Process 3 Exam 4

Ischemic changes

-ST elevation -T wave inversion or flattening -Q wave widening --ST elevation and T wave change will resolve over time if ischemia is resolved and pain is relieved

CKMB

-can be elevated in skeletal muscle injury -begins to increase 4-8hrs; peaks 24hrs after MI ***most specific marker for MI but does not peak until about 24hrs after onset of pain

EKG changes commonly seen in MI

-depression of ST segment -inversion of T segment -ST elevation indicative of ischemia NOT necrosis -Q wave development but up to 50% don't develop Q wave

ECG

-examines left ventricle function -can examine wall function and potential complications -infarcted area will be hypokinetic

A fib

-results in blood pooling in the bottom of the atria (risk for clot formation) -tx: coumadin cardioversion, BB, Diltiazem -if untreated pt symptomatic may result cardiogenic shock

Lab tests for MI

-serum cardiac markers ---myoglobin, troponin, CPK, CKMB -WBC (increase) -ABG's (assess oxygenation levels) -lipid profile -c-reactive protein

Troponin

-specific for cardiac cells ->0.6 indicates MI **I: no longer evident after 7-10 days **T: no longer evident after 10-14 days

Nuclear scans

-thallium used to see blood flow through heart --areas of necrosis will show up as blue or cold spots -Technetium 99m pyrophosphate used and accumulates in necrotic tissue thus showing as a hot spot

continuous cardiac monitoring

5 electrodes -white to the right -snow above grass -smoke above fire

Bradydysrhythmias

<60 -myocardial O2 demand decrease -coronary artery perfusion may be adequate bc prolonged diastole=good -coronary perfusion pressure may decrease if HR is too slow to provide adequate CO/BP= a serious consequence

Sinus bradycardia

<60 healthy athletic person other causes: increase vagal tone from drug abuse, hypoglycaemia, brain injury with ICP usually benign and often caused by pts on BB -pt may have temp pacer or perm pacer

Tachydysrhthmias

>100 -major concern in adult is CAD -shorten diastolic time (amt of time for blood to flow through the coronary arteries to the myocardium) -initially increase CO and BP -increases the work of the heart --palpitations --chest discomfort --restlessness and anxiety --pale, cool skin ***may also lead to HF

Troponin I and T CPK Myoglobin

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?

Perform a 12-lead ECG

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

Evaluating the client for N/V/anorexia

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?

"I plan to slow down if I am tired the day after exercising."

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

"These tests help determine the degree of damage to the heart tissues."

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

-Assess the implantation site for bleeding, swelling, redness, tenderness, or infection. -Teach about and monitor for the initial activity restrictions -Monitor the ECG rhythm to check that the pacemaker is working correctly.

A patient has had a permanent pacemaker surgically implanted. What are the nursing responsibilities for the care of this patient related to the surgery? (Select all that apply.)

Immediate defibrillation

A patient is found pulseless and the cardiac monitor shows a rhythm that has no recognizable deflections, but instead has coarse "waves" of varying amplitudes. What is the priority ACLS intervention for this rhythm?

Watching for bleeding signs

A patient scheduled to have elective cardioversion for AF will receive drug therapy for about 6 weeks before the procedure. What information about the drug therapy does the nurse teach the patient?

Sinus Arrhythmia

A sinus rhythm in which the rate varies with respiration, causing an irregular rhythm.

Pharmacological cardioversion

Amoidarone (IV) Cardiazem (IV) Mexiletine (PO) Sotalol (PO)

Serum Electrolytes

Before administering furosemide to a patient with heart failure, it is most important for the nurse to assess which diagnostic test result?

if taking or have taken any erectile dysfunction meds

Before giving nitro, what should you ask patient?

Malignany hyperthermia tx

Cooling blanket/ice IV fluids Give dentroline IV (muscle relaxant) Get labs (UA)

Preop assessments a nurse should perform

Head to toe Vital signs/baseline data Anxiety level DVT risk Evaluation of surgical procedure Detailed history Allergies

False

Infarction is when cardiac tissue is injured but is not necrotic T/F?

Pain relief improves oxygen supply and decreases oxygen demand.

Prompt pain management with myocardial infarction is essential for which reason?

Necrotic changes

Q waves widening that does not resolve

Asystole

Rhythm: flat Rate: 0 QRS: none P wave: none -cant defib -start CPR and IV meds -hyperthermia protocol for 3 days

Hacking Cough Oliguria during the day Frothy, pink tinged sputum

Symptoms of left sided HF

S wave

The first negative deflection after the R wave -represents late ventricular depolarization

Patient with third-degree heart block on the monitor

The nurse in the coronary care unit is caring for a group of patients who have had myocardial infarction. Which patient does the nurse see first?

Are P waves present? Are the P waves occurring regularly? Do all the P waves look similar? Are the P waves smooth, rounded, and upright in appearance?

The nurse is assessing a patient's ECG rhythm strip and analyzing the P waves. Which questions does the nurse use to evaluate the P waves?

Fatigue Tachycardia Chest discomfort or pain

The nurse is caring for a patient with heart failure. For which symptoms does the nurse assess?

Premature ventricular contraction

The nurse is reviewing a patient's ECG and interprets a wide distorted QRS complex of 0.14 second followed by a P wave. What does this finding indicate?

Myocardial injury and ischemia

The nurse is reviewing preliminary ECG results of a patient admitted for mental status changes. The nurse alerts the health care provider about the ST evaluation or depression in the patient because it is an indication of which condition?

Anxiety or stress Fever Hypovolemia Anemia or hypoxemia

The nurse is taking the initial history and vital signs on a patient with fatigue. The nurse notes a regular apical pulse of 130 beats/min. Which contributing factors does the nurse assess for?

-Report any pulse rate lower than what is set on the pacemaker. -Keep handheld cellular phones at least 6 inches away from the generator. -Avoid sources of strong electromagnetic fields, such as magnets -Carry a pacemaker identification card and wear a medical alert bracelet.

The nurse is teaching a patient with a permanent pacemaker. What information about the pacemaker does the nurse tell the patient? (Select all that apply.)

Crackles in lung bases Difficulty in breathing at rest Disorientation regarding time and place

The patient has heart failure. Which signs or symptoms would prompt the nurse to suspect pulmonary edema?

BNP

The patient presents to the emergency department with pedal edema, crackles on auscultation, and a report of a 10-pound weight gain in 1 week. The nurse suspects heart failure and knows which test will confirm her suspicion?

60-100bpm

The primary pacemaker of the heart, the sinoatrial (SA) node, is functional if a patient's pulse is at what regular rate?

Nitro

Vasodilator Angina (1 tab 3x, 5 min apart) *ORTHOSTATIC HYPOTENSION*

Dependent edema Increase in weight N/V

What are common signs and symptoms of right-sided heart failure?

Atrial depolarization

What does the P wave in an ECG represent?

Dyspnea Heart Block Pulmonary Embolism

What findings are common in a patient with dilated cardiomyopathy?

Less than 0.12 second

What is the normal QRS complex in an ECG?

0.12 to 0.20 second

What is the normal measurement of the PR interval in an ECG

It is commonly the initial rhythm before deterioration into ventricular fibrillation (VF).

What is the primary significance of ventricular tachycardia (VT) in a cardiac patient?

QT interval

What is the total time required for ventricular depolarization and repolarization as represented on the ECG?

ingest 4 low dose aspirin 81mg each

What should a patient do if he has a new-onset angina at home?

"There is no tx for this type of cardiomyopathy."

What statement by a patient diagnosed with dilated cardiomyopathy indicates a need for further teaching?

Prinzmetals angina

What type of chest pain or chest discomfort occurs from a coronary artery spasm and usually occurs after rest?

MI

What type of pain is only only relieved by opioids?

angina

What type of pain is precipitated by exertion or stress?

Angina

What type of pain is relieved by nitro or rest?

MI

What type of pain occurs without cause and frequently occurs in the morning?

Dilated cardiomyopathy Restrictive cardiomyopathy

What types of cardiomyopathy can be treated with heart transplantation?

Weakness and fatigue Dyspnea Decreased urine output

Which clinical manifestations are reflections of sustained tachydysrhythmias and bradydysrhythmias?

Ventricular fibrillation

Which dysrhythmia causes the ventricles to quiver, resulting in absence of cardiac output?

MI

Which factor reflects the most common etiology of heart failure?

my angina will be gone for good

Which statement by a patient scheduled for a percutaneous coronary intervention (PCI) indicates a need for further preoperative teaching?

Bundle Branch Block

abnormal conduction through bundle branches will cause depolarization delay through the ventricular muscle= widening QRS complex QRS: prolonged P wave: norm and same as QRS P-R interval: normal

Ventricular tachycardia

abnormal tissues in ventricles generating a rapid and irregular heart rhythm=poor CO and go into cardiac arrest -cardioversion! -ventricular dysrhythmias more life threatening Rhythm: reg Rate: 140-180 QRS: prolonged P wave: not seen Tx: O2, shock, amiodarone, potassium channel blocker **considered an emergency!

Beta Blockers

antidysrhythmic/antihypertensive reduces afterload and lowers HR

P wave

atrial depolarization -should all look alike -may be positive or negative depending on lead -multiple may indicate dysrhythmia

Atrial flutter

atrial dysrhythmia with ventricular rate around 300 Rhythm: regular Rate: around 110 QRS: usually normal P wave: replaced with multiple F waves (300) P-R interval: not measurable

AV node

bottom of right atria -fires slowing the impulse so blood flows into the ventricles

QRS complex

bundle of HIS, right and left bundle branches, and purkinje fibers depolarize (systole)

Atrial dysrhythmias

causes: -stress, fatigue, anxiety, inflammation, infection, caffeine/nicotine/alc, epinephrine, sympathomimetic, digitalis, anesthetic agents

First degree block

conduction delay through AV node all sinus impulses eventually reach the ventricles, just takes a little longer P-R interval: prolonged (>0.2) TX: none indicated (rarely symptomatic) husband comes home late from work every night at the same time every night

clinical manifestations of malignant hyperthermia

cool patient/ice IV fluids Can see temps up to 113 Muscle rigidity Increase carbon dioxide Decrease O2 saturation Dyspnea Tachycardia Temp lass thing you see

Cardioversion

delivery of electrical impulses to heart synchronized with R wave of ECG -used to correct an irregular rhythm

Defibrillation

delivery of electrical impulses to heart to simultaneously depolarize a large percentage of myocardium allowing the return of normal sinus rhythm -cannot attempt to synchronize as there is no cardiac rhythm other than fibrillation DO CPR UNTIL ABLE TO DEFIBRILLATE

Myoglobin

earliest indicator of injury to cardiac or skeletal muscles -normal: <90, increased within 2hrs of MI no longer evident after 24hrs cardiac marker

Second degree block type 2

electrical excitation sometimes fail to pass through the AV node or bundle of His -impulses blocked at regular or irregular intervals Rhythm: reg Rate: normal/slow QRS: prolonged P wave: 2:1, 3:1 P wave rate: normal but faster than QRS rate P-R interval: normal/prolonged but constant -missing QRS complexes husband unpredictable, never know if he'll come home on time or not at all

R wave

first upward deflection after p wave -early vent depolarization -enlarged: vent hypertrophy, thin chest wall or with athletic physique -reduced: variety of things, obesity

MI

has ST elevation everything is regular or normal

Malignant hyperthermia

hereditary, triggered by anesthesia, doesn't get caught a lot of the time, condition where calcium in muscle cells and damage in CNS

MI better outcomes

if pt is on aspirin, beta blockers, and angiotensin converting enzymes

1. aspirin (if haven't had any yet) 2. nitro 3. O2 (if <94) 4. morphine/pain med

if true STEMI what do you do?

Q wave

initial negative deflection produced by ventricular depolarization -wide and deep in heart attack -0.04-0.1 seconds

12 lead EKG

lead is either positive or negative a lead provides 1 view of the hearts electrical activity -shows 3 heart beats -can be monitored for changes (ischemia) shows 12 different pictures

A Fib

multiple rapid impulses from many atrial foci depolarize the atria in a totally disorganized manner at a rate of 350-600 times a minute Rhythm: irregularly irregular Rate: 100-160 but slower if on meds -no clear p wave -no atrial contractions -loss of atrial kick -irregular vent. response **tx CCB or BB, now cardioversion or ablation therapy **blood thinners 4-6 weeks before cardioversion --diltiazem, amiodarone, BB, if meds don't work then carioversion

Third degree block

none of sinus impulses reach the ventricles -the ventricles are therefore depolarized by a second, independent pacemaker Rhythm: regular Rate: slow QRS: prolonger P wave: unrelated P wave rate: normal but faster than QRS P-R interval: variation **complete AV block hallmark symptom: p wave and QRS complex present but do not sequence in relation to each other -emergency of r/t MI

CPK

normal 30-130 in females; 55-170 males -not specific to cardiac cells

PVC

occurs when a cardiac cell/cell group other than SA node become irritable and fires an impulse before the next sinus impulse is produced -heart depolarized earlier than it should, vents depolarize prematurely -doesnt allow vents to rest between contractions **heart has an extra beat (COPD, MI, CHF) tx depends on care: O2 for hypoxia, K+ for hypokalemia

Sinus tachycardia

originates from SA node -stress, fright, illness, exercise -meds may be required to suppress (BB)

Ventricular Fibrillation

pt becomes faint, loses consciousness, becomes pulseless and apneic -has no BP or heart sounds -considered cardiac arrest **immediate tx by defib is indicated may occur during or after an MI Rhythm: irregular Rate: 300+ QRS: not recognizable P wave: not seen

SVT

rapid stimulation of atrial tissue, p waves may not be visible -occurs in healthy young women Rhythm: regular Rate: 140-220 QRS: usually normal P wave: often in preceding t wave P-R interval: depends on the site of supraventricular pacemaker

Purkinje fibers

responsible for rapid conduction of electrical impulses throughout the ventricles leading to vent depolarization

PSVT

rhythm is intermittent -initiated suddenly by premature complex such as PAC and terminated suddenly with or without intervention

SA node

right atria **hearts primary pacemaker impulses move directly through the atrial muscle and lead to atrial depolarization= p wave

Bundle of HIS

right bundle branch down the right side of the interventricular septum to the apex of the right ventricle then it extends to the right and left bundle branches

Aspirin

should be admined with nitro helps to stop any other clots from forming monitor PTT/INR, bleeding should not give if platelets below 100,000 *watch for GI bleeding/pts with hx of GI ulcers

Second degree block

some impulses reach the vents but others do not bc they are blocked -progressive lengthening of P-R and then failure of conduction of atrial beat Rhythm: regularly irregular Rate: normal or slow QRS: normal or not there P wave: 1:1 for the first 2-4 cycles then 1:0, normal but faster than QRS rate P-R interval: progressive lengthening until QRS complex dropped husband keeps coming home from work late and it gets a little later every night until he just doesn't come home at all

informed consent

top priority for nurses preop period

Sinus arrhythmia

variant of NSR results from change in intrathoracic pressure during breathing -HR increases slighty during inspiration and decreases slightly during exhalation

T wave

ventricular repolarization -inverted or flat: myocardial ischemia, bundle branch block, vent hypertrophy, hypokalemia -tall/peaked: hyperkalemia -flat and notched: pericarditis, hypothyroid, cardiomyopathies