complex medsurg exam 3

EKG changes for MI

* Q wave (necrosis) is hallmark* T wave inversion (ischemia) ST segment elevation (injury)

symptoms of WOMAN having MI

*epigastric pain and nausea* shortness of breath fatigue and weakness of shoulders and upper arms

ACE inhibitors in MI

*given within 48 hours* prevent ventricular remodeling and the development of heart failure

bypass graft CABG

restores myocardial tissue perfusion by the addition of grafts bypassing the obstructed coronary arteries. vein is removed from body and reinserted to bypass the affected part of the artery

cardiac tamponade

results from fluid accumulation in the pericardial sac

cardiogenic shock signs and symptoms

tachycardia, hypotension inadequate urinary output decreased peripheral pulses and chest pain altered level of consciousness, cool, clammy skin respiratory distress ( crackles, tachypnea)

sign of aspirin toxicty

tinnitus, ringing in the ears

when to give thrombolytic agents and info

within 6 hours of infarction * monitor bleeding times- PT, aPTT, INR, fibrinogen levels, CBC* side effects- thrombocytopenia, anemia, hemorrhage

CABG post-op care

x

signs & symptoms of respiratory failure

*hypoxemia and hypercapnia* hypoxemia- dyspnea, restlessness, apprehension, impaired judgement, motor impairment, FIRST- tachycardia, hypertension, increased CO LATER- dysrhythmias, hypotension, decreased cardiac output hypercapnia- *dyspnea and headache EARLY sign* * if hypercapnia is severe it no longer stimulates the breathing drive, low oxygen level is main stimulant now, administering oxygen without ventilatory support may further reduce drive, causing respiratory arrest*

meds for pulmonary embolism

*prevention* anticoagulant- heparin, coumadin *treat* thrombolytic- streptokinase, urokinase, plasminogen activator (t-PA)

positive pressure ventilation

*push air into the lungs* increases lung volume redistribute fluid from alveolar to interstitial space decreases oxygen demand caused by increased work of breathing

hallmark of ARDS

*refractory hypoxemia* hypoxemia that does not improve with oxygen

pulmonary embolism risk factors

*thrombus in deep veins of legs leading cause* prolonged immobility (trauma, surgery) MI and heart failure obesity old women on oral contraceptives, pregnant, during childbirth

signs & symptoms of pulmonary embolism

*usually develop abruptly, minutes* *most common- dyspnea, pleuritic chest pain* anxiety, tachycardia, tachypnea crackles (rales), cough low grade fever not common, but possible *S3 and S4 gallop*

normal cardiac troponin T value

< 0.20 mcg/mL

nitroglycerin facts

treats *acute acute angina* *DILATION* of venous and arterials take every 5 minutes up to 3 times keep in original amber glass bottle replace every *6 months* * headache, mouth burning and tingling are EXPECTED*

IVC filter

used for pulmonary embolism umbrella like filter in inferior vena cava inserted via femoral/jugular vein, traps large emboli while allowing continued bleed flow. used with recurrent DVT or PE that does not respond to treatment

what is used to evaluate weaning from ventilator

vital signs respiratory rate extent of dyspnea blood gases clinical status

labs for diagnosing MI

CK-MB 0%-3% of total CK *normal value* * greater than 5% is positive for MI* appears- 4-8 hrs after peaks- 18-24 hrs after duration- 72 hrs

care prior to angioplasty PTCA

NPO 8 hr prior to procedure assess for iodine/shellfish allergy signed consent form

complication in ARDS because of PEEP ventilator

PEEP increases intrathoracic pressure which *decreases* cardiac output manifestations of decreased CO- hypotension and compensatory tachycardia. urine output falls and dysrhythmias may develop *record urine output HOURLY. < 30 mL is first sign of decreased cardiac output*

acute respiratory failure

PO2 < 50-60 PCO2> 50 COPD sudden drop in blood oxygen levels w/increased carbon dioxide levels

which of the following findings will help a nurse distinguish angina from an MI? a. angina can be relieved with rest and nitroglycerin b. an MI will be relieved with nitroglycerin c. an MI will have cardiac enzyme levels within the expected reference range d. angina can occur for longer than 30 min

a angina can be relieved with rest and nitroglycerin. an MI will need to be relieved using opioids. cardiac enzymes are abnormal with an MI. angina usually occurs for 15 mins or less.

a client asks a nurse why her provider prescribed 1 aspirin per day. which of the following responses should the nurse give? a. aspirin reduced the formation of blood clots that could cause a heart attack b. aspirin decreases any pain due to myocardial ischemia c. aspirin dissolves any clots that are forming in your coronary arteries d. aspirin relieves any headaches that are caused by other medications

a decreases platelet aggregation. aspirin does not dissolve clots.

which of the following nursing diagnoses is of highest priority for the patient undergoing fibrinolytic therapy? a. ineffective protection b. ineffective health maintenance c. risk for powerlessness d. anxiety

a disrupts the clotting cascade and can lead to potentially serious bleeding. establishing bleeding precautions is vital to preserve physiologic integrity

antidote for neuromuscular blockers

acetylcholinesterase (ACHE) inhibitor *neostigmine (prostigmin)*

risk factors for MI

age gender heredity race smoking obesity hyperlipidemia hypertension diabetes sedentary lifestyle diet

meds for PTCA

anticoagulants antiplatelets IV nitro calcium channel blocker

indications for mechanical ventilation

apnea or acute ventilatory failure hypoxemia unresponsive to oxygen therapy alone increased work of breathing with progressive patient fatigue

diagnosis of ARDS

arterial blood gas- PO2 < 60, respiratory alkalosis CT scan better to use than chest x-ray *pulmonary artery pressure monitoring shows normal pressure* which distinguishes ARDS from cardiogenic pulmonary edema

care post PTCA

vital signs * every 15 min until stable* then *every hour* ECG, continuous cardiac monitoring location, ververity, quality, and duration of pain hourly urine output *> 30ml/hr is renal perfusion*

antidote for coumadin

vitamin K

the nurse caring for a patient returning from a coronary angioplasty with stent placement plans which of the following interventions? a. securing chest tubes to bedding b. maintaining leg extension on the affected side c. discontinuing intravenous lines when taking oral fluids d. treating chest pain with intravenous morphine as needed

b the cardiac catheter used to insert the stent is usually inserted via the femoral artery. the leg is maintained in extension for a prescribed period after the procedure to reduce the risk of bleeding, hematoma formation, or clot formation at the insertion site

post op care and monitoring for aneurysms

bed rest avoid straining or bearing down blood pressure control monitor for signs of thrombosis or embolism cardiac monitoring monitor urine output

PTCA post op

bedrest,

a client who has angina reports that he is not able to make all of the lifestyle changes recommended. which of the following changes should the nurse suggest that the client work on first? a. diet modification b. relaxation exercises c. smoking cessation d. taking omega 3 capsules

c airway, breathing, circulation ABC priority setting framework ensuring that the client has adequate oxygen should be the nurse's first priority.

in reviewing laboratory results for a patient admitted with acute chest pain, the nurse is most concerned about which of the following? a. hematocrit 35% b. AST 65 U/L c. CK 320 U/L d. APTT 35 seconds

c is four times the normal level, is indicative of muscle tissue damage. in the patient with acute chest pain it often indicates acute myocardial infarction

a client who has a diagnosis of an MI reports that dyspnea began 2 weeks ago. which of the following cardiac enzymes should the nurse assess to determine if the infarction occurred 14 days ago? a. CK-MB b. troponin I c. troponin T d. myoglobin

c will still be evident 14 to 21 days following an MI. troponin I levels are no longer evident after 7 days.

myocardial infarction traits

can occur without cause, often in the *morning* after rest relieved only by opioids symptoms last > 30 min associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis

important info about beta blockers

cause bradycardia and hypotension HOLD if apical pulse is < 60

main diagnosis for pulmonary embolism

chest CT with contrast- *diagnoses* pulmonary angiography ECG- tachycardia, nonspecific T wave changes plasma D-dimer- formed during lysis of a blood clot; elevated coagulation studies to monitor therapy- aPTT & PTT (Heparin) INR- coumadin * therapeutic range of 2.0-3.0*

in planning care for the patient with acute myocardial infarction (AMI) the nurse identifies the highest priority goal of care as which of the following? a. stable ECG rhythm b. ability to verbalize causes and of CHD c. compliance with prescribed bed rest d. relief of pain

d relieving pain in AMI decreases sympathetic nervous system stimulation and cardiac work. pain relief is of highest priority, although the other goals also are appropriate for the patient

pain in anginal episode

described as a tight squeezing, heavy pressure, or constricting feeling in the chest *the pain can radiate to the jaw, neck, or arm*

manifestations of ARDS

develops within 24-48 hours *early* dyspnea, tachypnea, anxiety *progressive* increasing respiratory rate intercostal retractions accessory muscles use cyanosis that is unresponsive to oxygen clear breath sounds, that develop crackles and rhonchi *late sign* mental status changes- agitation, confusion, lethargy

ARDS treatment

endotracheal intubation and mechanical ventilation (PEEP settings) *ventilation does NOT cure, supports respiratory until underlying problem is identified and treated* prone positioning fluid replacement enteral or parenteral feeding treat infections heparin

extubation facts

gag, cough, and swallow reflexes must be intact to prevent aspiration. humidified oxygen is provided immediately following removal *inspiratory stridor within the first 24 hours indicates laryngeal edema*

cardiac tamponade signs

happens after CABG *decreased* blood pressure urine output tube output peripheral pulses *increased* heart rate central venous pressure

cardiac tamponade signs and symptoms

hypotension, jugular vein distention muffled heart sounds paradoxical pulse ( variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration)

angioplasty (PTCA)

inflating a balloon to dilate the arterial lumen and the adhering plaque, which widens the arterial lumen. a stent is often placed to prevent restenosis of the artery.

heart failure/cardiogenic shock

injury to the left ventricle can lead to decreased cardiac output and heart failure. progressive heart failure can lead to cardiogenic shock

Beta blockers in MI

metoprolol, coreg decrease the size of the infarct, decease occurrence of ventricular dysrhythmias and mortality rates

drug of choice for pain unrelieved by nitroglycerin and sedation in MI

morphine

which type of nitroglycerin is for acute agnia

nitroglycerin subligneal

respiratory distress syndrome (ARDS)

noncardiac pulmonary edema and progressive refractory hypoxemia, SEVERE form of acute respiratory failure * DOES NOT OCCUR AS A PRIMARY PROCESS, is complication*

nitroglycerin IV facts

only use glass bottles for mixture *non PVC infusion tubing* maintain systolic blood pressure greater than 100 mmHg give AFTER sublingual has NOT worked

MONA

order- Oxygen, Asa (aspirin), Nitro, Morphine

physical assessment findings for MI

pallor, cool, clammy skin tachycardia and/or heart palpitations diaphoresis vomiting decreased level of consciousness

antidote for heparin

protamine

why are ACE inhibitors used for MI

reduce ventricular remodeling following MI *reduce the risk for subsequent heart failure and reinfarction*