Chapter 40 Care of Patients with Acute Coronary Syndromes

Dysrhythmias

- are the leading cause of pre-hospital death in most patients with myocardial infarction (MI).

Atherectomy

- devices can either excise and retrieve plaque or emulsify it. One of the advantages of this procedure is that it creates a less bulky vessel with better elastic recoil.

After the PTCA, monitor for potential problems

- including acute closure of the vessel (causes chest pain), bleeding from the insertion site, and reaction to the contrast medium used in angiography. Also monitor for and document hypotension, hypokalemia, and dysrhythmias. Report any of these findings to the physician or Rapid Response Team immediately!

Patients with diabetes mellitus and coronary artery disease (CAD)

- may not experience chest pain or pressure because of diabetic neuropathy. -the onset of acute myocardial infarction (AMI) may be signaled by new onset of atrial fibrillation.

Patients with class II and class III heart failure

- may require diuresis and more aggressive medical intervention, such as afterload reduction and/or enhancement of contractility. IV nitroprusside or nitroglycerin may be used to decrease both preload and afterload. These drugs are given as continuous infusions in specialized units where the PAWP and BP can be closely monitored. The BP can drop in response to excessive vasodilation. -usually started on once-a-day beta blockers

Considerations for Older Adults

- presence of associated symptoms without chest discomfort is significant. -chest pain or discomfort may be mild or absent. -Some older patients may think they are having indigestion and therefore not recognize that they are having an MI. Others report shortness of breath as the only symptom. -The major manifestation of MI in people older than 80 years may be disorientation or acute confusion because of poor cardiac output.

If the patient has new-onset angina at home

- teach him or her to chew aspirin 325 mg (4 "baby aspirins" that are 81 mg each) immediately and call 911! -For patients taking aspirin every day, observe for bleeding tendencies, such as nosebleeds or blood in the stool. Aspirin should be discontinued if bleeding occurs

The minimally invasive direct coronary artery bypass (MIDCAB)

-(also known as "keyhole" surgery) may be indicated for patients with a lesion of the left anterior descending (LAD) artery. In one of the most common MIDCAB procedures, a 2-inch left thoracotomy incision is made and the fourth rib is removed. Then, the left internal mammary artery (IMA) is dissected and attached to the still-beating heart below the level of the lesion. Cardiopulmonary bypass (CPB) is not required.

Ischemia

-(lack of oxygen) that occurs with angina is limited in duration and does not cause permanent damage of myocardial tissue.

Infarction

-(necrosis, or cell death) occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue.

CLASS I

-Absent crackles and S3

CLASS IV

-Cardiogenic shock

cardiac tamponade

-Compression of the myocardium by fluid that has accumulated around the heart; this compresses the atria and ventricles, prevents them from filling adequately, and reduces cardiac output.

CLASS II

-Crackles in the lower half of the lung fields and possible S3

CLASS III

-Crackles more than halfway up the lung fields and frequent pulmonary edema

Psychosocial Assessment

-Denial is a common early reaction to chest discomfort associated with angina or MI -Fear, depression, anxiety, and anger are other common reactions of many patients and their families.

Changes in heart after infarct

-Do not occur until 6 hrs after the infarct, and area appears blue and swollen. -Need for intervention within first 4-6 hrs of symptoms IMPORTANT!! -After 48 hrs, area turns gray with yellow streaks -8-10 days, granulation tissue forms -2-3 months, thin firm scar develops. -Scar permanently changes size and shape of left ventricle (ventricular remodeling) -Decreased left Ventricular function scar tissue does not contract or conduct electricity--> Dysrhythmias

Modifiable risk factors

-Elevated serum cholesterol -Cigarette smoking -Hypertension -Impaired glucose tolerance/DM -Obesity-(hypertension [HTN], smoking, high cholesterol, excess weight, or diabetes mellitus). -Physical inactivity-30%-50% geater risk- walking helps -Stress -Excessive Alcohol -androidal shape "Thick middle people"

MI

-Occlusion of blood flow -Necrosis -Hypoxia-(decreased oxygen) from ischemia may lead to local vasodilation of blood vessels and acidosis. -Subendocardial MI, transmural MI, inferior wall MI -Ventricular remodeling -Potassium, calcium, and magnesium imbalances->changes in normal conduction and contractile functions-> lead to life-threatening ventricular dysrhythmias.

Three coronary arteries supply the myocardium

-Right -Left -Left Circumflex -Most happen in the left Vent. -If the left main artery is blocked, then the entire left side of the heart dies

cardiogenic shock

-accounts for most in-hospital deaths after an MI.

All CABG patients, especially those with IMA grafts

-are at high risk for atelectasis, the number-one complication. Encourage them to splint, cough, turn, and deep breathe to expectorate secretions. Early ambulation after surgery is essential.

Stents

-are expandable metal mesh devices that are used to maintain the patent lumen created by angioplasty or atherectomy. -Bare metal or drug-eluting stents (DES) (drug-coated) may be used. By providing a supportive scaffold, these devices prevent closure of the vessel from arterial dissection or vasospasm. A thienopyridine and aspirin (antiplatelet agents) are prescribed for 12 months after a stent has been placed

When giving GP IIb/IIIa inhibitors

-assess the patient closely for bleeding or hypersensitivity reactions. If either occurs, notify the health care provider or Rapid Response Team immediately.

During cardiac rehabilitation

-assess the patient's heart rate, blood pressure (BP), respiratory rate, and level of fatigue with each higher level of activity. Decreases greater than 20 mm Hg in the systolic BP, changes of 20 beats per minute in the pulse rate, and reports of dyspnea or chest pain indicate intolerance of activity. If these manifestations develop, notify the health care provider and do not advance the patient to the next level. Older adults with CAD often have needs and concerns different from those of younger adults

Use caution when giving positive inotropes

-because of the potential risk for increasing myocardial oxygen consumption and further decreasing cardiac output. Monitor the patient frequently, paying particular attention to the development of chest pain.

Coronary artery disease (CAD)

-broad term that includes chronic stable angina and acute coronary syndromes. It affects the arteries that provide blood, oxygen, and nutrients to the myocardium.

After a CABG

-check the patient's neurologic status every 30 to 60 minutes until he or she has awakened from anesthesia. Then check every 2 to 4 hours or per agency policy.

Chronic stable angina (CSA)

-chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. -frequency, duration, and intensity of symptoms remain the same over several months.

Unstable Angina Pectoris

-chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. -An increase in the number of attacks and in the intensity of the pressure indicates unstable angina. -May last longer than 15 minutes -poorly relieved by rest or nitroglycerin. -Patients with unstable angina will present with ST changes on a 12-lead ECG but will not have changes in troponin or creatine kinase (CK) levels.

acute coronary syndrome (ACS)

-describe patients who have either unstable angina or an acute myocardial infarction. -Believed that atherosclerotic plaque in coronary artery ruptures, resulting in platelet aggregation, thrombus formation or vasoconstriction 🌟-at least 40% plaque accumulation before it starts to block blood flow.

New-onset angina

-describes the patient who has his or her first angina symptoms, usually after exertion or other increased demands on the heart.

fibrinolytics

-dissolves thrombi in the coronary arteries and restores myocardial blood flow

Women and Coronary Artery Disease

-do not have normal coronary angiography -typically have smaller coronary arteries and frequently have plaque that breaks off and travels into the small vessels to form an embolus (clot). -"Positive remodeling" or outward remodeling (lesions that protrude outward) is more common in women -Age is the most important risk factor for developing CAD in women. - have a greater risk for dying during hospitalization. -When they are older than 40 years, women are more likely than men to die within 1 year after their MI -Premenopausal women have a lower incidence of MI than men. -those whose parents had CAD are more susceptible to the disease. - abdominal obesity (androidal shape) and metabolic syndrome

Pain relief

-helps increase the oxygen supply and decrease myocardial oxygen demand. -Give morphine as the priority in managing pain in patients having an MI!

If there is any question of acute graph closure

-immediately notify the health care provider. Patients tend to have more incisional pain after MIDCAB than after traditional CABG surgery, but the pain can usually be managed with oxycodone or codeine. Because they have a thoracotomy incision and a chest tube or smaller-lumen vacuum chest device, patients are encouraged to cough, deep breathe, and use an incentive spirometer for a week postoperatively.

Class IV heart failure

-is cardiogenic shock. In cardiogenic shock, necrosis of more than 40% of the left ventricle occurs. Most patients have a stuttering pattern of chest pain, resulting in piecemeal extension of the MI.

Variant (Prinzmetal's) angina

-is chest pain or discomfort resulting from coronary artery spasm and typically occurs after rest.

Cardiac rehabilitation

-is the process of actively assisting the patient with cardiac disease in achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress.

Atypical angina and women

-manifests as indigestion, pain between the shoulders, an aching jaw, or a choking sensation that occurs with exertion. -typically manifest during stressful circumstances or during activities of daily living. -Symptoms in women typically include fatigue, sleep disturbance, and dyspnea.

coronary artery bypass graft (CABG)

-most common type of cardiac surgery and the most common procedure for older adults. Almost half of all CABGs are done for patients older than 65 years -The occluded coronary arteries are bypassed with the patient's own venous or arterial blood vessels or synthetic grafts. 🌟-The internal mammary artery (IMA) is the current graft of choice because it has a 90% patency rate at 12 years after the procedure. -indicated when patients do not respond to medical management of CAD or when disease progression is evident.

Percutaneous transluminal coronary angioplasty (PTCA)

-most commonly done before stent placement, is an invasive but nonsurgical technique. -It is performed to reduce the frequency and severity of discomfort for patients with angina and to bridge patients to coronary artery bypass graft (CABG) surgery. -Because of the artery's normal elasticity and "memory" to retain its original shape, the artery often re-occludes if a stent is not used as part of the procedure. - A balloon-tipped catheter is introduced through a guidewire to the coronary artery occlusion. The physician activates a compressor that inflates the balloon to force the plaque against the vessel wall, thus dilating the wall, and reduces or eliminates the occluding clot. Balloon inflation may be repeated until angiography indicates a decrease in the stenosis (narrowing) to less than 50% of the vessel's diameter -past through groin/wrist -inflate balloon/ vacuum clot at the same time Risk--Clots in the lungs, legs MI, Stroke, allergic reaction to dye

Septal MI

-obstruction of left anterior descending artery

Anterior MI

-obstruction of left anterior descending artery -highest mortality rate

Lateral MI

-obstruction of the circumflex artery

Posterior MI

-obstruction of the circumflex artery

Inferior MI

-obstruction of the right coronary artery

Bleeding after CABG surgery

-occurs to a limited extent in all patients. Measure mediastinal and pleural chest tube drainage at least hourly. Report drainage amounts over 150 mL per hour to the surgeon. Patients with internal mammary artery (IMA) grafts may have more chest drainage than those with saphenous vein grafts (from the leg).

myocardial infarction (MI), often referred to as acute MI or AMI.

-occurs when myocardial tissue is abruptly and severely deprived of oxygen. -result of atherosclerosis of a coronary artery, rupture of the plaque, subsequent thrombosis, and occlusion (blockage) of blood flow. - it evolves over a period of several hours.MI

Monitor the neurovascular status

-of the donor arm of patients whose radial artery was used as a graft in CABG. Assess the hand color, temperature, pulse (both ulnar and radial), and capillary refill every hour initially. In addition, check the fingertips, hand, and arm for sensation and mobility at least every 4 hours. IV nitroglycerin is often given for the first 24 hours postoperatively to promote vasodilation in the donor arm and therefore maintain circulation.

Patients with class I heart failure

-often respond well to reduction in preload with IV nitrates and diuretics. Monitor the urine output hourly, check vital signs hourly, continue to assess for signs of heart failure, and review the serum potassium level.

MI may involve

-only the subendocardium (called a subendocardial MI) or may spread to the epicardium or to all three layers of cardiac muscle. -When all three layers are involved, the MI is termed transmural. -When fewer grams of myocardium affected, the "Q" wave (indicative of old infaction) may not appear. -A significant Q wave is a wave that is at least 1 mm wide and greater than 1/3 the height of the R wave. 🌟-These changes explain the need for intervention within the first 4 to 6 hours of symptom onset!

Nonmodifiable risk factors

-personal characteristics that cannot be altered or controlled. -age- most important -gender- especially women -family history -ethnic background-African-American and Hispanic women

Pre-infarction angina

-refers to chest pain that occurs in the days or weeks before an MI.

To prevent shivering

-rewarming should proceed at a rate no faster than 1.8° F (1° C) per hour. Discontinue the procedure when the body temperature approaches 98.6° F (37° C) and the patient's extremities feel warm.

Coronary artery disease (CAD), also called coronary heart disease (CHD) or simply heart disease

-single largest killer of American men and women in all ethnic groups.

🌟Chronic stable angina (CSA) results in...

-slight limitation of activity -fixed atherosclerotic plaque -relieved by nitroglycerin or rest -Pain will go away -No permanent damage to myocardium

Laboratory Assessment

-there is no single ideal test to diagnose MI, the most common laboratory tests include troponins T and I, creatine kinase-MB (CK-MB), and myoglobin.

CONTRAINDICATIONS TO THROMBOLYTIC THERAPY

Absolute • Any prior intracranial hemorrhage • Known structural cerebral vascular lesion (e.g., arteriovenous malformations) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed-head or facial trauma within 3 months Relative • History of chronic, severe, poorly controlled hypertension • Severe uncontrolled hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg)* • History of prior ischemic stroke within 3 months, dementia, or known intracranial pathology not covered in contraindications • Traumatic or prolonged (≥10 minutes) CPR or major surgery (within 3 weeks) • Recent (within 2-4 weeks) internal bleeding • Noncompressible vascular punctures • For streptokinase/anistreplase: prior exposure (>5 days ago) or prior allergic reaction to these agents • Pregnancy • Active peptic ulcer • Current use of anticoagulants; the higher the INR, the higher risk for bleeding

The Patient Who Has Had a Myocardial Infarction

Assess cardiovascular function, including:•Current vital signs (compare with previous to identify changes) •Recurrence of discomfort (characteristics, frequency, onset) •Indications of heart failure (weight gain, crackles, cough, dyspnea) •Adequacy of tissue perfusion (mentation, skin temperature, peripheral pulses, urine output) •Indications of serious dysrhythmia (very irregular pulse, palpitations with fainting or near fainting) Assess coping skills, including:•Is patient displaying denial, anger, or fear? •Is the caregiver providing adequate support? •Are the patient and caregiver disagreeing about treatment? Assess functional ability, including:•Activity tolerance (examine the patient's activity diary: review distance, duration, frequency, and symptoms occurring during exercise) •Activities of daily living (is any assistance needed?) •Household chores (who performs them?) •Does patient plan to return to work? When? Assess nutritional status, including:•Food intake (review patient's intake of fats and cholesterol) Assess patient's understanding of illness and treatment, including:•How to treat chest discomfort •Signs and symptoms to report to health care provider •Dosage, effects, and side effects of medications •How to advance and when to limit activity •Modification of risk factors for coronary artery disease

A client had a coronary artery bypass graft 2 days ago and has a new onset of atrial fibrillation. What diagnostic test will the nurse check that could explain this dysrhythmia?

B Serum potassium

An older client has a history of stable angina. Which modifiable risk factors will the nurse assess to guide the client's teaching plan?

B Tobacco use C Activity level D Serum lipid levels F Weight

A client who had thrombolytic therapy is receiving a continuous infusion of sodium heparin. In the past hour, the client's blood pressure changed from 122/74 to 98/46 mm Hg. His pulse is rapid and weak. What is the nurse's first action at this time?

D Stop the heparin infusion immediately.

For the traditional surgical procedure(CABG)

Explain that the patient will have a sternal incision; possibly a large leg incision; one, two or three chest tubes; an indwelling urinary catheter; pacemaker wires; and hemodynamic monitoring. An endotracheal tube will be connected to a ventilator for several hours postoperatively. Tell the patient and family that the patient will not be able to talk while the endotracheal tube is in place.

ventricular remodeling

Scar tissue permanently changes the size and shape of the entire left ventricle

Sexual Activity

Sexual activity is often a subject of great concern to patients and their partners. Inform the patient and his or her partner that engaging in their usual sexual activity is unlikely to damage the heart. Patients can resume sexual intercourse on the advice of the health care provider, usually after an exercise tolerance assessment. In general, those who can walk one block or climb two flights of stairs without symptoms can usually safely resume sexual activity. Suggest that initially these patients have intercourse after a period of rest. They might try having intercourse in the morning when they are well rested or wait hours after exercise or a heavy meal. The position selected should be comfortable for both the patient and his or her partner so that no undue stress is placed on the heart or suture line.

The AHA (2010) defines levels of fasting total cholesterol as:

• 130-159 mg/dL—borderline high • 160-189 mg/dL—high • ≥190 mg/dL—very high

🌟Emergency Care of the Patient with Chest Discomfort

• Assess airway, breathing, and circulation (ABCs). Defibrillate as needed. • Provide continuous ECG monitoring. • Obtain the patient's description of pain or discomfort. • Obtain the patient's vital signs (blood pressure, pulse, respiration). • Assess/provide vascular access. • Consult chest pain protocol or notify the physician or Rapid Response Team for specific intervention. • Obtain a 12-lead ECG within 10 minutes of reports of chest pain. • Provide pain relief medication and aspirin as prescribed. • Administer oxygen therapy to maintain oxygen saturation ≥95%. • Remain calm. Stay with the patient if possible. • Assess the patient's vital signs and intensity of pain 5 minutes after administration of medication. • Remedicate with prescribed drugs (if vital signs remain stable), and check the patient every 5 minutes. • Notify the physician if vital signs deteriorate.

Coronary Artery Bypass Graft Surgery

• Be aware that perioperative mortality rates are higher for the older patient than for the patient younger than 60 years. • Monitor neurologic and mental status carefully because older adults are more likely to have transient neurologic deficits after coronary artery bypass graft (CABG) surgery than younger adults are. • Observe for side effects of cardiac drugs because older patients are more likely to develop toxic effects from positive inotropes (dobutamine) and potent antihypertensives (nitroglycerin or nitroprusside). • Monitor the patient closely for dysrhythmias because older adults are more likely to have dysrhythmias, such as atrial fibrillation or supraventricular tachycardia, after CABG surgery. • Be aware that recuperation after CABG surgery is slower for older patients and that their average hospital stay is longer. • Teach the patient and family that during the first 2 to 5 weeks after discharge, fatigue, chest discomfort, and lack of appetite may be particularly bothersome for older adults. • Teach patient to let someone know where he or she is walking outside.

Activity for the Patient with Coronary Artery Disease

• Begin by walking the same distance at home as in the hospital (usually 400 feet) three times each day. • Carry nitroglycerin with you. • Check your pulse before, during, and after the exercise. • Stop the activity for a pulse increase of more than 20 beats/min, shortness of breath, angina, or dizziness. • Exercise outdoors when the weather is good. • Gradually increase the walking until the distance is mile twice daily (usually the end of the second week). • After an exercise tolerance test and with your physician's approval, walk at least three times each week, increasing the distance by mile every other week, until the total distance is 2 miles. • Avoid straining (lifting, push-ups, pull-ups, and straining at bowel movements).

During beta-blocking therapy, monitor for:

• Bradycardia • Hypotension • Decreased level of consciousness (LOC) • Chest discomfort -Do not give beta blockers if the pulse is below 60 or the systolic BP is below 100 without first checking with the health care provider.

Management of Chest Pain at Home

• Keep fresh nitroglycerin available for immediate use. • At the first indication of chest discomfort, cease activity and sit or lie down. • Place one nitroglycerin tablet or spray under your tongue, allowing the tablet to dissolve. • Wait 5 minutes for relief. • If no relief results, call 911 for transportation to a health care facility. • While waiting for emergency medical services (EMS), repeat the nitroglycerin and wait 5 more minutes. • If there is no relief, repeat and wait 5 more minutes. • Carry a medical identification card or wear a bracelet or necklace that identifies a history of heart problems.

🌟MYOCARDIAL INFARCTION S/S

• Pain or discomfort: •Substernal chest pain/pressure radiating to the left arm •Pain or discomfort in jaw, back, shoulder, or abdomen •Occurring without cause, usually in the morning •Relieved only by opioids •Lasting 30 min or more • Frequent associated symptoms: •Nausea/vomiting •Diaphoresis •Dyspnea •Feelings of fear and anxiety •Dysrhythmias •Fatigue •Palpitations •Epigastric distress •Anxiety •Dizziness •Disorientation/acute confusion •Feeling "short of breath"

Coronary Artery Disease

• Recognize that chest pain may not be evident in the older patient. Examples of associated symptoms are unexplained dyspnea, confusion, or GI symptoms. • Although older adults have a greater reduction in mortality rate from myocardial infarction (MI) with the use of thrombolytics, they also have the most severe side effects. Monitor older patients receiving thrombolytics extremely carefully. • Dysrhythmia may be a normal age-related change rather than a complication of MI. Determine whether the dysrhythmia is causing significant symptoms. Then notify the physician. • If beta blockers are used, assess the patient carefully for the development of side effects. Exacerbation of the depression some older adults have is a significant problem with beta blockade. • Plan slow, steady increases in activity. Older adults with minimal previous exercise show particular benefit from a gradual increase in activity. • Older adults should plan longer warm-up and cool-down periods when participating in an exercise program. Their pulse rates may not return to baseline until 30 minutes or longer after exercise.

🌟ANGINA S/S

• Substernal chest discomfort: •Radiating to the left arm •Precipitated by exertion or stress (or rest in variant angina) •Relieved by nitroglycerin or rest •Lasting less than 15 min • Few, if any, associated symptoms

Monitor for these signs of inadequate organ perfusion that may result from decreased cardiac output:

•A change in orientation or mental status •Urine output less than 30 mL/hr •Cool, clammy extremities with decreased or absent pulses •Unusual fatigue •Recurrent chest pain

Patients with transient (temporary) neurologic deficits usually return to baseline neurologic status within 4 to 8 hours. Permanent deficits associated with an intraoperative stroke may be manifested by:

•Abnormal pupillary response •Failure to awaken from anesthesia •Seizures •Absence of sensory or motor function

Monitor the patient for indications that the clot has been lysed (dissolved) and the artery reperfused. These indications include:

•Abrupt cessation of pain or discomfort •Sudden onset of ventricular dysrhythmias •Resolution of ST-segment depression/elevation or T-wave inversion •A peak at 12 hours of markers of myocardial damage

The decision for surgery is based on the patient's symptoms and the results of cardiac catheterization. Candidates for surgery are patients who have:

•Angina with greater than 50% occlusion of the left main coronary artery that cannot be stented •Unstable angina with severe two-vessel disease, moderate three-vessel disease, or small-vessel disease in which stents could not be introduced •Ischemia with heart failure •Acute MI with cardiogenic shock •Signs of ischemia or impending MI after angiography or PTCA •Valvular disease •Coronary vessels unsuitable for PTCA

Remind them to always call 911 for transportation to the hospital if they have:

•Chest discomfort that does not improve after 5 minutes or 1 sublingual NTG tablet or spray •Extremely severe chest or epigastric discomfort with weakness, nausea, or fainting •Other associated symptoms that are particular to them, such as fatigue and nausea

During and after thrombolytic administration, immediately report any indications of bleeding to the health care provider or Rapid Response Team. Observe for signs of bleeding by:

•Documenting the patient's neurologic status (in case of intracranial bleeding) •Observing all IV sites for bleeding and patency •Monitoring clotting studies •Observing for signs of internal bleeding (Monitor hemoglobin, hematocrit, and blood pressure.) •Testing stools, urine, and emesis for occult blood

Be alert for mediastinitis (infection of the mediastinum) by observing for:

•Fever continuing beyond the first 4 days after CABG •Instability (bogginess) of the sternum •Redness, induration, swelling, or drainage from suture sites •An increased white blood cell count

Monitor for, report, and document other complications of CABG, including:

•Fluid and electrolyte imbalance •Hypotension •Hypothermia •Hypertension •Bleeding •Cardiac tamponade •Decreased level of consciousness •Anginal pain

Teach patients to notify their health care provider if they have:

•Heart rate remaining less than 50 after arising •Wheezing or difficulty breathing •Weight gain of 3 pounds in 1 week or 1 to 2 pounds overnight •Persistent increase in NTG use •Dizziness, faintness, or shortness of breath with activity

When a dysrhythmia develops:

•Identify the dysrhythmia. •Assess hemodynamic status. •Evaluate for discomfort

Approaches to decrease lipids are focused on diet, exercise, and drug therapy that lowers cholesterol and triglyceride levels. Teach patients with elevated lipid levels to:

•Reduce intake of saturated fats to less than 7% of total calories •Avoid trans fatty acids •Consume less than 200 mg per day of cholesterol •Participate in daily physical activity •Manage weight

Obtain and record hemodynamic measurements, which include

•Right atrial pressure •Pulmonary artery systolic and diastolic pressures •Pulmonary artery wedge pressure (PAWP) (a measure of preload) •Pulmonary vascular resistance •Systemic vascular resistance (a measure of afterload) •Cardiac output •Central venous pressure (CVP) •Cardiac index

-acute myocardial infarction (MI) diagnosis -classified into one of three categories according to the presence or absence of ST-segment elevation on the ECG and positive troponin markers

•ST-elevation MI (STEMI) (traditional manifestation) •Non-ST-elevation MI (NSTEMI) (common in women) •Unstable angina 🌟Not all pt's will have an elevated ST elevation

Assess for, document, and report manifestations of cardiac tamponade immediately, including:

•Sudden cessation of previously heavy mediastinal drainage •Jugular venous distention but clear lung sounds •Pulsus paradoxus (BP more than 10 mm Hg higher on expiration than on inspiration) •An equalizing of PAWP and right atrial pressure •Cardiovascular collapse

🌟Monitor for, report, and document manifestations of cardiogenic shock immediately. These signs and symptoms include:

•Tachycardia •Hypotension •BP less than 90 mm Hg or 30 mm Hg less than the patient's baseline •Urine output less than 30 mL/hr •Cold, clammy skin with poor peripheral pulses •Agitation, restlessness, or confusion •Pulmonary congestion •Tachypnea •Continuing chest discomfort Early detection is essential because diagnosed cardiogenic shock has a high mortality rate!

prepare them for postoperative care of CABG, Stress that:

•The patient should report any pain to the nursing staff. •Most of the pain will be in the site where the vessel was harvested. (With the use of endovascular vessel harvesting [EVH] and one or two small incisions, the pain and edema are less than for previously performed procedures.) •Analgesics will be given for pain. •Coughing and deep breathing are essential to prevent pulmonary complications. •Early ambulation is important to decrease the risk for venous thrombosis and possible embolism.

Examples of these agents, which target the fibrin component of the coronary thrombosis, include:

•Tissue plasminogen activator (t-PA, alteplase [Activase]) (IV or intracoronary) •Reteplase (Retavase) (IV or intracoronary) •Tenecteplase (TNK) (IV push [IVP])

INDICATORS OF RISK FACTORS FOR METABOLIC SYNDROME Pt's who have at least 3 of these factors are diagnosed

🌟-Hypertension ---Either blood pressure of 130/85 mm Hg or higher or taking antihypertensive drug(s) -Decreased HDL-C (usually with high LDL-C) level ---Either HDL-C <40 mg/dL for men or <50 mg/dL for women or taking an anticholesterol drug 🌟-Increased level of triglycerides ---Either 150 mg/dL or higher or taking an anticholesterol drug -Increased fasting blood glucose (due to diabetes, glucose intolerance, or insulin resistance) ---Either 100 mg/dL or higher or taking antidiabetic drug(s) 🌟-Large waist size (excessive abdominal fat causing central obesity) ---40 inches (102 cm) or greater for men or 35 inches (89 cm) or greater for women