather than plaque (but atherosclerotic changes are present)

→ occurs @ rest and in clusters b/w midnight and 8AM

What labs would you want to draw for CAD? (7)

1. total cholesterol

2. triglycerides

3. LDL

4. HDL

5. CK (creatinine kinase)

• ⬆= muscle damage

6. CK-MB (mostly in heart muscle)

• ⬆= HEART muscle damage

7. troponin

Whats the gold standard diagnostic test for CAD?

• what does it help determine?

Coronary Angiography (left sided heart cath)

→ determines if PTCA/Stent placement is an option

(Percutaneous Transluminal Coronary Angioplasty aka Percutaneous Coronary Intervention)

What defines Coronary Artery Bypass Grafting (CABG):

• arteries (chest/arms) or veins (legs) are grafted to bypass blocked coronary arteries while cardiopulmonary bypass (CBP) maintains perfusion

  • heart is stopped during this to provide bloodless field to work in

whats a complication of CAD?

Acute coronary syndrome (ACS)

• aka MI

• STEMI vs NSTEMI

Key differences b/w STEMI and NSTEMI:

STEMI: (BAAAD)

1. infarction w/ complete obstruction of blood flow

NSTEMI:

1. ischemia w/ partial obstruction

Aside from classic chest pain, what other symptoms should nurse watch for in MI? (5)

1. epigastric discomfort

2. pain b/w shoulders and jawline

3. diaphoresis

4. syncope

5. SOB

What cardiac biomarkers specific to myocardium and stays elevated the longest? (2)

Troponin I: Normal: < 0.04 ng/mL (MI: > 0.04)

Troponin T: Normal: <0.01 ng/mL

NSTEMI vs STEMI ECG changes:

NSTEMI:

• ST depression

STEMI:

• ST elevation

emergent treatment bundle for STEMI at presentation: (4)

1. aspirin

2. nitroglycerin

3. morphine

4. O2 if < 90%

Whys aspirin given 1st in ACS?

Whats the 2 doses?

Key note when taking aspirin?

Given first to ⬇️platelet aggregation (stops platelets from sticking together= ⬇clot formation)

• initial dose: 325 mg CHEWED (quick onset)

• 2nd: 81 mg indefinitely

NOTE: dont take with other NSAIDS—prothrombic!!

What does nitro do?

What to monitor for?

Contraindications: (2)

Nitro is a vasoDILATOR

Monitor: hypotension, HA

Contraindicated: (2)

1. right ventricular MI

2. use of PDE-5 inhibitors aka Viagra

*life-threatening hypotension

• vasodilation → ↓ preload/BP

How is Nitro given?

Sublingual 0.4 mg q5mins x3

How is morphine used in ACS? (2)

• avoid in what and why?

1. used as adjunct to nitro (also vasodilator)

2. small doses!!!

• 1-2 mg IV q5-15 mins if CP not relived by Nitro

3. AVOID in right ventricular MI

• vasodilation → ↓ preload/BP

whats the door-to balloon time goal for STEMI treated w/ PCI?

90 mins!!!

• Door = hospital arrival

  • not 90 minutes from when symptoms started…

• Balloon = PCI opens the blocked artery

  
  

What are signs of a retroperitoneal bleed/Hematoma??? (RBH) (5)

catheter injures femoral artery → blood leaks into retroperitoneal space (behind abdominal organs)

1. hypotension

2. tachycardia (may be masked by beta blockers)

3. abdominal distention

4. back/groin pain (LATE)

5. flank ecchymosis (LATE)

how would u treat a retroperitoneal hematoma? (3)

1. hold pressure

2. percutaneous intervention w/ balloon tamponade

3. blood transfusion

Indications (2) for fibrinolytic therapy and whats the biggest risk?

indications: (2)

1. pain < 6 hrs with STEMI

2. ST elevation > 1 mm in 2+ leads

risk: BLEEDING!!!

• stop anticoags

• monitor PT/INR

• monitor fibrinogen, urine output, BUN/Cr

• give cryoprecipitate and platelets

• neuro assessments (brain bleed)

• NO punctures, invasive devices

If unable to get to cath lab in time, what would u give for a STEMI? (2)

1. TNKase (tenecteplase)

2. rtPA (Activase)

rural areas

Big 5 discharge meds after ACS? (5)

1. ASA—indefinitely

2. P2Y12 receptor blockers (Plavix/clopidogrel)

• at least 1 yr!!

3. BB—indefinitely

4. Statin—indefinitely

5. ACE-I (or ARB)

• EF < 40% or anterior MI

How should P2Y12 inhibitor typically be continued after ACS, and why does this matter for teaching?

At least 1 year

• Plavix

• continuing dual antiplatelet therapy for full yr is critical

  • if stopped early = stent thrombosis

preload measured on the Right vs Left side (and normals)

→ Right: RAP (right atrial pressure)

• CVP

• normal 2-6 mmHg (nickel)

→ Left: PAOP/PAWP

• normal: 8-12 mmHg (dime)

Explain central line vs swan-ganz catheter:

Central line: Give meds/fluids through a large vein.

• Location: internal jugular, subclavian, or femoral vein.

• Measures: CVP (right atrial pressure)

• Used for: Vasopressors (NE), long-term IV access (antibiotics)

Swan-Ganz/ Pulmonary Artery Catheter (PAC): measures pressures inside the heart and lungs

• Location: passed through the R.A and R.V, and advanced into the pulmonary artery.

• Measures: Pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP), and CO.

• Used for: determining how well heart pumps and understand pressure and blood-flow problems.

whats SVO2 (3)

• hows it drawn?

1. relationship b/w O2 delivery and O2 extraction at the tissue level

2. tells u how pt Utilizes O2

3. % of O2 bound to hgb in blood left over, returning to right side of heart

→ drawn from central line or Swan-Ganz

SVO2 normal value?

High vs low:

normal: > 70% (3 quarters)

• High: 70-100 % (aka normal)

• Low:

1. tissues extracting MORE O2 than normal

2. ⬇O2 delivery

SVO2 < 70% means?

tissue extracting more O2 than normal

• septic

Cause of ⬇DO2 delivery? (3) and Increased O2 consumption? (6)

DO2:

1. ⬇hemoglobin

2. ⬇CO

3. ⬇SpO2/SaO2

VO2:

1. shiver

2. increased work of breathing

3. fever

4. infection

5. agitation

6. nursing care

• giving a full bed bath tires pt out

A- Line measures what? (2)

1. MAP

• < 65 bad = Shock

• > 65 good perfusion

2. BP

How is pressure bag and transducer for A-line set up?

• inflate pressure bag to 300mmHg to prevent arterial blood from escaping!!

  • 0.9 NS

• transducer at Phlebostatic axis!!

Phlebostatic axis location?

• Left atrium @ 4th ICS, MAL

What to NEVER do with an A-Line?

Infuse/flush anything through it!!
- its arterial, not venous

What is Pulses Paradoxus?

• causes (3)

• exaggerated BP variation w/ respiratory cycle

  • large drop (> 10 mmHg) in systolic BP when the patient breathes IN.

    
    

• causes:

1. cardiac tamponade

2. COPD

3. asthma

what 3 meds need A-Lines?

• whats their MOA?

1. NE

2. Vasopressin

3. Phenylephrine

• all cause ⬆BP, CO

  • shunts blood back to heart

What meds need/ doesnt need to be tritiated?

Needs:

1. NE

2. Phenylephrine

Doesnt:

1. Vasopressin

NE (6)

• monitor

1. first line med to raise BP

2. monitor for extravasation

• go into tissue instead of blood stream → necrosis

3. digit/gut ischemia

4. bradycardia

5. HTN

6. renal artery vasoconstriction

• ⬇urine output < 30mL/hr x 2 hrs

titrate!!!

Vasopressin (3)

1. 2nd line—additive

2. also for GI bleeding and Diabetes Insipidus

3. no need to titrate—its a set amount

Phenylephrine

• monitor for: (5)

1. extravasation

2. reflex bradycardia d/t vasoconstriction and ⬆BP

3. arrythmias

4. HTN

5. CP

• titrate!!

Central venous pressure shows what?

• placement?

• normal pressure?

measures RIGHT side of heart preload

• jugular, subclavian, femoral vein

• normal CVP: 2-6 mmHg (nickel)

Low vs High CVP number:

Low: “dry

• fluid volume deficit

High: fluid volume overload

Pulmonary Artery Catheter (Swan-Ganz) measures what?

• right side of heart pressure (PAP)

  • high vs low

normal BP in pulmonary artery: 25/10 mmHg

• high: pulmonary HTN

• low: impaired right side HF

Left side: PAOP/PAWP measures what?

• Left Atrial pressure

  • normal: 8-12 mmHg (dime)

  • 
    

PA catheter key balloon rule?

balloon inflated only when moving FORWARD!! never backwards!!

PAWP/PAOP if high means? (6)

1. fluid volume overload

2. LV failure

3. cardiac tamponade

4. constrictive pericarditis

5. high PEEP

6. mitral stenosis

infective endocarditis key assessment findings: (4)

1. oslers nodes

• red, painful nodes in pads of fingers and toes

2. janeway lesions

• red, painless spots on palms and soles

3. splinter hemorrhages

• tiny blood clots that run vertically under nails

4. murmur

• turbulent blood flow across a heart valve

dx test for infective endocarditis: (4)

1. TTE (transthoracic echo)

• regular echo

2. TEE (transesophageal echo)

• more invasive; goes through esophagus to see backside of heart

3. blood cultures

4. ⬆WBCs

infective endocarditis main tx:

• for how long?

IV abx therapy (PICC line)

• standard tx 4-6 weeks but may be longer for prosthetic valves

major complications of endocarditis:

embolic events!!

• left side: TIA, stroke, kidney, spleen, liver

• right (lungs): pulmonary embolism

nursing actions endocarditis (4)

1. PICC line for long term abx

• standard 4-6 weeks

2. good oral hygiene

• bleeding gums = bacteria entry into blood

3. inform of previous dental/invasive procedures

4. prophylactic abx may be prescribed

myocarditis assessment findings:

1. cardiogenic shock

2. CP

3. SOB

4. palpitations

myocarditis dx tests: (2)

• whats definitive?

1. labs:

• C-reactive proteins (inflammatory marker)

• troponins

• BNP (fluid volume overload)

2. myocardial biopsy: definitive test—reserved for actue cases!

main nursing education for myocarditis:

• avoid strenuous activities!!

  • athletes no competitive sports while inflammation present

  • re-evaluate 3-6 months before continuing sport

complications for myocarditis: (2)

1. dilated cardiomyopathy

• heart chamber enlarges and lose contractility

2. sudden cardiac death in young athletes

pericarditis key findings: (6)

1. pleuritic CP

2. pericardial friction rubs: scratchy sounds that occur w/ each heart beat

• muffled heart sounds

3. pericardial effusion

4. EKG changes: widespread ST Elevation / PR Depression

5. pulses paradoxus

6. cardiac tamponade

how is pleuritic CP different from MI?

Pleuritic CP relieved by sitting up and leaning forward compared to MI

Dx testing in Pericarditis? (2)

1. EKG: widespread ST elevation / PR depression

2. CXR:

• cardiomegaly + clear lung fields = pericardial effusion (fluid build-up in pericardial sac)

Complications of pericarditis? (2)

1. pericardial effusion

• fluid build up >20-60 mL in pericardial space

  • tx: pericardiocentesis

2. pericardial tamponade

• Becks Triad

  • JVD, muffled heart sounds, hypotension

Nursing interventions for Pericarditis: (3)

1. sit up and lean forward

2. ASA, NSAIDs

3. raise HOB relieves SOB

Stenosis definition

• result

• narrowed valve opening = ⬇blood flow

  • ventricular hypertrophy: occurs to generate adequate force to open valve

    • over time the ventricle will fail and progress to HF

Regurgitation definition

• valve leaflets dont properly close = backflow of blood into atrium

  • signs of L/R sided HF develop

Prolapse definition

• valve flaps dont close smoothly (they balloon upward as ventricles contract)

  • progress to regurgitation