PED N203- exam 5

Med Surg Test 2 Leave the first rating What is the goal for family therapy? to help the family differentiate in a healthy manner 1 / 108 Flashcards Learn Test Match Q-Chat Beta Created by ejg1005 Terms in this set (108)Original What is the goal for family therapy? to help the family differentiate in a healthy manner What is differentitation? -getting to be your own self-everyone can do their own thing, have their own life, and have different emotions What is fusion/enmeshment? -everyone has to do the same thing-one person controls the emotions of the family What are the 3 things to assess in a family? -family development-family structure-family function What is family development? -what phases are the families going through (ex: marriage, children, sick child, nesting)-what tasks are they adding on What is family structure? who makes up the family What is the family projection process? anxiety and fears of the adult gets projected on to the child (ex: mom is afraid of spiders and now child is too) What is the multigenerational transmission process? patterns that get passed on to the next generation (ex: family violence, alcohol abuse) What is the cycle of violence? tension-building stage, a violent episode, and a calm or "honeymoon" stage Which stage of violence is the victim most willig to leave? battery stage What is the wanted outcome when dealing with family violence? for the abuse to stop (physical abuse needs to be stopped first) What is the number one most common form of abuse in children and the elderly? neglect What are Bowen's 8 principles? -Differentiation-Triangle-Nuclear family emotional system-Multigenerational transmission process-Family projection process-Sibiling position-Emotional cutoff-Societal regression-Spirituality Oppositional Defiant Disorder -pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months.-these individuals do not like rules and will say no to everything What are behaviors of Oppositional Defiant Disorder? -often loses temper-often touchy or easily annoyed-often angry or resentful-often argues with authority figures or, for children and adolescents with adults.-often actively defies or refuses to comply with requests from authority figures or with rules. -often deliberately annoys others-often blames others for his/her mistakes or misbehaviors. -often spiteful or vindictive What defines mild oppositional defiant disorder? symptoms are confined to only 1 setting (either home, school, at works, with peers etc.) What defines moderate oppositional defiant disorder? some symptoms are present in at least 2 settings What defines severe oppositional defiant disorder? some symptoms are present in 3 or more settings What is the difference between oppositional defiant disorder & conduct disorder? conduct disorder is more severe and includes aggression toward people or animals, destruction of property, stealing, and deceit. Conduct Disorder -persistent pattern of behavior in which the rights of others are violated and societal norms or rules are disregarded. -these individuals do what they want and do not care about rules-the behavior is usually abnormally aggressive and can frequently lead to destruction of property or physical injury. What are some behaviors of Conduct Disorder? -aggression to people and animals (forced sexual activity, initiates fights, used a weapon that can cause serious harm)-destruction of property (fire setting, destoyed others property) -deceitfulness or theft (broken into someones house, stolen items) -serious violations of rules (run away from home, stays out all night) What are treatment approaches for Oppositional Defiant Disorder? -Psychosocial Interventions: parent training, group therapy, anger management. -Pharmcological Interventions: Depakote (for anger and aggression) What are treatment approaches for Conduct Disorder? -Psychosocial Interventions: anger managment, parent management skills, problem-solving skills. -Pharmacological Interventions: antidepressanrs, mood stabilizers, stimulants, antipsychotics, anticonvulsants, and adrenergic medications (for aggression, impulsivity, hyperactivity, and mood symptoms) What is ADHD? an inappropriate degree of inattention, impulsiveness, and hyperactivity. How is ADHD diagnosed? symptoms must be present in at least 2 settings and occur before the age of 12. What are behaviors of ADHD? -fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities. -has difficulty sustaining attention in tasks or play activities. -does not seem to listen when spoken to directly. -difficulty organizing tasks and activities. -easily distracted-fidgets with or taps hands/feet-talks excessively -interrupts or intrudes others -difficulty waiting for his/her turn What are medications used to treat ADHD? -Methylphenidate (Ritalin) -Mixed Amphetamine Salts (Adderall) -Nonstimulant Selective Norepinephrine Reuptake Inhibitor, Atomoxetine (Strattera) What are some side effects of taking stimulant medications (ex: Ritalin, Adderall)? -insomnia-appetite suppression-headache-abdominal pain-lethargy What are some side effects of taking Nonstimulant SNRI's? -GI disturbances-reduced appetite-weight loss-urinary retention-dizziness-fatigue-insomnia What is involved in the assessment of a child/adolescent with a childhood disorder? -Collecting data, interviewing, screening, testing, observing and interacting with the child or adolescent. -The initital interview is key to observing interactions among the child, caregiver, and sibilings and building trust & rapport. -Nurses ask the young person about home environment, parents, sibilings, school, teachers, and peers. -Nurses use play activities, therapeutic games, drawings, and puppets for children who have difficulty responding to a direct approach. What is token economy? type of behavior modification in which desired behavior is rewarded with tokens/points and if the behavior is not done there is a consequence. What is the priority nursing intervention for a child with a childhood disorder? Safety What is play therapy? -type of intervention that allows children to express feelings such as, anxiety, self-doubt, and fear through the natural use of play. -may help young patients to access and work through painful memories -Ex: House Tree Person (child draws a house, a tree, and a person and it helps you see what is happening with the family), Expressive Art Therapy What is Bibliotherapy? involves using literature to help the child express feelings in a supportive environment, gain insight into feelings & behavior, and learn new ways to cope with difficult situations. What is schizophrenia? -A psychotic disorder characterized by disorientation and disorganized patterns of thinking.-A split between affect & mood and emotions & behaviors. What are some causes of Schizophrenia? -genetics-environment-pathophysiology-neurodevelopmental-stress vulnerability-dopamine hypothesis-drug induced (LSD) What are the positive symptoms of schizophrenia? -things that a person has but should not-ex: hallucinations & delusions-easier to treat with medications What are the negative symptoms of schizophrenia? -things that the person should have but is lacking-ex: affect, motivation, and social interaction-much harder to treat with medications What is Delusional Disorder? -a type of Schizophrenia Spectrum Disorder-characterized by delusions that have lasted 1 month or longer-characterized by positive symtoms which means this disorder is easier to treat What are symptoms of Catatonic Disorder? -motor immobility-motor agitation-mutism-echolalia (repeating everything that is said)-echopraxia (mimic behaviors that are put in front of the patient) What are symptoms of Schizophrenia? -delusions-hallucinations that can affect all 5 senses-disorganized speech-disorganized behaviors-avolitions = no motivation to move-blunt affect What is the number one problem with patient who are Catatonic? Nutrition and Fluids What are nursing inteventions for a patient who is having hallucinations? -Redirection-Reorientation-Medications -Focus on reality based activities What are nursing inteventions for a patient who is having delusions? -focus on activities and events occuring in the present -help identigy triggers for delusions-work with patients to find & promote helpful coping strategies -never debate the delusional content What is Schizo-affective disorder? schizophrenia combined with a mood component of either depression or mania. What are the type of characteristics of the first born child accoring to Bowen? -more responsible-successful child-caretaker-golden child-goal-oriented What are the type of characteristics of the second born child accoring to Bowen? -lost child-not as much attention given-trying to live up to the potential of the first born What are the type of characteristics of the third born child accoring to Bowen? -family problem-scapegoat What are the type of characteristics of the fourth born child accoring to Bowen? -court jester (provides entertainment)-humor-enlightnes the heavy load What is a triangle according to Bowen? when 2 members experiencing stress bring in another family member, another person outside of the family, or something else to relieve the tension in the relationship What is Nuclear Family Emotional System? patterns of interactions between family members and the degree to which these patterns promote emotional fusion. What is sibling position? birth order and sex are seen as determining facotrs in a person's personality profile What is emotional cutoff? a dysfunctional way in which some family members deal with intense family conflict by using either emotional isolation or geographical distance. What are some common signs of child & elder abuse? -a lot of healthcare visits-injuries do not match the story -vulnerable in some type of way-injuries are in various stages of healing-another person hovering the victim What does TRIADS stand for when it comes to family violence? T = TypeR = Relationship between abuser & victimI = IntensityA = Autonomic (involuntary body response)D = Duration (how lond did abuse go on for) S = Style What are the phases of group? -Pre Orientation-Orientation-Working-Termination What does the Pre Orientation phase of group consist of? -planning phase-what is the goal? are there subgroups? is there a prize?-identifying what the goal of the group is-getting an insight of the members attending group What does the Orientation phase of group consist of? -explain to the members what is going to happen-setting of ground rules/boundaries-advising the length of the group-having members introduce themselves What does the Working phase of group consist of? -leader steps back and is observing-the group is focused on their purpose and they are collectively moving forward towards the end goal-members are starting to connect-group members are taking the initiative What does the termination phase of group consist of? -group is over and it is time for members to leave-summarize what has happened in group -the group can reminisce or discuss what have gotten from the group experience What are the 3 types of roles in group? -task roles (growth producing) -maintenance roles (cohesive)-individual roles (growth inhibiting) What is the function of task roles? -to keep the group focused on the main purpose or function of the group.-they help the group get the work done and keeps the group moving forward. What is the function of maintenance roles? -neither good nor bad. somewhere in the middle. -they can be helpful to keep the group together and they can help keep the group cohesive. -these roles serve to help everyone in the group feel included and worth wiled and they contribute to group cohesion. What is the function of individual roles? purely related to an individual and their own personal agenda What are the different leadership styles? -Democratic-Autocratic-Laissez-faire What is the type of group an RN cannot run? Psychotherapy group What are some clinical manifestations of children having problems? -risk taking behaviors (ex: driving fast, moon-riding)-school changes and problems (ex: decrease in grades)-peer changes -pregnancy -substance use (drinking & drugs) -violence & acting out with knives & guns-sexually acting out-sadness & depression-Acting out VS Acting up-running away-suicide (copycat)-self harm (cutting)-deliquent behavior (not attending school) What is the difference between acting out and acting up? -acting up is when the children are not behaving (more oppositional defiant disorder). -acting out is usually a little more violent, aggressivem and more challenging to other people (more conduct disorder). What are some interventions for childhood disorders? -Behavioral Modification: token tconomy-Medications: antidepressants, antipsychotics, lithium, stimulants -Play Therapy What is the number one killer of women under the age of 40? domestic violence What is covert sexual abuse? -inappropriately talking about sex or body parts-exposure to pornography-being forced to watch sexual acts What is overt sexual abuse? -touching-physical portion What are some items to include in an escape plan for Intimate Partner Violence? -tell patients to identify signs of escalation of violence and to pick a particular sign that will them that "now is the time to leave". -include a destination and transportation in the plan-suggest packing a bag ahead of time with important documents and keep the bag hidden from the abuser-should the victim go through with leaving, give them information for the nearest shelter or safe house. What are some predictors of violence? -hyperactivity-increasing anxiety or tension (clenched jaw or fist, rigid posture, mumbling to self)-verbal abuse-loud voice-stone silence-intense or avoidance of eye contact-recent acts of violence-alcohol or drug intoxication-posession of a weapon or object that may be used as a weapon-isolation that is uncharacteristic What is it like during the tension-building phase? -Abuser: edgy, has minor explosions. May become verbally abusive, minor hitting, slapping, and other incidents begin. -Victim: feels tense and afraid, like "walking on eggshells". Feels helpless, becomes compliant, accepts blame. What is it like during the battery phase? -The tension becomes unbearable. -The victim may provoke an incident to get it over with. -The victime may try to cover up the injury or may look for help. What is it like during the honeymoon phase? -Abuser: loving behavior, such as bringing gifts & flowers and doing special things for the victim. Contrite, sorry, makes promises to change. -Victim: trusting, hoping for change, wants to believe partner's promises. What teaching is important for the nurse to impart regarding medication for ADHD? monitor & manage the timing and administration of the medication What is societal regression? -what is happening in society creeps into the family -comparison of societies response to stress with same response seen in individuals and families. What is Group Content? What is the group about, what is the goal/purpose, location of the group What is Group Process? What is happening in the group: what is happening between the members, and the leaders & the members What are some examples of task role individuals? -coordinator-elaborator-energizer-information giver & seeker-initiator-contributor-opinion giver-orienteer-procedural technician-recorder What are some examples of maintenance role individuals? -compromiser-encourager-follower-gatekeeper-group observer-harmonizer-standard setter What are some examples of individual role individuals? -aggressor-blocker-dominator-help seeker-playboy-recognition seeker-self-confessor-special-interest pleader Yalom said that in order for a group to be therapeutic and a good what must be present? at least one curative facors (helps the group be positive and helps the individuals grow) What are the curative factors? -interpersonal learning-catharsis-instillation of hope-universality-imparting of information-altruism-corrective recapitulation of the primary family group-socializing techniques-imitative behavior-group cohesiveness-existential resolution Storming, Norming, & Performing happens during which phase of group? working phase What is storming during the working phase? refers to the disagreements, attempts at dominance, and personality clashes that must be addressed in order for the work of the group to be done. The authority and lefitimacy of the leader may be questioned in this phase. What is norming during the working phase? when personality clashes and disagreements are resolved and a spirit of cooperation emerges. Team members begin to settle into their respective roles. What is performing during the working phase? when groups have established norms and roles.Group members focus on achieving goals. What is the dopamine hypothesis? the idea that schizophrenia involves an excess of dopamine activity Affectve symtoms refer to what? how a person looks and their mood Cognitive symtoms refer to what? how a person thinks What are symptoms of Delusional Disorder? -delusions (a false belief system)-religiosity-paranoiamagical thinking What are some positive symptoms of Schizophrenia? -motor retardation (slowing of movement)-waxy flexibility (patient allows body parts to be put in bizarre poses)-posturing (striking a bizarre pose) What are Schizophrenia Interventions? -Acute: Antipsychotic Medications, Mileu and Structure, Food & Fluid-Preventative: Psychosocial Rehab, Family Psychoeducation, Employment, Educations, Social Skills Training What are first generation antipsychotics? -traditional or typical dopamine antagonists-primarily affect positive symptoms but have little effect on negative symptoms-higher risk of EPS -EX: Haloperidol Decanoate (Haldol Decanoate) What are second generation antipsychotics? -also known as atypical -serotonin & dopamine antagonists -treat positive symptoms & can help negative symptoms-EX: Clozapine (Clozaril), Risperidone (Risperidal Consta), Aripiprazole (Abilify Maintena) What is the AIMS test? -abnormal involuntary movement scale-assesses whether somebody is struggling with the side effects of the drug. More specfically if they are struggling with tardive dyskinesia. -early detection of tardive dyskinesia Which medications can treat the side effect of EPS symptoms? Anti-Parkinson's medications (Benztropine and diphenhydramine) What is acute dystonia? sudden, sustained contraction of one of several muscle groups, usually of the head & neck. What is Akathisia? motor restlessness What is pseudoparkinsonism? tremor, shuffling gait, drooling, rigidity What is tardive dyskinesia? abnormal involuntary movements What is included in preventive treatment of Schizophrenia? Education of client & family:-help the client find appropriate treatment and the means to pay for it. -learn about the disorder. -Encourage the client to comply with treatment. -Handling symptoms. -Learn the warning signs of suicide. -Psychosocial rehabilitation-Acute inpatient treatment-Learn to recognize signs of relapse -Don's expect too much during recovery-Handling crisis-Support groups What is the role of the group leader during the orientation phase? -describes the purpose of the group-encourages members to get to know each other through their own introduction-points out similarities between members, encourages them to talk to each other directly, and reminds members to be respectful during interactions What is the role of the group leader during the working phase? -facilitates communication, flow of group, and group conduct-encourages focus on problem solving consisten with the purpose of the group-guides and supports conflict resolutions What is the role of the group leader during the termination phase? -ensures that each patient summarizes personal accomplishmets, shares new insights, and identifies future goals-encourages group members to provide positive & negative feedback regarding their experience

Med surg exam 2

P wave depolarization of the atria measure with a piece of paper Rate: Count the p-waves within that 6-second strip and multiple by 10...this is the atrial rate ATRIAL RATE should be AROUND 60-100 BPM for normal sinus rhythm Resemblance: How do they look? Only one p-wave in front of every QRS complex? Are they all identical in how they are round and pointing up and less than 0.12 seconds...less than 3 squares? QRS depolarization of the ventricles Rate: Count QRS complex within that 6 second strip and multiply by 10...this is the ventricular rate ATRIAL RATE AND VENTRICULAR RATE SHOULD BE THE SAME (AROUND 60-100 BPM) for normal sinus rhythm Resemblance: How do they look? A QRS complex is present after each p-wave, no more than 0.12 seconds (less than 3 boxes)..measure at the start of the q wave and end of the s wave x 0.04 T wave ventricular repolarization How to calculate heart rhythm? Distance between R intervals How to calculate heart rate? Count R (QRS complex) within 6 secs of strip then multiply by 10 How to measure PR interval? beginning of P wave to beginning of Q3-5 different boxes How to measure QRS complex? measure from beginning of the Q as it leaves baseline to the end of S- count the number of small squares 1-3 small boxes0.06 sec to 0.10 seconds in length How to measure QT interval? beginning of QRS to end of T wave Should measure: 0.35-0.44 seconds. How to determine the rhythm? -Take a piece of paper-Hold it where the QRS complexes are and mark off the first dot where the R is-Then put another dot on the other R-Finally compare the dots along with the rest to determine if the rhythm is regular How to analyze P waves? -Do you see a p wave in front of each complex?-Do they look the same?-P waves tells us the impulses originate in the atria where it originates from the SA node What should a normal heartbeat be like? -60- 100-Regular-P wave should present & consistent-PR interval 0.12-0.20-QRS: 1-3 little boxes Sinus bradycardia -Too slow-Regular Rhythm-HR is <60-Everything else is normal-SA node is lazy Sinus bradycardia teaching -Avoid Valsalva maneuvers/bearing down-Pacemaker Therapy could be temporary or permanent-Symptoms: chest pain, hypotension, SOB, syncope, or diaphoresis Sinus Bradycardia Treatment -Atropine med: symptomatic-Isoproterenol (Beta-Adrenergic Agonist)-IV fluids-Oxygen Therapy Sinus Bradycardia Nursing Care -Give O2 if ordered by provider-Assess the pt every 5 minutes for: LOC, palpable pulses. BP and HR-Obtain a 12-lead ECG-Administer medications Sinus Tachycardia -Regular Rhythm-Too fast-HR is >100bpm-SA is messed up and can't calm down-Hard to read because its going so fast Sinus Tachycardia Treatment -Avoid things that will cause symptoms-Can administer RBC and IV fluids-Beta Blockers-Calcium Channel Blockers Sinus Tachycardia Patient Teaching -Decrease caffeine intake-Decrease alcohol intake-Stop smoking-Work on stress management Sinus Tachycardia Nursing Care Treating the underlying cause- anemia, etc. Atrial Fibrillation (A-Fib) -Most common-No round P wave-The Gatekeeper (AV Node) blocks many impulses-Multiple impulses that are happening within atria-Atria is quivering: this can cause a clot build up and not allowing the atria from pumping enough blood-There is a decrease in O2-No PR interval to measure A-Fib Treatment Controls The Rate -Calcium Channel Blocker: Digoxin (Cardiac Glycoside) ,Atenolol, Metoprolol, Carvedilol, Sotalol (Beta Blockers) -Diltiazem Controls the Rhythm -Antiarrhythmic-Amiodarone, Dromedaronetran, Dofetilide Clot Prevention -Anticoagulant: Warfarin, Dromedaronetran, Rivaroxaban, Apixaban, Edoxaban, Heparin Other Therapies -Cardiac Ablation -Synchronized Cardioversion PVC- Premature Ventricular Contractions -Chaotic Ventricular activity-QRS Wide and Atypical-Purkinje Fibers are not working properly-This is typically only treated if pt is symptomatic PVC Treamtment Remove the underlying cause:-Stress-Caffeine-Drugs-Electrolyte Replacement to Maintain Appropriate Levels (Mg+, K+) Ventricular Tachycardia ■ Pt starts alert but not for long■ CO drops dramatically■ HR >150bpm■ Rhythm will be variable■ PR interval absent■ QRS is wide and bizarre-Can be pulseless Ventricular Tachycardia Treatment ○ Antiarrhythmic-Amiodarone○ Lidocaine- Anesthetic○ Sodium Channel Blocker Mexiletine○ Electrolyte Replacement: Mg, K■ W/ Pulse: Synchronized Cardioversion■ W/O Pulse (pulseless VT): Defibrillation Ventricular Tachycardia Nursing Care ○ Activate medical emergency team.○ Start and maintain compressions.○ Defibrillate per ACLS guidelines.○ Ensure IV access is available and patent.○ Hang free flowing IV fluids such as 0.9 NS.○ Administer emergency medications as ordered, such as:• Epinephrine• Antiarrhythmic (e.g., amiodarone [Cordarone, Pacerone]) Ventricular Tachycardia Teaching Regarding disease management to avoid future occurrences if patient has return of circulation and survives the event Ventricular fibrillation (V-fib) EMERGENCY■ Need to start chest compression■ Defibrillation■ HR, P waves, PR interval, QRS are all absent■ Ventricles are quivering■ Rhythm is chaotic/undetectable/irregular■ No CO2 V-Fib Treatment ○Chest compression○Defibrillation○Epinephrine (Vasopressor)○Antiarrhythmic-Amiodarone Asystole -Everything is absent-Flatlining Asystole Treamtment ○ CPR○ Epinephrine (to stimulate heart)○ Treat the underlying cause■ Pacemakers■ Transcutaneous pacing■ Permanent Pacemakers● All of the following Pacing Devices have their own setting that is patient specific for the HR and rhythm.● You may not be able to see/detect a P-wave or PR interval● The QRS is usually normal if pacemaker is placed on atria, if placed on ventricle than it can be more wide Asystole Nursing Care ■ Give O2 if ordered by provider■ Assess the pt every 5 minutes for: LOC, palpable pulses. BP and HR■ Obtain a 12-lead ECG■ Ensure the IV access is available and patent. What are causes and risk factors of dysrhythmias? ○ Heart surgery (and procedures) ■ Because of the irritability of the heart ○ Electrolyte disturbances ■ Problems with gas exchange ■ Patients that have respiratory problems can develop dysrhythmia is because once again, anything that affects oxygenation of the tissues can cause dysrhythmias ○ Age ■ Older adults lose their normal pacemaker cells as part of the SA node. ■ May have more fat deposits around SA node ○ Medication toxicities such as digoxin toxicity ■ Myocardial infarction (MI) ■ Hypertension (HTN) ■ Heart valve disease ■ Heart failure (HF) ■ Cardiomyopathy (CM) ■ Infections ■ Diabetes mellitus ■ Sleep apnea ■ Recreational drug use such as cocaine, alcohol, or tobacco What is Caridoversion? ■ Controlled electrical discharge of energy at the peak of the R wave■ For tachydysrhythmias with a pulse■ Place pads anterior/posterior on the patient "sandwiching"● SVT and AFL start between 50 and 100 J, then slowly increases to 200 J● AF starts between 120 and 200 J, then increases until maximum energy energy of 200 J.● VT with a pulse starts nat 120-200 J What is Defibrillaton? ■ Uncontrolled electrical discharge of energy anywhere during the cardiac cycle■ For tachydysrhythmias without a pulse■ Place pads anteriorly (apex/sternum) but can be used anterior/posterior■ VT/VF = 200 J What should you teach your patient about a Pacemaker? ■ Use of pacemaker is typically when someone has bradycardia■ There can be transcutaneous on top of the skin or a permanent pacemaker that is under the skin and electrodes are placed through the heart to the atria or ventricle or both■ For transcutaneous you will see a spike before the QRS complex■ For permanent pacemaker you will see a spike for atria right before the P wave and for ventricle right before the QRS complex, you can also see both in an EKG What should you teach your patient about AICD Therapy? ■ Is an implantable cardioverter-defibrillator or automated implantable cardioverter defibrillator is a device implantable inside the body■ Able to perform cardioversion, defibrillation, and pacing of the heart■ Capable of correcting most life-threatening cardiac arrhythmias What does a cardiac catheterization (Angiography) do? ○ This is to look at the coronary arteries and the degree of atherosclerosis What is the nursing care related to Cardiac Catherization Pre-Procedure? ■Establish baseline vital signs■Review blood work focusing on renal studies■Complete pre-procedure checklist that includes obtaining height and weight and ensuring patient has been NPO■Administer pre-procedure hydration■Check glucose levels while NPO■Anticipate holding diabetic medications What is the nursing care related to Cardiac Catherization Intra Procedure? ■ Psychological support of the patient during the procedure to help ease fears■ Vigilant cardiac monitoring during the procedure to observe for dysrhythmias■ Readiness and ability to respond with advanced cardiac life-support interventions should a lethal dysrhythmia occur What is the nursing care related to Cardiac Catherization Post Procedure? ■Maintaining the patient on flat bed rest for 2 to 6 hours to prevent stress on the insertion site, which may cause bleeding■Observation of the catheter insertion site for bleeding or hematoma formation■Cardiac monitoring and frequent vital signs■Monitoring the patient for chest pain■Assessing for signs of stroke, such as confusion, weakness, or slurred speech■Monitoring peripheral pulses, color, and temperature in the affected extremity■Monitoring urine output secondary to the osmotic diuresis caused by the contrast dye■Maintaining sufficient oral and/or IV fluid intake to ensure renal clearance of the dye and to maintain adequate hydration status■Obtain blood work to assess renal function, hemoglobin/hematocrit, and coagulation studies What is an Echocardiogram? ○ This shows chamber size, hypertrophy, valve dysfunction, ejection fraction, and amount of regurgitated flow Pre-Procedure nursing care for a patient getting an Echocardiogram? ■ When scheduled for a TEE, patients are instructed not to eat or drink for at least 8 hours prior to the procedure. Small sips of water with medications are the exception. Intra Operative & Post Operative nursing care for an Echocardiogram? ■ Patients are given sedation for the test, so they should be instructed to have someone with them who can drive them home. What are the modifiable risk factors for CAD? ■ Cigarette Smoking■ Hypertension■ Diabetes■ Obesity: BMI over 30■ Sedentary lifestyle: exercise 30 minutes a day, 5 days a week■ Stress■ Excessive Alcohol Intake What are the nonmodifiable risk factors for CAD? ■ Race: more likely for white male rather than AA or Hispanic. Female AA higher than white, Native Americans are highest risk■ Heredity■ Age: as age increases risk increases■ Gender: post menses womenGenetics/family history What is angina? ○ Chest pain and is the main sign of an MI because of the decreased oxygen flow to the myocardium. Indicator of hypoxia or ischemia of myocardial tissue What are some nursing assessments for angina? ■ Check O2 SAT level and if low, administer oxygen. ■ Pain assessment ■ Administer meds ■ Labs/diagnostic tests ■ *Perform a 12-lead ECG to help determine if the patient requires perfusion therapy or not to treat the cause of chest pain. Also may indicate an MI. What are the treatments for an MI? *First priority-Put the patient on oxygen immediately upon arrival at the hospital. ○ Medications ■ NITRATES: Nitroglycerin (Vasodilator)- helps to open up coronary arteries to get more blood flow through the arteries so that more oxygen gets to the myocardial tissue. ■ ANTIPLATELET: Aspirin (Antiplatelet Agent)- helps decrease platelet aggregation and prevent clots from not becoming larger. ■ NARCOTIC: Morphine (Opioid)- analgesic, may need this if nitroglycerin did not help relieve pain but needs to be given with caution because some patients may have a worsening outcome because morphine can actually mask worsening of the MI ○ Reperfusion Therapy ■ PCI (*preferred method) within 90 minutes. ■ Fibrinolytic therapy- *if it is not contraindicated. Clot busters that help to break up the clots ■ Surgery (CABG) Coronary Artery Bypass Graft Surgery What are the priority assessments for an acute MI? ○ Check O2 SAT level. If low, administer oxygen. ** Monitor oxygen level. Monitor vital signs especially BP and pulse.○ Administering medications. Elaborated in treatments for acute MI○ Assess for chest pain not relieved by rest or medications. What are the priority labs to be drawn for an acute MI? ○ *Troponin preferred laboratory test for MI q 6 hrs -Troponin will be elevated or very high when there is a significant injury and death to cardiac cells. -Set of 3 different sets are drawn: Serial enzymes ○ Other labs drawn: -Total cholesterol--Triglycerides -LDL -HD -CK. Elevations in their total cholesterol, triglycerides, and LDL levels aka lipid profile. -Total cholesterol level (200 mg/DL or less), LDL: <100mg/dL and HDL:>40-60mg/dL. PTT: 10-13seconds, INR: <2.0, platelets: 150,000-400,000mc/L, troponin: <0.4. Look at PT and INR when monitoring anticoagulant warfarin. What diagnostic tests are a priority for a Acute MI? 12-lead ECG- *Preferred diagnostic test for acute MI. ECG changes, in an acute MI, there is significant T segment elevation, very tall, like a hill. Change in Q wave: a very deep Q wave that drops very far below the isoelectric line and that is pathological and can indicate an acute MI or a previous MI. You will see T wave inversion where it is turned upside down, with ischemia. When ischemia has been prolonged, necrosis occurs and you will see an elevation in the ST segment known as a very elevated ST segment aka ST elevated, MI, or STEMI. These are really bad signs indicative of an acute MI. ○ Exercise stress test ○ Imaging studies (Thallium scan or Echocardiogram) ■ Thallium scan- the patient is injected with a radioactive type substance and then pictures are taken to see where the dye is taken up in the heart by the vessels and they can determine if there are cold spots in the heart or areas where there is decreased perfusion. ■ Echocardiogram- uses sound waves to evaluate wall motion as well as the valvular motion within the heart. ■ Coronary angiography- Left sided heart catheterization is performed, utilizing one of the major arteries such as the femoral artery, where the catheter is threaded up, where dye can be injected into the coronary arteries and then the degree of blockage or occlusion can be evaluated. So that gives very specific information about blockages. - IV access, consent, allergies, Page 557. Look at Nursing care*** Nursing implications, pre procedure, intra procedure, post procedure. Left side catheterization looks at the coronaries. What are the Interventions done prior to sending the patient off for cardiac catheterization? -IV access-Consent-AllergiesPage 557. Look at Nursing care*** Nursing implications, pre procedure, intra procedure, post procedure.Left side catheterization looks at the coronaries. What is the nursing care for a Percutaneous Transluminal Coronary Angioplasty (PTCA) also referred to as "PCI" ? *Main type of treatment that will be utilized.○ Monitored Anesthesia Care Used for sedation: Conscious sedation-Balloon-tipped catheter is advanced through an artery to the occluded coronary vessel and then inflated to open the vessel or help compress the plaque into the walls of the vessel to open it up. A stent may be left in place to maintain vessel patency. *For most patients, a stent will be placed. What are the complications for a PTCA (PCI)? ■ Bleeding at insertion site ■ Abrupt vessel closure ■ Dysrhythmias ■ Rupture of the artery What nursing care assessments should you do after the CABG procedure (Bypass Surgery)? ● Monitor HR and BP continuously with arterial catheter every 15 minutes then every 4hrs when pt is stable● Hemodynamic monitoring● Continuous cardiac monitoring● Assess heart tones● Monitor breath sounds and continuous oxygen saturation● Monitor core temperature every hour● Assess LOC, pupils, and responsiveness● I&Os every hour- notify provider if less than 30 ml/hr for 2hrs● Assess skin temp & color, pulses, edema, & cap refill● Monitor chest tube output, color, volume hourly● Assess H&H, electrolytes, Creatinine, BUN, glucose What nursing actions should you do aftersomeone goes through Bypass Surgery? ● Maintain tight BP control● Administer fluids and medications● Rewarm pt slowly with warm fluids, blankets, or airflow devices● Administer pain med and continuous sedation meds● Pulmonary hygiene while intubated- reposition frequently, oral care every 4 hrs● Pulmonary hygiene after intubation- IS, C&DB every 1-2hrs What teaching should you give to your patients after they had a CABG? ● Signs of infection● Weight limits of 10lbs, don't raise arms overhead. Bend at the waist, or do strenuous activities● Participate in cardiac rehabilitation What are some expected changes that occur in the elderly that are related to neurologic functioning? ○ Motor changes: slower movements, slower response times ○ Sensory changes: visual disturbances and hearing disturbances ○ Cognitive changes: slower processing time, longer response time ○ Acute mental status change can mean infection What to assess for CN 1? Olfactory-smell: bring coffee, oranges, or vanilla and ask if they can name the smell How to assess for CN II? Optic: vision■ Snellen's chart- ask pt to read a book, assess peripheral vision How to assess CN III? Oculomotor: eye movement up, down, lateral, opening of eyelid, pupil constriction■ Darken the room, check pupils with flashlight- should be rapid and pupils equal How to assess for CN IV? Trochlear: Medial and downward medial eye movement■ Ask pt to follow finger with eyes as it is moved towards their nose How to assess for CN V? Trigeminal: touch, temperature, and pain sensation from upper and lower face, chewing■ Assess facial sensation for light touch, sharpness, and dullness- use fingertips and soft cotton. Make sure to check all areas of the face. Ask pt to clench teeth and attempt to move jaw side to side How to assess for CN VI? Abducens: lateral eye movements■ Ask pt to follow finger by moving eyes laterally How to assess for CN VII? ○ Facial: taste, facial expressions■ Ask pt to smile, frown, puff cheeks, raise eyebrows, close eyes tightly How to assess for CN VIII? Vestibulocochlear: hearing and balance■ Check for hearing by rubbing fingers close to pt ear. Check balance and ability to walk straight. Check for nystagmus How to assess CN IX? Glossopharyngeal: taste, touch, pressure, pain and temperature■ Check gag reflex with tongue depressor. Ask pt to swallow How to assess CN X? Vagus: taste, sensation of hunger, fullness, and GI discomfort, bronchoconstriction■ Assess gag and ability to swallow. Check voice for weakness and quality, ask pt to say "ah" How to assess CN XI? Accessory: swallow, head, neck, and shoulder movements■ Ask pt to shrug shoulders against resistance. Ask pt to turn head from side to side with resistance. How to assess CN XII? Hypoglossal: tongue movement with speech, food manipulation and swallowing■ Ask pt to stick out tongue and move it side to side What lab tests should you get for a stroke? -CBC-Platelets-Electrolytes-BUN/Cr-Lipid studies What Radiologic Imaging studies should someone with a stroke recieve? CT scan- INVASIVE ○ Get BUN and Cr levels before doing this because the dye cannot be given to anyone with impaired renal function ○ Check for an iodine allergy ○ Assess for DM and see if they are taking Metformin- contraindicated ○ Provide pt education before procedure- what to expect and for post procedure- what to do MRI scan -NOT INVASIVE ○ Screen the pt for any metal objects and remove them ○ Provide pre and post procedure education Doppler Ultrasound of carotid arteries Cerebral angiography - INVASIVE ○ Preprocedural teaching ○ Instruct pt not to eat or drink anything after midnight before the procedure ○ Tell pt procedure takes 1hr-2hrs ○ Tell pt IV will be placed pre procedure ○ Tell pt that IV contrast can cause a warm, flushed feeling ○ Check all pulses, VS, and neurologic assessment before procedure to evaluate any changes that may happen ○ Assess for allergy to dye ○ Evaluate BUN and Cr b/c dye is nephrotoxic ○ Assess pt if they use anticoagulant ○ Post procedure teaching ○ Monitor VS, neurological status, assess puncture site and pulses distal to catheter insertion site every 15 minutes for first hour, then every hour as ordered ○ Maintaining pressure on arterial puncture site for at least 15-20 minutes after removal to avoid bleeding or hematoma ○ Make sure pt keeps leg straight and on bedrest for 3-12 hours as ordered to avoid bleeding or hematoma ○ Maintain IV fluids ○ Monitor for bleeding, hematomas, or infection at catheter site and renal function (BUN, Cr) Echocardiography ○ TTE (transthoracic) NOT INVASIVE ○ TEE (transesophageal) INVASIVE What is the clinical presentation of a stroke? ■ Sudden weakness (may see more on one side of the body)■ Dizziness and loss of coordination■ Difficulty talking■ Facial droop■ Sudden vision problems■ Sudden and severe headache What is the treatment for stroke? Medications ■ Thrombolytics- clot busters (ischemic strokes) ■ Anticoagulants ■ Antiplatelet agents ■ Lipid lowering agents ■ Antihypertensive ■ Calcium channel blockers ■ Analgesics ■ Antianxiety drugs ■ Stool softeners ■ IV fluids- colloids, crystalloids Surgical Management ■ Thrombectomy- clot retrieval device with stent (ischemic stroke) ■ Aneurysm clipping (hemorrhagic stroke) ■ Aneurysm coiling (hemorrhagic stroke) ADVERTISEMENT

Med surg exam 3

Med serg week 7

Review modifiable and nonmodifiable risk factors for CAD/ MI same for MI 1 / 83 Flashcards Learn Test Match Q-Chat Beta Created by ejg1005 Terms in this set (83)Original Review modifiable and nonmodifiable risk factors for CAD/ MI same for MI MI/ CAD Modifiable Risk Factors: • Cigarette Smoking (any tobacco products/ marijuana regularly, vapes, e-cigs) **Never teach to decrease, but to STOP smoking.** • High total cholesterol, high LCL levels, low HDL levels, high triglycerides *lower sodium/ fatty food consumption) • HTN • Diabetes (neuropathy → don't always feel pain) • Obesity (BMI over 30) • Sedentary lifestyle (exercise minimum of 30 mins/day - 5 days a week) • Stress (lowers catecholamine levels cause increased workload on the heart; epinephrine & norepinephrine) • Excessive alcohol intake (4-5 drinks per week) • Unhealthy diet MI/ CAD Nonmodifiable Risk Factors: • Race (caucasian males & African American females - higher incidence of coronary artery disease) • Heredity (major risk factor; higher incidence of heart disease when a direct relative like parent or sibling that has heart disease) • Age (risk of coronary artery disease increases with age ) • older than 45 for men • Gender • Being postmenopausal (postmenopausal women higher chance, estrogen has a protective effect on the heart, and lower incidence than men but that incidence is more equal as women pass menopause) Which two populations have the highest incidence of CAD? 1. Native Americans (American Indians) 2. Alaskans Review nursing assessments that are important with angina and acute MI. What are the differences in angina and MI? ... MI Most serious acute coronary syndrome Myocardial tissue is abruptly and severely deprived of oxygen -occlusion of blood flow ischemia-> injury -> necrosis risk factors discussed with cad already in another card injury to tissue b/c of prolonged ischemia in MI you will begin to see an elevation in the ST segment (normally flat) necrosis to cells you will see a very elevated ST segment and a deeping Q wave (pathological Q) MI clinical manifestations CAD: Patho Ischemia: - tissues that don't get insufficient oxygen can progress to necrosis if the time of ischemia is long Necrosis: -Cell death around 40% blockage is when patients begin to show signs. CAD: Clinical manifestations Stable Angina: with exertion Unstable Angina: -at rest -can lead to MI **Tx as an emergency Cardiovascular assessment photo Cardiovascular physical assessment photo CV Diagnostic Assessment photo Medical Management: Diagnosis Assessments same for CAD and MI Laboratory requires Lipid profile: • important because elevated lipid levels increase the risk for the atherosclerosis process, plaque build-up in the arteries (arterial lining injury/ fatty deposit build-up in the lining of the arteries) • Total cholesterol < 200 mg/dL • Triglycerides <150 mg/dL • LDL <100 mg/dL • HDL > 40-60 mg/dL **know ranges for these above NSG implications: Labs Nursing Implications The nurse's responsibilities are primarily associated with patient education. Most of the laboratory tests mentioned previously do not require any specific patient preparation, but a lipid panel requires the patient to fast for approximately 8 to 12 hours prior to the test. Blood glucose increases risk of atherosclerosis; encourages build-up of fats/ products within the vessels; major risk factor for cardiovascular disease Homocysteine C-reactive protein the two inflammatory markers Cardiac enzymes: Markers for heart disease CK CK-MB (Creatine kinase myocardial bands) - specific to cardiac tissue • 0-3 ng/mL • Enzymes are specific to cardiac tissue that will tell you if there is an injury in the heart, a better marker for cardiac injury than CK in general. Troponin (Troponin T) • <0.4 ng/mL • Important b/c they tend to stay elevated longer and can be a better indicator when time has passed like a few hrs post an MI. • Very indicative of injury/ death of cardiac tissues • Gold standard to do a troponin level • Drawn for cardiac enzymes q 6 hrs, 3 different sets are drawn → considered serial enzymes/ serial biomarker testing - looking to see when you peak and fall. Can take days to fall back to normal. enzymes are released from the cells when there is an injury to a tissue or cell certain enzymes such as troponin are specific enzymes are cardiac tissue Troponin Troponin is another specific marker of cardiac muscle damage and is the preferred method for diagnosing cardiac injury. It is a protein released from damaged tissue and, as with CK-MB, can elevate within 4 hours of injury. It can stay elevated for up to 10 days. Because it stays elevated longer than CK-MB, it is a valuable marker when attempting to diagnose injury in the recent past. Myoglobin & Brain natriuteric peptide (PNP) Myoglobin, another protein, is released and elevated in muscle damage but is not specific for cardiac tissue. It can be used in conjunction with the other values to help rule out or rule in a myocardial infarction. Brain natriuretic peptide (BNP) is released from overstretched ventricular tissue. Physiological responses to increased levels of BNP include venous dilation, which decreases preload; arterial dilation, which decreases afterload; and diuresis. Elevations are an indicator of heart failure. Markers of heart disease CK-MB -0-3 ng/mL Troponin -Less than 0.4 ng/mL Myoglobin -0-85 ng/mL Brain natriuretic peptide (BPN) -Less than 100 pg/mL 12-lead ECG - preferred test • Telemetry - 5 leads are only looking at the heart from one direction. • 12-lead ECG utilized for diagnostic purposes to determine if there is an injury to various parts of the heart. • Looks at the heart from several different angles and sees the distribution of energy from many different angles. chest x-ray (CXR) May be first test that shows problem with heart; patient may have chest x-ray due to pulmonary issue and chest x-ray may indicate a problem with the heart Exercise Stress Test • Looks at heart during stress • Ex: riding on a bicycle or treadmill • Monitored for EKG changes/ pain during the test Cardiac stress test NSG implications Nursing Implications Patients are instructed to: • Not eat or drink for 4 hours prior to the procedure to avoid any nausea that might be associated with heavy exercise • Avoid smoking prior to the test • Avoid caffeine prior to the test During the procedure, the patient is closely monitored for the appearance of symptoms such as chest pain and/or dysrhythmias as noted previously. The nurse must be prepared to respond if patient decompensation occurs. Imaging Studies (Thallium scan or Echocardiogram) • Thallium scan → injected with radioactive type substance and pictures are taken to see where the dye is in the heart to determine if there are "cold spots" in the heart → areas of the heart that are not getting an adequate supply of blood. Cold spots appearing at both rest and exercise indicate heart tissue damage. Or decreased perfusion. •Echocardiogram →Uses sound waves to evaluate wall motion & valvular motion in the heart. ****Coronary angiography - DIAGNOSTIC (Gold standard)**** • Where L-sided heart catheterization is performed, utilizing one of the major arteries such as the femoral artery where the catheter is threaded up where the dye can be injected into the coronary arteries and the degree of blockage or occlusion can be evaluated. • Gives very specific information about blockages. Assess chest pain (angina) for: • Intensity• Location• Radiation• Duration• Quality• Dyspnea at rest or with exertion• Palpitations• Syncope• Weight gain from edema Myocardial Infarction : Clinical Manifestations • Chest pain • Diabetic patients may not have classic chest pain b/c diabetes damages the nerve endings causing neuropathy • Arm pain (more on the left) • Jaw or tooth pain • Shoulder blade pain • Upper back pain • Shortness of breath • Nausea & vomiting (emesis) • Change of color in skin, pale - perform EKG • Diaphoresis • Generalized fatigue (women more common atypical symptoms like general fatigue or not feeling well) MI potential complications Assessment Post MI: (from Amy's study guide) • Murmurs: damage leading to valves not closing properly • Clot formation: weakened heart leading to stasis & inc. clot formation • Pericarditis: damage/ inflammation • Heart failure: weakened muscle and inability to pump blood out Conductions disturbances • Reentry circuits: electrical activation of heart tissue is caught in a loop which destabilizes the heart • Blockage of electrical signals d/t damaged cells being unable to move signal forward - AV blocks arise from anterior and inferior MIs; Longer PR intervals as signal from atria to ventricles is delayed, QRS may be "dropped" if signal does not reach the ventricles • Afib: irregular P waves, inc. risk of blood clots • PVCs: wide, distorted QRS - pairs= couplets - Every other beat = bigeminy - After every 2 normal beats = trigeminy • Ventricular tachycardia: series of widened QRS complexes without associated P and T waves; defib may be necessary; An ECG of ventricular fibrillation will show a PVC that appears to fall on a T wave of the prior beat. As the T wave represents the refractory period, destabilization of the heart may result. Heart attack or angina (chest pain)? Heart attack vs. chest pain - troponin & CK-MB release into the bloodstream will be the indicator between the two to tell if it's a heart attack. What lab value will help with contractility? higher magnesium levels Review treatments for acute MI including medication classes that were discussed (refer to any tables in the chapter that were mentioned in class). Focus more on the classes rather than specific drug names Nursing Management Assessment and Analysis MI The clinical presentation of MI is related to lack of oxygen delivery to the heart and the resulting decrease in CO. The patient complains of chest pain, shortness of breath, nausea and vomiting, and dizziness. The patient presents with diaphoresis and pallor. Women and older adults may present differently, with women complaining of neck, shoulder blade, and jaw pain as well as abdominal pain. Older adults may present with dyspnea, syncope, weakness, or confusion. Hemodynamics are variable, but typically the patient is tachycardic with a borderline low BP. Nursing Interventions ■ Assessments • Vital signs and pulse oximetry Tachycardia with a borderline low BP and decreased oxygen saturation is a sign of inadequate CO and oxygen delivery. • Assess characteristics of pain including location, radiation, duration, intensity, precipitating or alleviating factors; use a 1 to 10 pain scale Chest pain is an indication of MI. Continued or changing pain characteristics can be indicative of a worsening condition. • Assess ECG changes ST-segment depression is indicative of ischemia. The ST-segment elevation is indicative of injury. If present, a Q wave is diagnostic for MI. • Assess for restlessness Restlessness may be found in the early stages, but progression to severe anxiety and a sense of doom is a late-stage symptom. • Assess skin color and temperature, peripheral pulses, diaphoresis Decreased pulses and cold, clammy, pale skin are signs of inadequate tissue perfusion and inadequate CO. Activation of the sympathetic system with low CO will stimulate diaphoresis. • Monitor urine output Decreased or absent urine output is a sign of decreased renal perfusion related to decreased CO • Assess troponin and CK, CK/MB levels Troponin is a protein released from damaged cardiac muscle. It elevates within 4 hours and can stay elevated for 10 days. CK/MB, the CK isoenzyme marker specific to cardiac tissue, is released from the cells with cardiac muscle damage. Increased levels can be seen at 3 hours and remain elevated for as long as 36 hours. Myocardial Infarction: Medical Management Oxygen Immediately on arrival (1ST TX because the heart isn't getting enough oxygen to the myocardial tissue) Medications • Nitroglycerin • Aspirin (decrease platelet aggregation & help clots from becoming larger) • Pain medication (e.g. Morphine) → may have a poorer outcome b/c it can mask the worsening of MI making it difficult to recognize. Usually always given to a patient having an MI. Reperfusion therapy: restoring blood flow to the heart where the injury is occurring. PCI/ PTCA (same) • TX (preferred method) • within 90 minutes (door to balloon time) hard and fast; NO LATER (Gold standard tx) • Fibrinolytic therapy if not contraindicated -Medication is used as a "clot buster" to break up clots/ demise clots Surgery (CABG) coronary artery bypass prevent clots Goals: • Maximize oxygenation • Control pain • Dilate coronary artieries • Prevent clots • Decrease myocardial workload CAD med tx Medications are provided to: Stop agglutination of blood components to vessel wall trying to make sure vessels don't have plaque build-up and allow thrombus formation • Antiplatelets • Anticoagulants Control factors leading to endothelial damage: help lower damage to the internal lining of the artery, which allows plaque formation to happen, or atherosclerosis. • Statins (help lower cholesterol levels) • Cholesterol Absorption inhibitors (block absorption of cholesterol & increase excretion of it Medications relieve symptoms These medications will decrease the workload on the heart and myocardial oxygen demand which will relieve the patient's pain. • Vasodilators (if they're having pain, this will improve blood flow through coronaries and allow for more oxygen-rich blood to the heart) • Beta Blocks (decrease heart workload) • Ace Inhibitors • Calcium Channel Blockers Aspirin (ASA) Prevent platelet aggregation Side effect: Black tarry stools/ bloody gums - both indicate bleeding Atorvastatin (Lipitor) Cholesterol medication HMG-CoA reductase inhibitors Statins reduce total cholesterol when used for an extended period. Statins reduce cholesterol synthesis in the liver and increase clearance of LDL from the blood. Reduce the risk of recurrent myocardial infarction Side effects: Unexplained muscle pain, cramping, or tenderness Carvedilol - Beta blocker (Plavix) Inhibits the sympathetic nervous system response to physical activity, which decreases cardiac workload and oxygen consumption Decrease HR/BP Decrease the force of cardiac contraction Side effect: Increased SOB Lisinopril (ACE Inhibitor) & ABRs Reduces blood pressure, which decreases workload and oxygen demands Particularly beneficial in patient with HTN, diabetes, renal disease, and heart failure Prevent the development of heart failure Side effects: Swelling of tongue and throat - angioedema Alpha & beta cardiac meds Alpha: • R side of heart optimizing output • Ace Inhibitors - • R side • max to prevent heart failure Beta-blockers: • L side of the heart • slow contraction • slow rate • maximize force • combating adverse effects of HTN What are priorities of care for acute MI ... Priority actions: 1. Oxygen - priority 2. DX: • EKG • Lab's - troponin, CK-MB every 6 hrs x3 3. Cardiac catheterization → PTCA Goals for MI: 1. Maximize oxygenation 2. Control pain 3. Dilate coronary arteries 4. prevent clots, and decrease myocardial workload. Oxygen - is a medication-priority action MI potential complications Myocardial Infarction: Potential Complications Heart Failure (CHF): Management Once a part of the heart tissue dies or the myocardial tissue is never the same. It becomes nonfunctional. Ex: If a patient has a large area affected by an MI, its not going to beat or be able to function as it previously did which causes a drop in cardiac output and it can cause ineffective pumping of the heart, which is the definition of heart failure. Hemodynamic Monitoring (CO, CVP) Various types of catheters are utilized to help monitor cardiac output such as pulmonary artery catheters or central venous pressure catheters are used to look at the pressures within the heart. Medications Diuretics (excess fluid) Nitrates (Nitroglycerin) - helps dilate the coronaries Antihypertensives → decrease workout on the heart by lowering BP Inotropes (digoxin)→ helps increase the force of contraction of the heart Arrhythmias Common arrhythmias in MI: ■Asystole ■Sympathetic Bradycardia ■Heart block ■Ventricular tachycardia ■Ventricular fibrillation Treatment: ■Medications ■Pacemaker & other therapies The main goal if a patient develops heart failure: to make sure that they don't have any kind of extension of their MI injury. Part of the NSG care closely observing for any types of signs of heart failure. A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response? "The pain is controlled, so there is no damage." "It will take years to know the extent of the damage to the heart muscle." "The medication will dilate the blood vessels and any damage will be corrected." "A heart attack evolves over several hours. We won't know the extent of the damage immediately." "A heart attack evolves over several hours. We won't know the extent of the damage immediately." Rationale: 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. NSG Actions: MI ■ Actions • Administer oxygen Oxygen consumption and demand increases; therefore, oxygen supply should be increased. • Insert two large-bore IVs IV access is essential for medication delivery and fluid resuscitation. • Administer medications as ordered Medications are essential to be given in a timely manner: • Aspirin and heparin Aspirin and heparin are given to prevent new clot formation. • Nitroglycerin SL Nitroglycerin dilates the coronary arteries, increasing blood flow and decreasing pain. • Morphine Morphine is a narcotic given for pain relief if nitroglycerin is not effective. • Beta-blockers Beta-blockers decrease the sympathetic response to an MI, decreasing cardiac workload and oxygen consumption. • Fibrinolytics Fibrinolytics work to dissolve clots. • Continuous ECG monitoring Electrocardiogram monitoring is essential to evaluate the evolution of the MI and the effectiveness of treatment and to monitor for dangerous dysrhythmias that can occur. • Bed rest The patient may require bed rest as well as emotional rest to decrease oxygen and cardiac demands. Patient teaching after symptoms of MI ■ Teaching • Immediately report signs and symptoms of MI such as chest pain or chest discomfort or increased shortness of breath Understanding of the signs and symptoms of MI allows the patient to have earlier intervention, thus decreasing the complications and severity of present or future MIs. • Purpose, dose, and side effects of medications Prescribed medications are to treat the effects of MI and prevent future MIs. • The American Heart Association "Life's Simple 7": 1. No smoking of cigarettes or other tobacco products 2. Maintain a normal body weight 3. Exercise for at least 150 minutes with moderate-intensity activity, or 75 minutes of vigorous-intensity activity, or a combination of each per week 4. Eat a healthy diet that follows the current American Heart Association recommendations 5. Maintain total cholesterol level less than 200 mg/dL 6. Keep BP less than 120/79 mm Hg 7. Keep fasting blood glucose less than 100 mg/dL Evaluating Care Outcomes: MI A well-managed patient is free from pain and has normal vital signs with an improved SpO2. Signs of decreased perfusion from inadequate CO such as cool extremities, weak pulses, and decreased urine output are resolving. The goals for effective care include resumption of a normal active life free from pain and feelings of anxiety and doom. Myocardial infarction survivors can reduce their risk for repeated MIs through secondary prevention measures such as Life's Simple 7. Review PTCA concepts of care for MI patients ... percutaneous transluminal coronary angioplasty (PTCA) PTCA= Gold Standard TX • Also referred to as "PCI" • Monitored Anesthesia Care Used for sedation (conscious sedation) • Balloon-tipped Catheter advanced through an artery to where the occluded coronary vessel and then inflated to help compress the plaque back into the walls of the vessel to open the vessel. • Stent may be left in place to maintain vessel patency of the vessel; peripheral pulses need to be monitored, pt. With PTCA pt needs to have an anticoagulant medication that they are taking to prevent a complete occlusion within 24 hrs. A large loading dose is given of Plavix prior to surgery. An effective way to directly treat coronary artery disease. PTCA- potential complications • Bleeding at the insertion site - most common used: femoral artery (most common site) & radial artery - Most common to occur, but still rare. The patient needs to adhere to activity level, keep extremities straight, and maintain bed rest → minimal risk. Good education is important. • Abrupt vessel closure once the artery is open and the plaque is occluded there can be a spontaneous episodic closure after the procedure • Dysrhythmias from the irritation of the heart • ***Rupture of the artery → #1 concern Review CABG (bypass surgery) and nursing care before and after Coronary Artery Bypass Graft (CABG) Surgery: • Large catheters are placed within the aorta or the vena cave & the blood is filtered around through a machine that oxygenates the blood (can receive medications through the machine) & then the blood is returned so it can be distributed through the descending aorta. • Allows the surgeon to operate on the heart when it is not beating. The heart is cooled down to a very cold temperature & eventually will slow enough to where it stops beating just during the surgery. Once the heart stops beating, the surgeon will take different vessels from another part of the body, either an artery or a vein. Typically, the artery is taken from the chest wall, and the internal mammary artery (IMA) or a saphenous vein from the leg can also be utilized. The saphenous vein is preferred because it's longer and you can get more sections from it for a patient who requires multiple grafts to the heart. A new piece of the vessel is stitched into place and part of it is connected above the aorta and the distal portion is attached below where the blocked coronary is located. Blocked coronary vessels are bypassed using arteries/ veins from arms/legs/chest CABG post-op complications • Excessive bleeding • High BP (can burst if too high) - managing BP = priority (emergency) • Oxygenation (leak in one of the vessels, oxygenation will be impaired) CABG post-op recovery Post-operative Recovery • Patient goes to critical care, coronary care unit • Very serious surgery • Minimally invasive techniques may be used & there are advantages: (heart continues to beat throughout the surgery → not always the best option they are not on a cardiopulmonary bypass) • Faster recovery time • Fewer complications A patient returning from heart catheterization has a slight increase in serum creatinine from 1.0 to 1.2 mg/dL and a blood urea nitrogen (BUN) of 30 mg/dL (previously 22 mg/dL). The nurse anticipates an order for which medication? A. Nitroglycerin B. IV fluids C. Dialysis D. Furosemide B. IV fluids Rationale: Contrast-induced nephropathy is a potential complication of heart catheterization. It is evidenced by increased Cr/BUN and requires IV hydration to augment flow to the kidneys to flush out the dye. A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response? "The pain is controlled, so there is no damage." "It will take years to know the extent of the damage to the heart muscle." "The medication will dilate the blood vessels and any damage will be corrected." "A heart attack evolves over several hours. We won't know the extent of the damage immediately." "A heart attack evolves over several hours. We won't know the extent of the damage immediately." Rationale: Infarction is a dynamic process that does not occur instantly. The MI evolves over a period of several hours Post CABG continued.. Post-CABG • Maintain tight BP control Hypotension may result in graft collapse; hypertension may result in bleeding. • Administer fluids and medications (vasodilators, vasoconstrictors, inotropes, and diuretics) as ordered Maintains hemodynamic stability • Rewarm patient slowly with warm fluids, blankets, or air flow devices. Prevent shivering. Rapid rewarming may cause dysrhythmias and/or hypotension due to vasodilation. Shivering increases oxygen needs. • Administer pain medication and continuous sedation medications Maintains effective sedation and analgesia to decrease anxiety and pain which may potentially increase cardiac workload. • Pulmonary hygiene while intubated: Reposition frequently, suction as needed. Oral care every 4 hours. Pulmonary hygiene after extubation; Incentive spirometry (IS), cough and deep breathe (C&DB) every 1 to 2 hours while awake, encourage chest splinting when coughing. Helps with weaning toward extubation, oral care helps prevent ventilator associated pneumonia, IS and C&BD reduces risk of hospital acquired pneumonia, improves oxygenation. • Plan for and initiate early mobility or ambulation Reduces complications related to immobility: deep venous thrombosis, pneumonia, constipation, skin breakdown • Wound care: Initial dressing to be removed or changed by provider, then change daily or as needed. Helps prevent wound infection and promotes healing Post-CABG - last card Post-CABG • Signs of infection Wound infection requires prompt intervention to promote healing. • Sternal precautions; do not lift weight over 10 lbs, raise arms overhead, bend at the waist, participate in vigorous activity until cleared by physician These activities may interfere with sternal wound healing. • Participate in cardiac rehabilitation: includes a medical evaluation, exercise training and physical activity counseling, coronary risk factor reduction/secondary prevention, including nutritional counseling and weight management, psychosocial support, and education regarding diet, weight management, purpose of medications, medication side effects, effects on exercise tolerance, and reinforcement for medication adherence. Changing modifiable risk factors decreases the patient's risk of repeated MIs. Post CABG Post-CABG • Monitor heart rate and BP continuously with an arterial catheter at least every 15 minutes initially and then every 4 hours when the patient is stable. Tachycardia, bradycardia, hypotension, and hypertension may be signs of decreased cardiac output or compensatory mechanisms. • Hemodynamic monitoring Decreased preload (CVP, PAOP), SvO2 may indicate a decreased cardiac output leading to poor tissue perfusion • Continuous cardiac monitoring Dysrhythmias are common after CABG. • Assess heart tones Muffled heart tones may indicate tamponade. S3, S4, and crackles may indicate heart failure. • Monitor breath sounds and continuous oxygen saturation monitoring Decreasing saturation may indicate pulmonary complications. Diminished or unilateral absent breath sounds may indicate atelectasis, pleural effusions or pneumothorax. • Monitor core temperature hourly Hypothermia during surgery reduces metabolic rate and risk of organ ischemia. Rewarming may produce hypotension from vasodilation. Core temperatures are most reliable. • Assess LOC, pupils, and responsiveness Assesses effectiveness of sedation and evaluates neurological function. • Hourly intake and output. Notify provider for output less than 30 ml/hr for 2 hours. Decreased urine output may be a sign of renal damage or decreased cardiac output. • Assess skin color and temperature, pulses, edema, and capillary refill Pale, cool skin with delayed capillary refill and weak pulses may indicate decreased cardiac output. Edema can be an expected response after CABG due to fluid resuscitation during surgery. • Monitor chest tube output, color, and volume hourly Sudden increases in output greater than 100 to 200 ml not associated with position changes or increased bright red drainage may indicate hemorrhage and the need to return to the operating room. • Assess hemoglobin, hematocrit, electrolytes, creatinine and blood urea nitrogen, glucose Changes may indicate bleeding, fluid shifts, and renal dysfunction. Tight glucose control is associated with improved outcomes. • Assess incisions for drainage, warmth, redness, swelling. Redness, warmth, swelling, and purulent drainage may indicate infection. The health care provider prescribes esmolol for a client with supraventricular tachycardia. During esmolol therapy, what should the nurse monitor? body temperature. heart rate and blood pressure. ocular pressure. cerebral perfusion pressure. heart rate and blood pressure. A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers the client to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation? "When I finish the rehabilitation program I'll never have to worry about heart trouble again." "I won't be able to jog again even with rehabilitation." "Rehabilitation will help me function as well as I physically can." "I'll get rest during these rehabilitation classes. All I have to do is sit and listen to the instructor." "Rehabilitation will help me function as well as I physically can." A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse? "Moderation is the key to everything." "Ask your physician to prescribe the new reverse lipid drug." "Increase the soy in your diet." "Exercise, keep your blood sugar in check, and manage your stress." "Exercise, keep your blood sugar in check, and manage your stress." 4. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate? "Everything will be fine. Your family is here for you." "Don't cry; you have the best team of doctors." "Would you like something to calm your nerves?" "Tell me what concerns you most." "Tell me what concerns you most." A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving anticoagulant therapy. Which response by the charge nurse is best? "It's just a coincidence; most clients with atrial fibrillation don't receive anticoagulants." "Anticoagulant therapy controls heart rate in the client with atrial fibrillation." " Anticoagulant therapy prevents atrial fibrillation from progressing to a lethal arrhythmia." " Anticoagulant therapy prevents clot formation in the atria of clients with atrial fibrillation." "Anticoagulant therapy prevents clot formation in the atria of clients with atrial fibrillation." The nurse is caring for a client who is having chest pain associated with a myocardial infarction (MI). What medication will the nurse administer intravenously to reduce pain and anxiety? fentanyl hydromorphone hydrochloride morphine sulfate codeine sulfate morphine sulfate A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia? Atropine Dobutamine Amiodarone Lidocaine atropine Rationale: I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation. The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse's best explanation? In many clients a heart rate slower than 60 beats per minute is considered too slow to maintain an adequate cardiac output. Sinus bradycardia means your heart is not beating fast enough to keep you alive. Sinus bradycardia is nothing to worry about. In many clients a heart rate slower than 70 beats per minute is considered too slow to maintain an adequate cardiac output. In many clients, a heart rate slower than 60 beats per minute is considered too slow to maintain an adequate cardiac output. The nurse is in the mall and observes a client slump to the floor. The nurse assesses the client and notes no pulse. The nurse calls for assistance to others in the mall and requests which piece of equipment? A blood pressure cuff A cell phone to call 911 An automatic external defibrillator A stethoscope An automatic external defibrillator A client reports chest pain and palpitations during and after jogging in the mornings. The client's family history reveals a history of coronary artery disease (CAD). What should the nurse recommend to minimize cardiac risk? Protein-rich diet Liquid diet Smoking cessation Mild meals Smoking cessation A female patient is being seen in the ER complaining of fatigue and shoulder blade discomfort. She is also short of breath. Based on these symptoms, what condition should the nurse suspect? Myocardial infarction (MI) Deep vein thrombosis (DVT) Stroke Intracerebral hemorrhage Myocardial infarction (MI) The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs? The client experiences chest pain, palpitations, or dyspnea. The client experiences a noticeable increase in heart rate during activity. The client's oxygen saturation level drops below 96%. The client's respiratory rate exceeds 30 breaths/min. The client experiences chest pain, palpitations, or dyspnea. The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial fibrillation? Sinusoidal Triangular (before QRS - aflutter) Absent (afib = no definable p wave) Square Absent (afib = no definable p wave) When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize? Core body temperature Heart rate and rhythm Blood pressure Oxygen saturation level Heart rate and rhythm If the pacemaker is functioning properly, good HR and rhythm pacing accurately control BP. Which term refers to chest pain brought on by physical or emotional stress and relieved by rest or medication? Atherosclerosis Angina pectoris Atheroma Ischemia Angina pectoris The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified? Gender, obesity, family history, and smoking Inactivity, stress, gender, and smoking Cholesterol levels, hypertension, and smoking Stress, family history, and obesity Cholesterol levels, hypertension, and smoking A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching? "I'll keep a log of each time my ICD discharges." "I can't wait to get back to my football league." "I have an appointment for magnetic resonance imaging of my knee scheduled for next week." "I need to stay at least 10 inches away from the microwave." The client stating that he should keep a log of all ICD discharges indicates effective teaching. A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply. Reduces myocardial oxygen consumption Decreases the urge to use tobacco Dilates blood vessels, delivers oxygen rich blood, decreases workload Decreases ischemia Relieves pain Dilates blood vessels, delivers oxygen-rich blood, decreases workload The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply. Balance rest with activity. Stop smoking. Avoid all physical activity. Carry nitroglycerin at all times. Follow a diet high in saturated fats Balance rest with activity. Stop smoking. Carry nitroglycerin at all times. The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client? Select all that apply. Avoid handheld screening devices in airports Refrain from walking through anti-theft devices Check pulse daily, reporting sudden slowing or increase Avoid the usage of microwave ovens and electronic tools Wear a medical alert, noting the presence of a pacemaker avoid handheld screening devices in airports check pulse daily, reporting sudden slowing or increase wear a medical alert, noting the presence of a pacemaker