AH2 CH 35 Critical Care of Patients With Acute Coronary Syndromes

The nurse is caring for a client who is scheduled for a percutaneous transluminal angioplasty (PTCA). Which client statement indicates a need for further teaching? "I will be awake during this procedure." "I must lie still after the procedure." "My angina will be gone for good." "I will have a balloon in my artery to widen it."

"My angina will be gone for good." In this situation, further teaching is needed when the client states that angina will be gone after the PTCA. The client's angina may not be eliminated. Reocclusion is possible after PTCA.The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. INCORRECT

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which nursing response is appropriate? "This way you will not need to have a leg incision." "These arteries remain open longer." "The surgeon has chosen this approach because of your age." "The surgeon prefers this approach because it is easier."

"These arteries remain open longer." The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts.Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.

A client with angina has received education about acute coronary syndrome. Which client statement indicates understanding? "Because this is temporary, I don't need medications for my heart." "I need to tell my wife I've had a heart attack." "This is a warning sign and I need to change my lifestyle to prevent a heart attack." "Angina is a temporary blood flow problem that will resolve."

"This is a warning sign and I need to change my lifestyle to prevent a heart attack." The statement by the client that angina is a warning sign and needing to alter lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of progression in unstable angina and/or MI.Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." Which nursing response is appropriate? "You must find someplace to walk." "Where might you be able to walk?" "You are right. Focus more on your diet." "Walk around the edge of your apartment complex."

"Where might you be able to walk?" In this situation, the best response by the nurse is to ask the client where he or she might be able to walk. This calls for cooperation and participation from the client. Increased activity is imperative for this client.Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.

STEMI - ST Elevation MI

-EKG- ST elevation in the affected area of the heart which means MI/necrosis -Diagnosed with EKG, confirmed with Bloodwork •CK-MB, Troponin T, Troponin I -Complete or near complete blockage of affected artery -Can be severe causing severe myocardial damage and death -Urgent heart catheterization STEMI is attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture The thrombus causes an abrupt 100% occlusion to the coronary artery; this is a medical emergency and requires immediate revascularization of the blocked coronary artery.

An LPN/LVN is scheduled to work on the stepdown cardiac unit. Which client will the charge nurse assign to the LPN/LVN? A 69 year old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia. A 66 year old who has a prescription for a nitroglycerin patch and is scheduled for discharge to a long-term care later today. A 60 year old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain. A 62 year old who underwent open-heart surgery 4 days ago for mitral valve replacement and who has a temperature of 100.8° F (38.2° C).

A 66 year old who has a prescription for a nitroglycerin patch and is scheduled for discharge to a long-term care later today. The nurse will assign the 66-year-old client with a prescription for a nitroglycerin patch to the LPN/LVN. The LPN/LVN scope of practice includes administration of medications to stable clients.Third-degree heart block is characterized by a very low heart rate and usually requires pacemaker insertion. The skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability. This client will need medications and monitoring beyond the scope of practice of the LPN/LVN.

Assessment

ABCDE approach Airway- ensure patency Breathing- assess the respiratory rate; oxygen saturation; depth and symmetry of chest expansion Circulation- assess the pulse for rate, rhythm; blood pressure; capillary refill; urine output; general color; attach the patient to a cardiac monitor and perform a 12-lead electrocardiogram Disability - establish conscious level using either AVPU (alert, voice, pain, unresponsive) or the Glasgow Coma Scale Exposure - record the temperature, observe the patient for any external abnormal signs, for example rashes or bruising

A client has come to the emergency department with a new onset of chest pain rated at 7 on a 0-10 scale. Which laboratory test does the nurse anticipate will be ordered? A.CK B.HDL C.WBC D.Troponin

ANS: A Troponins T and I are not found in healthy clients, so any rise in values indicates cardiac necrosis or acute MI. Specific markers of myocardial injury, troponins T and I, have a wide diagnostic time frame, making them useful for clients who present several hours after the onset of chest pain. Even low levels of troponin T are treated aggressively because of increased risk for death from cardiovascular disease (CVD).

The nurse is caring for a female client with atypical angina. Which symptom does the nurse anticipate?(Select all that apply.) A.Vomiting B.Dizziness C.Indigestion D.Aching jaw pain E.Irregular bowel movements F.Decreased patterns of activity

ANS: B, C, D, F Rationale: Many women experience atypical angina which manifests as indigestion, pain between the shoulders, an aching jaw, or a choking sensation that occurs with exertion. Other symptoms may include unusual fatigue, shortness of breath, dizziness, palpitations, generalized anxiety or weakness and flu-like symptoms.

A client presents to the ED and is diagnosed with an acute MI. The client's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response? A."The pain is controlled, so there is no damage." B."It will take years to know the extent of the damage to the heart muscle." C."The medication will dilate the blood vessels so damage will be corrected." D."A heart attack evolves over several hours. We won't know the extent of the damage immediately."

ANS: D Infarction is a dynamic process that does not occur instantly. The MI evolves over a period of several hours. Controlled pain does not indicate that there is no cardiac muscle damage. The medications do vasodilate to prevent further damage. They do not correct damage that has already been incurred.

Which characteristics place women at high risk for myocardial infarction (MI)? (Select all that apply.) Breast cancer Abdominal obesity Family history Increasing age Premenopausal

Abdominal obesity Family history Increasing age Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. Also, a large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI.Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.

The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment data indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 ml of bloody drainage in chest tube over 4 hours

Answer: A Rationale: A heart rate of 50 beats per minute is a risk for decreased perfusion. All other choices are not risks for decreased perfusion or normal parameters.

The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use? A. "The nitroglycerin should tingle when I put it in my mouth." B. "I will keep nitroglycerin in the glove compartment of my car" C. "Since the pills are small, they won't be hard to swallow." D. "The nitroglycerin should relieve the pain immediately."

Answer: A Rationale: Nitroglycerin should tingle when placed under the tongue. If it does not, it is likely old and should be replaced. Nitroglycerin should be kept with the client at all times, not stored in the car. Nitroglycerin is not swallowed; it dissolves under the tongue. Nitroglycerin should begin to work in 5 minutes, not immediately.

The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? A. Incisional pain with decreased urine output B. Muffled heart sounds with the presence of JVD C. Sternal wound drainage with nausea D. Increased blood pressure and decreased heart rate

Answer: B Rationale: Symptoms are part of Beck's Triad, which are indicative of tamponade. Incisional pain is expected. While sternal wound drainage is a problem, it is not an indicator of cardiac tamponade. With tamponade, blood pressure will decrease and the heart rate will increase.

A client who is 9 days post coronary artery bypass graft presents to a follow up appointment. Which client statement requires nursing action? A. "My chest hurts when I sneeze or cough." B. "If I get tired when I walk, then I stop and rest for a bit." C. "I have a bandage on my sternum to collect the drainage." D. "I haven't had my normal appetite since the surgery."

Answer: C Rationale: Sternal wound infections can develop between 5 days and several weeks following CABG surgery. The client should not be experiencing any drainage from sternum at this time, and the need for a bandage to collect the drainage is indicative of sternal infection. This requires immediate notification of the healthcare provider. It is expected that the client will have chest discomfort when sneezing or coughing because of the sternotomy incision. Resting after walking or walking until tired is also an appropriate method to build stamina following surgery. It is not uncommon to have a decreased appetite for 5 -6 weeks following CABG surgery.

The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15-25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased.

Answers: A, C, D, E Rationale: A normal troponin value is anticipated with unstable angina. A troponin value of 0.6ng/mL is elevated and would be indicative of a myocardial infarction. All other assessment data can accompany unstable angina.

The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply A. Denial is a common reaction to chest pain. B. A myocardial infarction can occur in minutes. C. Exercise at least 20 minutes 3 to 4 times per week. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.

Answers: A, D, E, F Rationale: Denial is a common reaction to chest pain that often causes a delay in seeking treatment. Age is a significant risk factor in the development of CAD, with risk increasing with age. Women are more likely to experience atypical symptoms of chest pain such as indigestion. Atherosclerosis is the primary factor in development of CAD. A myocardial infarction evolves over hours, not minutes. Exercise for 20 minutes 3 to 4 times a week is not often enough or long enough.

A 45 year old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? (Select all that apply.) A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight

Answers: B, D, F Rationale: Tobacco use, diet, and weight are all considered modifiable risk factors and should be included in the plan of care

Diagnostic Assessment/Interventions

Cardiac catheterization Percutaneous intervention (PCI) -Balloon angioplasty -Coronary stent Surgery ØCoronary Artery Bypass Grafting (CABG) -PCTA is same as PCI

A client has just returned from coronary artery bypass graft surgery. Which assessment data requires immediate nursing action? Chest tube drainage 175 mL last hour Temperature 98.2° F (36.8° C) Incisional pain 6 on a scale of 0-10 Serum potassium 3.9 mEq/L (3.9 mmol/L)

Chest tube drainage 175 mL last hour The nurse needs to report chest drainage over 150 mL/hr to the surgeon. Although some bleeding is expected after surgery, 175 mL/hr is excessive. This requires immediate nursing action to notify the health care provider.Although hypothermia is a common problem after surgery, a temperature of 98.2° F (36.8° C) is a normal finding. Serum potassium of 3.9 mEq/L (3.9 mmol/L) is a normal finding. Incisional pain of 6 on a scale of 0-10 is expected immediately after major surgery; the nurse would administer prescribed analgesics.

The nurse in the coronary care unit is caring for a group of clients who have had a myocardial infarction. Which client will the nurse see first? Client with third-degree heart block on the monitor Client with dyspnea on exertion when ambulating to the bathroom Client who refuses to take heparin or nitroglycerin Client with normal sinus rhythm and PR interval of 0.28 second

Client with third-degree heart block on the monitor The client with the third-degree heart block needs to be seen first. Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved. This type of block usually requires pacemaker insertion.A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.

Which assessment data cause the nurse to suspect that a client who had a myocardial infarction (MI) is developing cardiogenic shock? (Select all that apply.) Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness Respiratory rate of 12 breaths/min Temperature of 100.4° F (38.0° C) Bradycardia

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/min is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.

The client in the cardiac care unit has had a large myocardial infarction. What assessment data indicates to the nurse the onset of left ventricular failure? Expectoration of yellow sputum Crackles in the lung fields Pedal edema Urine output of 1500 mL on the preceding day

Crackles in the lung fields Signs and symptoms of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields.A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.

Acute Coronary Syndrome (ACS)

Describes patients with unstable angina or acute MI

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? Do not smoke or chew tobacco. Avoid alcoholic beverages. Reduce abdominal fat. Implement stress-reduction techniques.

Do not smoke or chew tobacco. The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) Sharp, inspiratory chest pain Dyspnea Extreme fatigue Dizziness Anorexia

Dyspnea Extreme fatigue Dizziness Many women who experience an MI present with dyspnea, light-headedness and dizziness, and fatigue.Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.

Angina vs MI

EAQs asked some questions

Emergency Care of the Patient With Chest Discomfort

EAQs asked some questions

NSTEMI - Non ST Elevation MI

EKG - can be normal, inverted Twaves or ST depression Diagnosed with combination of blood work and EKG •Creatinine kinase (CK-MB) •Troponin T and I Usually indicative of partial blockage of coronary artery Usually less severe and causes less cardiac damage Causes: coronary vasospasm spontaneous dissection sluggish blood flow due to narrowing of the coronary artery

Nitroglycerin

First try sublingual or spray 3 times by 3 to 5 min interval *** CALL 911 IS PAIN IS NOT RELIEVED 5 MINUTES AFTER FIRST DOSE *** With persistent pain, hypertension or signs of heart failure continue with IV route 10 gm/min Contraindications: hypotension, extreme bradycardia (< 50 beat/min), RV infarction, recently received sildenafil

Chronic STABLE Angina

KINDA "SIMPLE" Discomfort that occurs with moderate-to-prolonged exertion in a pattern that is familiar to the patient. The frequency, duration, and intensity of symptoms remain the same over several months. CSA results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. It is usually relieved by nitroglycerin (NTG) or rest and often is managed with drug therapy.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? Administers oxygen therapy. Provides pain relief medication. Remains calm and stays with the client. Obtains the client's description of the chest discomfort.

Obtains the client's description of the chest discomfort. A description of the chest discomfort must be obtained first, before further action can be taken.Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first. Remaining calm and staying with the client are important but are not matters of highest priority.

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? Planning and participating in a walking program Placing a chair in the shower for independent hygiene Consultation with social worker for disability planning The need to increase activities slowly at home

Placing a chair in the shower for independent hygiene Placing a chair in the shower is an activity performed in phase 1 cardiac rehabilitation. It begins with the acute illness and ends with discharge from the hospital. Phase 1 focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities.Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning. It consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.

The Nurse's Role in ACS

Relieve pain, anxiety, reduce myocardial workload MONA •Oxygen •Aspirin •Nitroglycerine Morphine Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications. -Apply 12 lead or telemetry -Promote cardiac health, self-care -Reduce modifiable risk factors

The nurse is caring for a client 36 hours after coronary artery bypass grafting. Which assessment causes the nurse to terminate an activity and return the client to bed? Incisional discomfort HR 72 beats/min and regular Respiratory rate 28 breaths/min Urinary frequency

Respiratory rate 28 breaths/min The activity should be terminated when the nurse assesses the client's respiration rate of 28 breaths/min. This indicates activity intolerance.Pulse 72 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.

The nurse is assessing a client with chest pain to evaluate whether the client is experiencing angina or myocardial infarction (MI). Which assessment is indicative of an MI? Chest pain brought on by exertion or stress. Substernal chest discomfort relieved by nitroglycerin or rest Substernal chest pressure relieved only by opioids Substernal chest discomfort occurring at rest.

Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI.Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.

After receiving change-of-shift report in the coronary care unit, which client will the nurse assess first? The client who had a percutaneous coronary angioplasty who has a dose of heparin scheduled. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min. The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea.

The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea. The nurse needs to first assess the client with acute coronary syndrome with dyspnea and weight gain. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention.A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate.

To assess if a client has had a myocardial infarction (MI), which lab value will the nurse assess? Troponin Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase Homocysteine and C-reactive protein

Troponin Positive findings for troponin are the most specific cardiac marker used to determine whether an MI has occurred.Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome will the nurse include? (Select all that apply.) Elevated homocysteine levels Truncal obesity Client taking losartan Glucose intolerance Hypercholesterolemia

Truncal obesity Client taking losartan Glucose intolerance Hypercholesterolemia Truncal obesity related to large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (89 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 45 mg/dL (1.17 mmol/L) for men or less than 55 mg/dL (1.42 mmol/L) for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome.Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.

Coronary artery disease

Usually caused by plaque or thrombus ØDamage or reduced blood flow in the vessels in the heart ØCan be asymptomatic, cause angina- stable/unstable, and myocardial infarction- acute coronary syndromes Ischemia- reversible ØInsufficient oxygen is supplied to meet requirements of myocardium Injury Infarction- infarcted (dead) Necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue

Unstable Angina

is chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. An increase in the number of attacks and in the intensity of the pressure indicates UA. The pressure may last longer than 15 minutes or may be poorly relieved by rest or nitroglycerin. Unstable angina can include: new-onset angina vasospastic angina variant or Prinzmetal angina) is chest pain or discomfort resulting from coronary artery spasm and typically occurs after rest pre-infarction angina chest pain lasting < 30 min during a period of 7 days before the acute myocardial infarction Myocardial infarction when myocardial tissue is abruptly and severely deprived of oxygen. When blood flow is quickly reduced by 80% to 90%, ischemia develops 2 types: -NSTEMI -STEMI Patients with unstable angina may present with ST changes on a 12-lead ECG but NO CHANGE IN TROPONIN. Ischemia is present but is not severe enough to cause detectable myocardial damage or cell death.