Unstable Test 2: ACS/ sudden cardiac Death (33); immune disorders/connective tissue disorders (64); Hemodynamics in unstable client (65)

dopmine

Dopamine (giving for hypotension and bradycardia. Vasoconstrictor)

Antidysrhythmics -

* remember that dysrhythmias are the most common complication after an MI*. Antidysrhythmics will help prevent or treat dysrhythmias. Examples include: Diltiazem (Cardizem), Propafenone (Rythmol), Amiodarone (Cordarone) Know generics

Morphine

- analgesic and sedative; vasodilates coronary vessels to reduce preload & oxygen consumption

Coronary Angiography

- as stated before, with a STEMI the pt must have coronary angiography within 90 minutes of presentation or receive thrombolytic therapy within 30 minutes in agencies without PCI capability. Angiography=dye! Ask re: iodine/shellfish allergy.

stool softeners in ACS

- helps prevent straining & vagal stimulation (bradycardia and provoke dysrhythmias).

treatment for OA

-Alternative treatments: heat or cold, weight reduction, ROM, acupuncture/massage -Medications: based on severity of symptoms (Aleve, Motrin, Icy Hot, oral steroids, steroid injections into joint)

arthritis

-Arthritis, a type of rheumatic disease, involves inflammation of a joint or joints. -Most forms of arthritis affect women more frequently than men in every age group -Osteoarthritis is the most common form of joint disease in the world -Other forms that occur often include rheumatoid arthritis, fibromyalgia, systemic lupus erythematosus, and gout.

nursing care for RA

-Assessment: fever, pain, nodules, deformities, cyanosis (Raynaud's) -Diagnoses: impaired mobility, pain, depression, impaired body image -Planning: satisfactory pain level, minimal loss of function, be able to perform ADL's, maintain good body image -Implement: : targeting reduction of inflammation ; maintain joint mobility, manage pain, decrease joint deformities, pt/caregiver teaching, exercise, diet modification -Evaluate

Reactive Arthritis

-Associated with a symptom complex that includes urethritis, conjunctivitis, and mucocutaneous lesions -Exact etiology is unknown, reactive arthritis appears to be a reaction triggered in the body after exposure to specific genitourinary or GI tract infections --Chlamydia, shigella, salmonella, campylobacter

Sjögren's Syndrome

-Autoimmune disease, relatively common -Targets the exocrine glands, which causes dry mouth and dry eyes -Throat, nose, and skin can also become dry -Can affect other glands, such as those in the stomach, pancreas, and intestines --Primary and secondary --Primary is traced back to the lacrimal and salivary glands --Secondary is typically caused by a prior autoimmune disorder

Lyme disease

-Bacterial infection transmitted by tick bite -Peak in summer months in northeastern, midwestern, and northwestern states -Symptoms usually occur in a week but may be delayed up to 30 days --Bull's eye rash --Flu like symptoms (chills, fever, headache, muscle aches, swollen lymph nodes) --Loss of muscle tone in face can mimic Bell's palsy -If untreated, bacterial can spread to heart, joints, and CNS --Short term memory loss, cognitive impairment, numbness and tingling in feet --Heart blocks, myocarditis --Chronic arthritis and swelling in large joints --Diagnosis on clinical manifestations, enzyme immunoassay, western blot ---Cerebrospinal fluid analysis

Diagnostic Studies - Percutaneous Coronary Intervention (PCI)

-Can be done with cardiac catheterization. -A catheter with a deflated balloon tip is inserted into the appropriate coronary artery. The deflated balloon is positioned in the blockage and inflated. This compresses the plaque against the artery wall, resulting in vessel dilation and a larger vessel diameter, so blood flow can resume or improve. This is called a balloon angioplasty. Must be on blood thinners for life. -Intracoronary stents are usually placed along with balloon angioplasty. -A stent is an expandable mesh-like structure designed to keep the vessel open after balloon angioplasty.

fibromyalgia

-Chronic central pain syndrome marked by widespread, nonarticular musculoskeletal pain and fatigue with multiple tender points -Nonrestorative sleep, morning stiffness, IBS, anxiety -Commonly diagnosed, major cause of disability -2% of the U.S. population, more common in women -Involves abnormal processing of nociceptive pain input --Abnormal sensory processing in the CNS -Multiple abnormalities -Genetics, illness, and trauma may be triggers -Widespread burning that worsens and improves through the day -Pain in locations difficult to describe/determine -Pain to a stimulus not thought to cause pain normally -Difficulty concentrating/memory lapses -Migraines, depression, anxiety -IBS: constipation/diarrhea, abdominal pain, bloating -Increased frequency of urination/urinary urgency -Diagnosis -Nursing care --Requires high level of patient cooperation/motivation --Medication management: lyrica, Cymbalta, antidepressants, avoid opiods

lyme disease prevention

-Create tick-safe zones: mow, remove brush, discourage deer -Wear long pants in light colors to spot ticks -Insect repellent -Inspect pets, have them wear tick collars -Save tick if one is found --Remove with tweezers --Wash area with soap and water or alcohol -Contact HCP immediately if symptoms appear within 2-30 days

Ankylosing Spondylitis patient teaching

-Disease/prognosis -Regular exercise/range of motion/posture training -Medications -Smoking cessation: decrease risk of lung complications -Baseline ROM assessment -Discourage excessive physical exertion during periods of increased disease activity. -Encourage sports that facilitate natural stretching, such as swimming and racquet games, yoga.

Interprofessional care for chronic stable angina Drug therapy

-Drug Therapy - aims to reduce symptoms and the risk of MI and death -Beta blockers and calcium channel antagonists are first-line options for treatment. (look over MOA) (learn generic names) -Short-acting nitrates can be used for symptom relief. -Short acting nitrates - first-line treatment for angina. They dilate peripheral blood vessels which will decrease SVR, venous pooling, and preload. This will decrease myocardial oxygen demand. Nitrates also will dilate coronary arteries and collateral vessels which will increase blood flow to the ischemic areas of the heart. (bp goes down regardless if pain is relived) -Low-dose aspirin and statins are prescribed to prevent cardiovascular events. (81mg works just as well as 325 mg aspirin for clotting) Sublingual: usually relives the pain within 5 minutes and will last for 30-40 minutes. Recommended dose is one tablet SL (or one metered spray to the tongue if in spray form) as soon as angina symptoms occur. May repeat every 5 minutes for a max of 3 doses. If patient is not in the hospital, they need to call 911 or go to the ER if the symptoms are not resolved after 3 doses. Long acting nitrates: - (isosorbide dinitrate and isosorbide mononitrate) are longer acting and are used to reduce the frequency of angina attacks. The main SE is HA and the patient can take acetaminophen for these HAs. Must build up in system to work. -Nitroglycerin paste (ointment on chest) (Nitropaste) is a long-acting nitrate that is dosed by the inch. It is placed on the upper body and works for approximately 3-6 hours at a time. The ointment should be wiped off to allow for 10-14 hours of nitrate-free intervals to prevent nitrate tolerance. Transdermal controlled-release nitrates are available for some patients and work for approximately 24 hours at a time. These drugs should also be removed for 10-14 hour intervals.

gout management:

-Drug therapy: treat pain, colchicine for acute flare, NSAIDs, allopurinol for chronic gout: only works as long as you take it and take it even if they don't feel a flare up -Promote good renal function

RA diagnostics

-Early diagnosis helps prevent disability -Positive Rheumatoid factor

nursing actions for the cardiac catheterization

-Ensure the pt understands the procedure prior to signing informed consent. -Remains NPO prior to procedure for the specified amount of time according to agency policy or MD orders. -Assess that the pt and family understand the procedure. -Assess for Iodine, shellfish allergy (contrast media)

Coronary Surgical Revascularization:

-Failed medical management -Presence of left main coronary artery or three-vessel disease (critera for surgery) -Not a candidate for PCI (e.g., lesions are long or difficult to access),Cant do angioplasty, then you need surgery, or if you did one and didn't work. -Failed PCI with ongoing chest pain Coronary artery bypass graft (CABG) surgery -Requires cardiopulmonary bypass -Uses arteries and veins for grafts Minimally invasive direct coronary artery bypass (MIDCAB) -Alternative to traditional CABG -no bypasss -less risk, more successful for elderly

causes of osteoarthritis

-Heredity -Obesity -Injury -Joint overuse may be caused by a known event or condition that directly damages cartilage or causes joint instability. -trauma -mechanical stress -inflammation -joint instability -neuro disorders -skeletal deformaties -hematologic or endocrine disorders -drugs.

Diagnostic Studies - Cardiac Catheterization (coronary angiogram)

-Invasive diagnostic procedure used to evaluate the presence and degree of coronary artery blockage. -Angiography involves the insertion of a catheter into a femoral (sometimes a brachial) vessel and threading it into the right or left side of the heart. -Coronary artery narrowing and occlusions are identified by the injection of contrast media under fluoroscopy.

scleroderma care and treatment

-No specific treatments -Care is supportive to prevent complications -PT/OT to help with range of motion -vasoactive meds for Raynaud's -Avoid corticosteroid use -Patient teaching: small frequent meals when difficulty swallowing, avoid finger sticks with Raynaud's, look at wounds for optimal healing.

systemic lupus erythematosus (SLE) nursing process

-Nursing assessment: past med history, meds, symptoms, how long, when did you notice it happens more, what makes it worse, what helps it, management at home -Diagnosis: fatigue, skin integrity, impaired comfort, body image, depression, -Planning: pain management, follow treatment regimen, maintain optimal role function and body image, avoid making it worse -Implementation -Evaluation: use energy conservation techniques, adapt lifestyle to current energy, maintain skin integrity, prevent disease flare with sunscreen

Polymyositis and Dermatomyositis

-Polymyositis: diffuse, idiopathic, inflammatory myopathy of striated muscle that produces bilateral weakness, usually most severe in the proximal or limb girdle muscles -Dermatomyositis: polymyositis with distinctive skin changes -? Autoimmune origin; ? Environmental -Manifestations: muscular, dermal, joint -Biopsy is gold standard for diagnosis; EMG can be used also -High dose corticosteroids tapered down eventually, immunosuppressants -Physical Therapy, rest, conservation of energy

Gerontological Considerations with arthritis

-Prevalence of arthritis is high in older adults --Careful not to over diagnose osteoarthritis, when it could be another type of arthritis -Medications could cause alterations in lab values -Musculoskeletal pain can also be caused by inactivity and depression --Polypharmacy concerns --Osteopenia

ankylosing spondylitis management

-Prevention is not possible: genetic and environmental factors -Early identification and intervention -Maintain maximal skeletal mobility -Decrease pain and inflammation -Heat, NSAIDs, Salicylates -Exercise/stretching -Attention to posture

teamwork and collaboration with rheumatoid arthritis

-Role of Nursing Personnel Registered Nurse (RN) --Administer drug therapy as ordered and provide teaching --Assess disease impact on quality of life and joint function. --Assess pain intensity and administer analgesics as ordered. Assess patient response. --Develop program for rehabilitation and education with the interprofessional team. --Teach patient about need for balance of rest and activity, with use of joint protective strategies. -Unlicensed Assistive Personnel (UAP) --Assist patient with passive ROM of affected joints. --Notify RN about patient complaints of pain. --Assist patient with self-care needs.

gout nursing care

-Supportive -Pain management/positioning: joint immobilization -Avoid rich foods that are high in purines and excessive alcohol use

skin and joint changes in scleroderma

-Symmetric painless swelling or thickening of the skin of hands and fingers -Can progress to scleroderma of the of the trunk -Skin can lose elasticity and range of motion, can become taut and shiny -Internal organ involvement Skin Heart Lungs Kidneys

•SCD: Psychosocial Adaptation & Teaching & Medications:

-Teaching the symptoms of impending cardiac arrest and the actions to take can save lives. --Rapid cardiopulmonary resuscitation (CPR) --Rapid defibrillation with an automated external defibrillator (AED) --Combined with early advanced cardiac life support (ACLS) (know generic terms of emergency medications: https://www.acls-pals-bls.com/drugs/ ) --Adenosine (stops heart. Fast push. Anti-arrhythmic) (have to have MD in room, AED, and code cart. Medical procedure) --Amiodarone (antiarrhythmic; PO or IV) --Atropine (give for bradycardia to increase HR) used until can get a pacemaker. Main reason for a pace maker is low HR. --Diltiazem (primarily - antiarrhythmic; also, for hypertension & angina) --Dopamine (giving for hypotension and bradycardia. Vasoconstrictor) --Epinephrine /Adrenaline (vasoconstrictor; raises BP; primary drug during a code) --Lidocaine (antiarrhythmic, sodium channel blocker) --Magnesium (antiarrhythmic, given for torsades de pointes- a V-fib that fluctuates) --Naloxone (Narcan) (antidote for opioid overdose) -Psychosocial adaptation - "brush with death." Many of these patients develop a "time bomb" mentality. They fear the recurrence of cardiac arrest and may become anxious, angry, and depressed. Their caregivers are likely to experience the same feelings. -Patients and caregivers may also need to deal with additional issues: --possible driving restrictions --role reversal --change in occupation

hemodynamic monitoring

-The measurement of pressure, flow and oxygenation within the cardiovascular system, (p. 1558) •The purpose of hemodynamic monitoring is to understand heart function, fluid balance and the effects of fluids and drugs on the cardiac system. •Hemodynamic monitoring can be noninvasive monitoring or invasive monitoring

potential complications of IABP

-Vascular injuries •Dislodgment of plaque leads to vascular injuries •Aortic dissection •Compromised distal circulation •Thrombus and embolus formation •Destruction of platelet causing thrombocytopenia •Movement of the balloon can block •-Left subclavian • -Renal artery • -Messianic arteries •Infection •Mechanical complications •Improper timing of balloon inflation which can increase afterload and decrease cardiac output, myocardial infarction and increase myocardial O2 demands

ankylosing spondylitis

-a chronic inflammatory disease that primarily affects the axial skeleton, including the sacroiliac joints, intervertebral disc spaces, and costovertebral articulations. -Genetic predisposition -Inflammation in the joints and adjacent tissue causes the formation of granulation tissue (pannus) and dense fibrous scars that can lead to joint fusions -Inflammation can affect the eyes, lungs, heart, kidney, and peripheral nervous system. -symmetric sacroiliitis and progressive inflammatory arthritis of the axial skeleton -inflammatory spine pain are the first clues to diagnosis of AS -inflammation can affect the eyes, lungs, heart, kidneys and PNS -complains of low back pain, stiffness, and limitation of motion that is worse --during the night and in the morning but improves with mild activity -symptoms such as fever, fatigue, anorexia, and wt. loss are RARELY present -may also experience distressing chest pain and sternal/costal cartilage tenderness. -Aortic insufficiency, pulmonary fibrosis, cauda equina syndrome -Lower back pain that seems to get worse and not get better

scleroderma

-a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. -Exact cause is unknown --Immunologic dysfunction and vascular abnormalities may play a role -Environmental and occupational exposures -Localized or diffuse systemic -Collagen is overproduced, leading to tissue fibrosis and blood vessel occlusion --Vascular alterations are almost always present

Psoriatic Arthritis

-a progressive inflammatory disease that affects about 30% people with psoriasis. --Psoriasis is a common, benign, inflammatory skin disorder characterized by red, irritated, and scaly patches -Genetic component -Occurs in different forms

gout

-acute arthritis characterized by elevation of uric acid (hyperuricemia) and the deposit of uric acid crystals in one or more joints -marked by painful flares lasting days to weeks followed by long periods without symptoms -Hyperuricemia --primary or secondary --Primary: heredity error of purine metabolism and leads to overproduction fo uric acid --secondary: related to another acquired disorder or may be caused by drugs known to inhibit uric acid excretion -Causes: increased uric acid, reduced excretion of uric acid by kidneys, increased foods with purines (fatty rich foods, shellfish, high fructose corn syrup drinks) -Occurs acutely in one or more joints but usually less than four -Affected joints may appear dusky or cyanotic and are extremely tender -Triggers: highly sensitive to touch -Reduced uric acid excretion can occur with chronic kidney disease or metabolic syndrome

Life vest for SCD

-bridge to ICD or heart transplantation) external defibrillator that has two main parts: a garment and monitor. --The garment is worn under clothing and has electrodes that continuously record the patient's ECG. --The monitor is worn around the waist. If the patient has ventricular tachycardia or ventricular fibrillation, the device sounds an alarm to confirm that the patient is unresponsive. If the patient is conscious, the patient can press two buttons to stop the shock. If the patient does not respond, the device warns bystanders that a shock is about to be delivered. If the dysrhythmia continues and the patient still does not respond, a treatment shock is delivered through the electrodes. Change batteries q24hr. teach family members (CPR) and what an AED is.

SCD nursing/interprofessional care:

-diagnostic workup to rule out or confirm MI --cardiac biomarkers (ROMI panel, EKG, cardiac cath, PCI, dysthymia assessment: v-fib/v-tach) --ECG -Cardiac catheterization (cardiac catheterization is done to determine the possible location and extent of coronary artery occlusion) -PCI or CABG may be indicated after heart cath is complete.

-With both STEMI and NSTEMI, an echocardiogram may show

-hypokinesis: ( low contractility) -akinesis: (absent contractility) -look at Ejection fraction as well (want it to be 60-80%) -The degree of LV dysfunction depends on: the area of the heart involved and the size of the infarction. -MIs will be described based on the location of the damage (anterior, inferior, lateral, spetal, etc.)

Systemic Lupus Erythematosus (SLE)

-multisystem inflammatory autoimmune disease -multifactorial origin resulting from interactions among genetic, hormonal, environmental, and immunologic factors -typically affects the skin, joints, and serous membranes (pleura, pericardium), along with the renal, hematologic, and neurologic systems -chronic unpredictable course with alternating periods of remission and exacerbation -Etiology is unknown, but genetics may play a large part --Hormones can also influence exacerbations -Environmental --Sun/light exposure, stress, exposure to toxins/chemicals/infections --Medications: procainamide, hydralazine, quinidine -Autoantibodies are produced again nucleic acids, erythrocytes, coagulation proteins, lymphocytes, platelets, etc. -Autoimmune reactions are directed, causing circulating immune complexes to deposit in the basement of the capillaries in kidneys, heart, skin, brain, and joints -Dermatologic -Musculoskeletal -Cardiopulmonary -Renal -Nervous System- seizure, stroke, peripheral neuropathy -Hematologic: antiphospholipid: can predispose someone to clot formation= strokes, MI, PE -Infection: steroid use can increase risk for infection

Traditional CABG

-requires the chest to be opened and cardiopulmonary bypass (CPB) during the procedure. -IMA (internal mammary artery) used as bypass graft (supplies the anterior chest wall and the breasts). -Saphenous veins are also used for bypass grafts (longest vein in the body, running along the length of the lower limb).

The healing process after MI

-the body's response to cell death is the inflammatory process. -10-14 days after an MI, new scar tissue is present but still weak. -The heart muscle is vulnerable to increased stress during this time. -At 6 weeks post-MI, scar tissue has fully replaced necrotic tissue and the injured area is considered healed.

Assessment of Dysrhythmias:

1. 24-hour Holter monitoring (go home with this) 2. Exercise stress testing (shows how your heart works during physical stress) 3. Signal-averaged ECG (SAECG) (electrocardiographic technique, in which multiple electric signals from the heart are averaged to remove interference and reveal small variations in the QRS complex)(not common) 4. Electrode Physiological Study (EPS): During EPS, doctors insert a thin tube called a catheter into a blood vessel that leads to your heart. A specialized electrode catheter designed for EP studies lets them send electrical signals to your heart and record its electrical activity. If they should treat a problem by destroying the place inside your heart that is causing the abnormal electrical signal. This procedure is called catheter ablation.

Complications of MI

1. Dysrhythmias - most common complication after an MI 2. Heart Failure - the right or left heart's pumping action is reduced 3. Cardiogenic Shock - oxygen and nutrients supplied to the tissues are inadequate •Tachypnea with SOB •Sudden, rapid heartbeat (tachycardia) •Low blood pressure (hypotension) •Loss of consciousness •Weak pulse •Sweating •Pale skin •Cold hands or feet •Urinating less than normal or not at all 4. Left Ventricular Aneurysm - the infarcted heart wall is thin and bulges out during contraction. 5. Pericarditis - inflammation of the visceral and/or parietal pericardium 6. Dressler Syndrome - type of pericarditis where fever & chest pain develops 1-8 weeks post-MI

blood flow through the heart

1. Travels through the inferior and superior vena cava; sinuses; 2. deoxygenated blood enters the right atrium; 3. passes through the tricuspid valve into the right ventricle; 4. the deoxygenated blood then goes through the pulmonary valve 5. Then through the pulmonary artery 6. into the trunks of the arteries that go to the lungs; 7. blood loses the CO2 and gains O2 as it reaches the pulmonary capillaries; 8. oxygenated blood enters into the pulmonary veins and 9. enters the left atrium 10. from the left atrium through the mitral valve 11. then to the left ventricle 12. leaves left ventricle through the aortic valve 13. goes through the aorta and to the systemic capillaries.

A patient is complaining of chest pain. On the bedside cardiac monitor, you observe pronounce T-wave inversion. You obtain the patient's vital signs and find the following: BP 190/98, HR 110, O2 96% on room air, and respiratory rate 20. Select-all-that-apply in regards to the MOST IMPORTANT nursing interventions you will provide: A. Obtain a 12-lead EKG B. Place the patient in supine position C. Assess urinary output D. Administer Nitroglycerin sublingual as ordered per protocol E. Collect cardiac enzymes as ordered per protocol F. Encourage patient to cough and deep breath G. Administer Morphine IV as ordered per protocol H. Place patient on oxygen via nasal cannula

ADEGH

Implementation: acute coronary syndrome:

Acute care: Assess pain and relieve pain; physiologic monitoring; promote rest and comfort; alleviate stress and anxiety; understand the pt's emotional and behavioral reactions. Prepare for coronary revascularization. Coronary revascularization (PCI or CABG): After intervention: monitor VS, heart rhythm, evaluate catheter insertion site for signs of bleeding (PCI); neurovascular assessment of the involved extremity (PCI); and maintenance of bedrest per hospital policy. With CABG, pt will be in the ICU for at least 24-36 hours post-operatively. ACS - Ambulatory Care: educate about and encourage participation in cardiac rehabilitation. Cardiac rehab is the restoration of a person to an optimal state of ruction in 6 areas: physiologic, psychologic, mental, spiritual, economic, and vocational. ACS pt teaching: must occur at every stage of the pt's hospitalization and recovery. The purpose of teaching is to give the patients and caregivers the tools they need to make informed decisions about their health. Pt teaching will include all aspects previously discussed with health promotion, and also instructions about resuming physical activity and sexual activity. Must shunt with pillow when cough/deep breathe. Definitions: Metabolic Equivalent Unit (MET) = amount of oxygen needed by the body; determines the energy costs of various exercises (TABLE 33-18).

adenosine

Adenocard stops heart. Fast push. Anti-arrhythmic) (have to have MD in room, AED, and code card. Medical procedure)

lidocaine

Antiarrhythmic sodium channel blocker

accusation heart locations

Aortic Pulmonic Erbs point Tricuspid Mitral

Nursing Management: Chronic Stable Angina and Acute Coronary Syndrome (The Nursing Process)

Assessment: *Review focused Cardiac Assessment* Diagnosis: NCLEX: what is the priority diagnosis? what will kill you first? --Decreased CO-most important: you can't live if your heart can't pump blood --Acute pain --Anxiety --activity intolerance --ineffective health management Plan: overal goals include: --relieve pain --Preserve heart muscle --Treat immediately and appropriately --encourage effective coping with illness-associated anxiety --the patient will participate in effective rehabilitation --reduce risk factors Implement: for ACS and Chronic stable angina Evaluate: Expected outcomes for a patient with ACS: maintain stable signs of cardiac output; report relief of pain; report decreased anxiety levels and increased sense of self-control; achieve a realistic program of activity; describe the disease process, measures to reduce risk factors, and rehabilitation activities necessary to manage the therapeutic regimen.

most common arteries used for arterial monitoring

Brachial •Radial •Femoral •umbilical (neonates)

Systemic Exertion Intolerance Disease (SEID)

Chronic fatigue syndrome --Complex multisystem disease in which exertion of any sort can adversely affect multiple organs -Patho remains unknown --? neuroendocrine abnormalities --? Microorganisms --? CNS •Many patients have cognitive deficits -Clinical manifestations: profound fatigue at least 6 months, malaise, unrefreshing sleep, worsening of symptoms upon standing -Diagnosis -Supportive care and management -NSAIDs for headaches and joint aches -Antidepressants/sleep aids -Avoid total rest to help with body image -Nutritional teaching

amiodarone

Cordarone Antiarrhythmic PO or IV

electrocardiogram (ECG/EKG) -diagnostic study for ACS

EKG vs cardiac cath: EKG doesn't tell where the blockage is and shows the electrical current issues; cath shows the plaque buldup. -should compare with previous EKG when symptoms are present

*Nitrates cannot be taken with which other types of medications?

Erectile dysfunction meds (Viagra/ Cialis)

Rheumatoid nodules

Firm, nontender, unattached subcutaneous nodules at pressure points (e.g., elbow, back of forearm) associated with rheumatoid arthritis -subcutaneously as firm non tender, granuloma type masses. they are often on bony areas exposed to pressure, such as fingers and elbow. treatment is usually not needed but they can break down just like pressure ulcers.

myofascial pain syndrome

Form of chronic muscle pain --Musculoskeletal pain and tenderness, especially in the chest, neck, shoulders, hips, and lower back --Referred pain to the buttocks, hands, and head, causing headaches --Complaints of deep, aching pain, along with a sensation of burning, stinging, and/or stiffness -Physical therapy --Spray and stretch: coolant spray, followed by stretching --Topical patches, lidocaine injections -massage, acupuncture

Interprofessional Care: Acute Coronary Syndrome

Goal is to quickly diagnose and treat to preserve heart muscle. Refer to table 33-12 on p. 723, very helpful! 1. Obtain a 12-lead ECG and start continuous ECG monitoring 2. Position pt upright unless contraindicated 3. Start oxygen therapy to keep O2 sat above 93% 4. Obtain IV access for drug administration 5. Give SL NTG and ASA (chewed for quicker results) if not given before arrival to ED 6. Give a high-dose statin if not taking at home (atorvastatin = Lipitor) (rosuvastatin = Crestor) (pravastatin = Pravachol) 7. Give Morphine for pain unrelieved by NTG. (TX: MONA = Morphine, Oxygen, Nitroglycerine, Aspirin) (not specifically in that order) The patient will be transferred to a critical care unit from the ED. 1. Treat dysrhythmias per protocol 2. Prepare for PCI 3. Then monitor VS frequently and according to protocol 4. Maintain bedrest and limit activity for 12-24 hours after PCI *Emergent PCI is the first line treatment for pt's with confirmed STEMI*

implementation for Chronic stable angina

Health promotion --Monitor BP and adhere to anti-HTN drug regimen as prescribed, reduce salt intake, stop smoking, control or reduce weight, increase physical activity level, reduce total fat and saturated fat intake, take prescribed drugs for lipid reduction, alter patterns that add to stress Acute care: If pt experiences angina: position the pt upright unless contraindicated; apply oxygen; assess vital signs; obtain a 12-lead ECG; provide prompt pain relief first with NTG followed by an opioid analgesic prn; assess heart and breath sounds Ambulatory care: Help the pt identify modifiable risk factors and methods to avoid those risk factors (resting if pain occurs with exercise or activity, etc.); teach proper use of NTG; teach when to call 911 or go to the ER (after 3 doses 5 min apart)

arterial lines are indicated for clients with:

Hypertension •Hypotension •Respiratory failure •Shock •Continuous infusions of vasoactive drugs (dopamine, nipride, cardine) •Trauma (car accidents; neuro issues) •Frequent Arterial blood sampling -COPD, pneumonia pt that's septic

if blood pulsates when inserting a IV what does that mean?

If blood pulsates in the line then you are in the artery; if it does, pull out the catheter and hold pressure for 5 minutes to allow it to coagulate. -arterial blood is bright red, venous is dark red.

FITT Activity Guidelines After Acute Coronary Syndrome

Include the following information in the teaching plan for the patient with acute coronary syndrome and the caregiver: Warm-Up/Cool-Down: Perform mild stretching for 3-5 min before the physical activity and 5 min after the activity. Activity should not be started or stopped abruptly. Frequency: Perform physical activity on most days of the week. Intensity: Activity intensity is determined by the patient's HR. If an exercise stress test has not been performed, the HR of the patient recovering from an MI should not exceed 20 beats/min over the resting HR. Type of Physical Activity: Select physical activity that is regular, rhythmic, and repetitive, using large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Time: Physical activity sessions should be at least 30 min long. Begin slowly at personal tolerance (perhaps only 5-10 min) and build up to 30 min.

Coronary Artery Bypass Graft (CABG) surgery

Indicated in pt's who: fail medical management, have left main coronary artery disease or 3-vessel disease, are not candidates for PCI, or have failed PCI and continue to have chest pain.

Cardiovascular Manifestations of MI

Initially, BP & HR will be elevated. Then the BP will drop because of decreased CO. If BP drops enough, may result in: decreased renal perfusion; decreased urinary output. Crackles in the lungs can suggest left ventricular dysfunction. JVD, hepatic engorgement, and peripheral edema may all indicate right ventricular dysfunction. Distant and extra heart sounds may be present upon examination

types of ciruclatory assist devices

Intraaortic Balloon Pump •Ventricular Assist Devices •Implantable Artificial Heart •Circulatory Assist Devices Type of device depends upon the extent and nature of the heart problem -•Provides interim support: When the left, right or both ventricular problems have occurred from acute injury -•When the septum has ruptured and stabilization is required prior to surgical repair of the septum •-When the patient's heart has failed and the patient is awaiting a heart transplant -All circulatory assist devices decrease cardiac workload, increase myocardial perfusion and increase organ perfusion and circulation. •What do these devices do?** assist in decreasing the cardiac workload of the pts. Heart by increasing the myocardial perfusion of the time they are used due to MI; septum rupture, or when pt is waiting on heart transplant.

contraindications for IABP

Irreversible brain damage •Major coagulopathy (DIC) •Terminal or untreatable diseases •Abdominal aortic and thoracic aneurysms •Moderate to severe aortic insufficiency •Generalized peripheral vascular disease (PVD)

energy expenditure in metabolic equivalents

Low-Energy Activities (<3 METs or <3 cal/min): Activities in Hospital • Resting supine • Eating • Washing hands, face Activities Outside Hospital • Sweeping floor • Painting, seated • Driving a car • Sewing by machine Moderate-Energy Activities (3-6 METs or 3-5 cal/min) Activities in Hospital • Sitting on bedside commode • Showering • Using bedpan • Walking at 3-4 mph Activities Outside Hospital • Ironing, standing • Cycling at 5.5 mph on level ground • Golfing • General gardening • Painting, standing • Ascending a flight of stairs High-Energy Activities (6-8 METs or 6-8 cal/min) • Walking 5 mph • Performing carpentry • Mowing lawn using walking mower Very-High-Energy Activities (>9 METs or >9 cal/min) • Cross-country skiing • Running at >6 mph • Cycling at >13 mph • Shoveling heavy snow

myocardial infarction

MI includes NSTEMI and STEMI -abrupt stoppage of blood flow through a coronary artery due to thrombus caused by platelet aggregation -this causes IRREVERSIBLE myocardial cell death (necrosis) in the heart muscle beyond the blockage. Remember: ischemia is reversible but MI causes irreversible damage.

osteoarthritis diagnostics:

MRI CT bone scan synovial fluid analysis helps rule out other causes

venous oxygen saturation monitoring

Measures O2 saturation of hemoglobin in venous blood to determine the adequacy of tissue oxygenation

MONA

Morphine Oxygen Nitroglycerin Aspirin

can you administer meds in an arterial line?

NO you can possibly infuse like 5cc of NS to keep it patent

osteoarthritis clinical manifestations

NO fatigue, fever, organ involvement; -mild to severe discomfort and pain (clinic visits), joint stiffness, crepitus. joint pain is the primary symptom and the reason most seek medical attention. pain worsens with joint use. -stiffness occurs after periods of rest or unchanged position (opposite of how the pain is) -early morning stiffness is common but resolves within 30 minutes.

nutrition in the ACS pt

NPO initially after occurrence -cardiac diet (low salt, low saturated fat, low cholesterol)

•Which treatment below would decrease cardiac preload? Select all that apply. •1. Intravenous fluids •2. Norepinephrine (Levophed) •3. Nitroglycerin •4. Furosemide (Lasix)

Nitroglycerin Furosemide

•Nursing Responsibilities Associated With Arterial Lines

Obtain baseline data •General appearance of client •Level of consciousness •Skin color and temperature •Vital signs •Peripheral pulses •Capillary refill • Urine output (30cc/hr) •Reinforce education after the health care provider has explained the procedure to the patient. Dr. needs to get the consent not the nurse. •Position the patient and obtain needed equipment (brachial, radial- sitting; femoral-supine) Set up of pressure monitoring system and equipment •Observe monitoring tracing and assess the quality of the tracing of waveform •Recording of data • Monitor insertion site •Correlate observational data with data obtained •Provide safety measures for client

pulmonary artery flow directed catheter

PA pressures and evaluates mixed venous blood O2 sats. -guides the management of pts. with select complicated heart and lung problems. AKA Swan Ganz -used to measure the Pulmonary artery pressure including the PAWP

Percutaneous Coronary Intervention

PCI, formerly known as angioplasty with stent) is a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup, a condition known as atherosclerosis.

Clinical Manifestations of MI:

Pain - severe chest pain not relieved by rest, position change, or nitrates is the hallmark of an MI. -It is usually described as heavy, pressure, tight, burning, constricted, or crushing pain. It is commonly felt substernal or in the epigastric area. It may radiate to the neck, lower jaw, arms, and back. It often occurs in the early morning hours. -Women may have different symptoms. -Diabetics may experience silent MIs because of cardiac neuropathy. -Older adults may experience change in mental status, SOB, pulmonary edema, dizziness, or a dysrhythmia. Nausea and Vomiting -Results from reflex stimulation of the vomiting center by severe pain and from vasovagal reflexes initiated from the area of the infracted heart muscle. Fever -Temp may increase to 100.4 within 24-48 hours and may last up to 4-5 days. This is caused by a systemic inflammatory process.

scleroderma diagnosis

Physical exam, skin biopsy to see excess levels of collagen -mild hemolytic anemia as a result of RBC damage -if kidneys involved: protein may be in urine, microscopic hematuria, and casts. -pulmonary fibrosis on x ray -decreased vital capacity and lung compliance

Serum Cardiac Biomarkers (also called cardiac enzymes, cardiac markers) (ROMI panel)

Proteins released into the blood from necrotic heart muscle after MI -Will be ordered STAT and then repeated at least: 3 sets 8 hours apart. (q8hr x 3) 1. Myoglobin (MB) - Earliest marker of injury to cardiac or skeletal muscle (peaks 2 hr following onset). -Levels no longer evident after 24 hr. 2. Creatine kinase-MB (CK-MB) - elevation > 5% is + indicator for MI (second best option) -Peaks around 24 hr after onset of chest pain. -Levels no longer evident after 3 days. 3. Troponin I or T - Any positive value indicates damage to cardiac tissue and should be reported (best option) specific to cardiac muscle only -Troponin I - Levels no longer evident after 7 days. -Troponin T - Levels no longer evident after 14 to 21 days

Ventricular assist devices: VADs

Provides short and long-term support for failing heart •Allows patient mobility Do not ambulate for 24 hours after insertion •Inserted into the Path of flowing blood to augment or replace the action of the ventricle •Placement •Internally- usually interanally placed •Externally

PAWP

Pulmonary Artery Wedge Pressure (PAWP) is a measurement of pulmonary capillary pressure

flexion contractures and deformities

RA cause diminished grasp strength and affect the patients ability to perform self care tasks. depression may occur from struggling with chronic pain and disability.

felty syndrome

RA, splenomegaly, neutropenia (low WBC count) increased risk of getting infection and lymphoma

The most significant factor in long-term survival of a patient with sudden cardiac death is a)Absence of underlying heart disease. b)Rapid institution of emergency services and procedures. c)Performance of perfect technique in resuscitation procedures. d)Maintenance of 50% of normal cardiac output during resuscitation efforts.

Rapid institution of emergency services and procedures.

Raynaud's phenomenon

Raynaud's Most common complaint of scleroderma -Diminished blood flow followed by erythema

Pulmonary artery wedge pressure

Reflects left ventricular end diastolic pressure.

Implantable Artificial Heart (IAH)

Replaces the heart of patients who are not eligible for a transplant and have no other treatment options •Advantage of the artificial heart compared to a heart transplant: •Cost for implantation •Cost of drug therapies •Patients do not require immunosuppressive therapy •Patients do require lifelong anticoagulation therapy

Sympathetic Nervous System (SNS) Stimulation occurs with MI.

Results in diaphoresis, increased HR and BP, and vasoconstriction of peripheral blood vessels. -On physical exam, the pt's skin may be ashen, clammy, and cool to touch.

when you see V-Tach you know the swan ganz catheter is in the

Right Ventricle

•Complications of Arterial Lines

Risk of infection •Risk of hemorrhage (possible when catheter dislodges or line disconnects) •Risk of thrombus formation •Risk of embolus (air in the line) •Risk of neurovascular impairment •Risk of loss of limb

STEMI

ST elevation myocardial infarction - creates ST-elevation in the ECG leads facing the area of infarction -Emergency situation -The artery must be opened within 90 minutes of presentation in order to limit cell death -This can be done by PCI or thrombolytic drug therapy -PCI is the first-line treatment in hospitals capable of performing PCIs -Complete thrombus occlusion; elevated cardiac enzymes; more severe symptoms

afterload

The force or resistance against which the heart pumps. the forces opposing ventricular ejection. These forces include systemic arterial pressure, the resistance offered by the aortic valve, and the mass and density of the blood to be moved.

implantable cardioverter defibrillator (ICD)

The most common approach to preventing a recurrence is the use of an implantable cardioverter-defibrillator (ICD). NOT the same as pacemaker can have both though.

Swan-Ganz catheter

The most invasive type of central line catheter that is inserted through vessels into right side of heart,and it is used to measure pulmonary artery pressure. -CVP, PA, PCWP soft, flexible catheter that is inserted through a vein into pulmonary artery. used to provide continuous measurements of pulm artery pressure. can exercise with device but patient should avoid activities that increase pressure on injection site

Contractility of the heart

The strength of contraction of the heart at any given end-diastolic volume

types of CABG surgeries

Traditional MIDCAB OPCAB TEBCAB TLR

A patient is admitted with chest pain to the ER. The patient has been in the ER for 5 hours and is being admitted to your unit for overnight observation. From the options below, what is the most IMPORTANT information to know about this patient at this time? A. Troponin result and when the next troponin level is due to be collected B. Diet status C. Oxygen saturation at time of admission D. CK result and when the next CK level is due to be collected

Troponin result and when the next troponin level is due to be collected

intraaortic balloon pump (IABP)

Type of Circulatory Assist Devices • Similar to an introducer •Inserted into the femoral artery either percutaneously or surgically (descending thoracic aorta just below the subclavian artery and above the renal arteries) •Placement is confirmed by an x-ray •Reduces afterload and augments aortic diastolic pressure; acts as the diastolic pressure •Increases coronary artery blood flow/perfusion Limits clients positioning to side-lying or supine position •Head of bed should always be less than 45 degrees •Client may require ventilatory support and/or multiple invasive lines

Sudden Cardiac Death (SCD)

Unexpected death from cardiac causes - almost 400,000 annually • Abrupt disruption in cardiac function, resulting in loss of CO and cerebral blood flow • SCD is often the first sign of illness for 25% of those who die of heart disease. • Most commonly caused by o Ventricular Dysrhythmias o Structural heart disease o Conduction disturbances • Persons who experience SCD because of CAD fall into two groups: o (1) those who have not had an acute MI o (2) those who have had an acute MI • The first group accounts for the majority of cases of SCD. In this instance, victims usually have no warning signs or symptoms. Patients who survive SCD are at risk for another SCD event due to the continued electrical instability of the myocardium that caused the first event to occur. • The second, smaller group of patients includes those who have had an MI and have suffered SCD. In these cases, patients usually have prodromal symptoms, such as chest pain, palpitations, and dyspnea. Death usually occurs within 1 hour of the onset of acute symptoms.

azathioprine (imuran)

Used in RA treatment report unusually bleeding and bruising immediately: therapeutic response may take up to 12 weeks; avoid pregnancy; encourage fluid intake to decrease risk of hemorrhagic cystitis

•Circulatory Assist Devices

Used to decrease cardiac workload and improve organ perfusion with patient with heart failure when drug therapy does not meet the needs of the client; Implantable device (internal);

what do you watch for when inserting the pulmonary artery catheter/swan Ganz catheter

V-Tach

•What condition below can result in an increased cardiac afterload? Select all that apply. •1. Vasoconstriction •2. Aortic Stenosis •3. Vasodilatation •4. Dehydration •5. Pulmonary hypertension

Vasoconstriction Aortic Stenosis pulmonary hypertension

psoriatic arthritis diagnostics

X-ray: cartilage loss and erosion that is similar to RA

Rheumatoid arthritis

a chronic systemic autoimmune disease characterized by inflammation fo connective tissue in the diarthroidal (synovial) joints -typically marked by periods of remission and exacerbation -probably results from a combo of genetics and environmental triggers ---autoimmune etiology -antigen> formation of abnormal immunoglobulin> autoantibodies form (rheumatoid factor)> form immune complexes in joints> inflammation -without treatment, functional independence is lost, leading to disability

spondyloarthropathies

a group of multi system inflammatory disorders that affect the spine, peripheral joints, and periarticular structures -negative for rheumatoid factor (RF) and thus are often referred to as seronegative arthropathies. -genetic and environmental factors play a role -share clinical and laboratory characteristics that may make it difficult to distinguish among them in early disease -redness of the eyes, intestinal inflammation, skin lesions

osteoarthritis

a slowly progressive NONinflammatory disorder of the diarthrodial (synovial) joints -the gradual loss of articular cartilage formation of bony outgrowths (osteophytes) at joint margins -may be caused by a known event or condition that directly damages cartilage or causes joint instability.

lyme disease medications

active lesions can be treated with oral antibiotics: Doxycycline (Vibramycin), cefuroxime (Ceftin), and amoxicillin used to treat the early stage infection and prevent later stages of the disease -Doxycycline is preferred. -short term therapy for 14 days. -IV therapy with Rocephin or penicillin for 2-4 weeks may be needed in those with neurologic or cardiac complications.

Invasive pressure monitoring (arterial)

allows for continuous blood pressure monitoring; every time the heart pumps- you will know what the pts. Blood pressure is. Commonly inserted by Physician, CRNA or an ACP (advanced care practitioner) •Sutured in place after insertion • Immobilized to prevent dislodging or kinking of the catheter line •Measures the clients Blood Pressure in real-time Continuous arterial blood pressure (BP) monitoring • Arterial line catheter is longer than a venous; at least 2.5 inches long; 18-20g • Issues with lines: positioning of the arm can affect the arterial waveform; flush line and reposition hand/arm

magnesium

antiarrhytmic; given for tornadoes de pointes: a v-fib that fluctuates

lipid lowering drugs

are used in all patients with chronic stable angina, unless contraindicated

silent ischemia

asymptomatic; no chest pain to go along with ischemia

Sjogren's syndrome

autoimmune destruction of minor salivary glands and lacrimal glands dry mouth itchy eyes burning eyes decreased tearing and photosensitivity

• ACE Inhibitors and ARBs

both result in vasodilation

The nurse is caring for a patient who survived a sudden cardiac death. What should the nurse include in the discharge instructions? a) "Because you responded well to CPR, you will not need an implanted defibrillator." b) "The most common way to prevent another arrest is to take your prescribed drugs." c) "Your family members should learn how to perform CPR and practice these skills regularly." d) "Since there was no evidence of a heart attack, you do not need to worry about another episode."

c) "Your family members should learn how to perform CPR and practice these skills regularly."

Reactive arthritis symptoms

cervicitis in women low grade fever conjunctivitis asymmetric arthritis of large joints of lower extremities and toes lower back pain in severe cases lesions chillies tendinitis or plantar fasciitis

angina

chest pain due to lack of o2 to the heart

unstable angina

chest pain that is new in onset, occurs at rest, or occurs with increasing frequency, duration, or with less effort that the patient's chronic stable angina pattern. -Pain usually lasts over 10 minutes or more --Prompt treatment is needed --UA is unpredictable (you never know when it's coming on) -Women will manifest UA differently than men, therefore many women don't know they are suffering UA: fatigue, SOB, indigestion, and anxiety (fatigue is most common) -non occlusive thrombus; non specific EKG; normal cardiac enzymes

stable angina

chest pain that occurs INTERMITTENTLY over a long period of time with a similar pattern of onset, duration, an d intensity of symptoms * it is caused by physical exertion, stress, or emotional upset. *it is relieved by rest or nitroglycerin (NTG)

vasodilator effect on heart

decreases blood pressure lowers systemic vascular resistance -benefits HF patients by reducing after load (the forces opposing ventricular contraction) on the left ventricle with enhances the strove volume (amount of blood pumped with each heartbeat) and CO (amount of blood in liters pumped by heart in one minute)

drug therapy for RA

disease modifying anti rheumatic drugs (DMARDs) -methotrexate -biologic response modifiers. -immunosuppressants -Steroids/NSAIDs

MIDCAB (minimally invasive direct coronary artery bypass)

does not require a sternotomy and CPB. Creates a tiny, 2.5 in opening (or multiple 2.5 in. openings) between two ribs in the left side of the chest. Harvest an artery from the chest. May be done directly or may use a surgical robot. Perform stitching, or suturing, while the heart is still beating, so you do not need to go on a heart-lung bypass machine.

reactive arthritis medications

doxycycline, corticosteroids for the conjunctivitis -Most patients recover within 2 to 16 weeks with complete remission ---Some may develop mild chronic arthritis -Will have elevated BUN

mitral valve location

fifth intercostal space, left MIDCLAVICULAR line

tricuspid location

fourth or fifth intercostal space at lower left of sternal boarder

atropine

given for bradycardia to increase HR -used until can get a pacemaker. main reason for a pacemaker is low HR

nursing management for OA

good history all information about pain frequency, worsening of pain, swelling, heat in joint, pain scale 1-10, weather worsens pain? how does pain affect ADL's? -risk for injury; chronic pain; social isolation; immobility -provide medication teaching and lifestyle motivation; adequate rest.

SCD treatment opetions

implantable cardioverter defibrillator -drug therapy -life fest

sexual activity after acute coronary syndrome

include the following teaching plan for pt. and partner: -Sexual activity should be resumed at a level that relates to sexual activity before experiencing ACS. • Physical training may improve the physiologic response to intercourse. Encourage daily physical activity during recovery. • Consumption of food and alcohol should be reduced before intercourse is anticipated (e.g., waiting 3-4 hr after ingesting a large meal before engaging in sexual activity). • Familiar surroundings and a familiar partner reduce anxiety. • Hot or cold showers should be avoided just before and after intercourse. • Foreplay is desirable because it allows a gradual increase in heart rate before orgasm. • Positions during intercourse are a matter of individual choice. • A relaxed atmosphere free of fatigue and stress is optimal. • Prophylactic use of nitrates to decrease chest pain during sexual activity may be suggested • Use of erectile agents (e.g., sildenafil) is contraindicated if taking nitrates in any form. • Anal intercourse should be avoided because of the possibility of inducing a vasovagal response.

TLR transmyocardial laser revascularization

indirect revascularization, high-energy laser to create channels in the heart muscle to allow blood flow; not candidates for other CABG procedures.

what is the first clues to diagnosing ankylosing spondylitis

inflammatory spine pain

prinzmental angina (variant angina)

is RARE and often occurs at rest and is unrelated to physical activity. usually goes away quickly

rheumatic disease

is any disease or condition involving the musculoskeletal system

cardiac output

is the volume of blood in liters pumped by the heart in one minute

ACS cause:

its caused by a the decline of a once stable atherosclerotic plaque. this plaque ruptures, releasing substances into the vessel. this causes platelet aggregation and thrombus formation. The vessel may be partially blocked by a thrombus (UA, NSTEMI) or totally blocked (STEMI)

phlebo static axis

level of right atrium (fourth intercostal space at the mid-anterior-posterior diameter of the chest wall). Used when zeroing to confirm that when pressure within the system is zero the monitor reads zero.

Arterial pressure-based cardiac output (APCO)

measures continuous CO and continuous CI; used to assess a pts ability to respond to fluids by increasing SV. -minimally invasive

Ankylosing Spondylitis diagnostics

mild anemia ESR marker which is specific antigen that marks HIGH predisposition for AS

cardiac tamponade sound

muffled

Beta blockers decrease:

myocardial contractility, HR, SVR, and BP, all of which will reduce the myocardial oxygen demand

naloxone

narcan used for opioid overdose

OPCAB (off pump coronary artery bypass)

no CPB, performed on a beating heart, median sternotomy.

NSTEMI

non-ST elevation myocardial infarction -does not create ST-segment elevation on the 12-lead ECG, -Cardiac Markers (troponin/CKMB) come back + -These patients will be monitored closely -They will undergo PCI within 12-72 hours of presentation -occluding thrombus sufficient to cause tissue damage and mild myocardial necrosis; ST depression with or without T wave inversion on the EKG; elevated cardiac enzymes

Sodium Current Inhibitors (ranolazine (Ranexa))

not a first line drug, only used when other antianginals do not provide adequate treatment. This drug prolongs the QT interval.

Unstable angina

occurs with exercise or emotional stress but it increases in occurrence, severity, and duration over time. *it can also occur at rest*

what is a SE of all nitrates?

orthostatic hypotension

mean arterial pressure

pressure forcing blood into tissues, averaged over cardiac cycle

diltiazem

primarily antiarrhytmic also used for hypertension and angina

Acute Coronary Syndrome (ACS)

prolonged ischemia, not immediately reversible ACS includes: •Unstable angina (UA) •Myocardial Infarction (MI) •Non-ST elevation Myocardial infarction (NSTEMI) •ST elevation Myocardial infarction (STEMI). -The heart muscle becomes hypoxic within the first 10 seconds of total coronary occlusion. 1st line drug: subling nitro -ACS is caused by the decline of a once-stable atherosclerotic plaque. -The plaque ruptures, releasing substances into the vessel. -This caused platelet aggregation and thrombus formation. -The coronary vessel may be partially blocked - manifests as UA or NSTEMI -Or totally blocked - manifests as STEMI

IV nitroglycerin

promotes coronary artery vasodilates and prevents/controls coronary artery vasospasm (cannot be titrated on a normal medical-surgical unit)

scleroderma manifestations

range from cutaneous thickening with organ involvement to limited skin involvement. -CREST syndrome: --C - Calcinosis: painful deposits of calcium in skin of fingers, forearms --R - Raynaud's: vasospasm of fingertips in response to cold or stress --E - Esophageal dysfunction: difficulty swallowing --S - Sclerodactyly: Tightening of skin on fingers and toes --T - Telangiectasia: red spots on hands, forearms, face, etc., from capillary dialation

B-Adrenergic Blockers

reduces HR, contractility and BP; reduces ischemia, decreases afterload

TECAB: total endoscopic coronary artery bypass

robot is used to perform CABG, no CPB used.

pulmonic location

second intercostal space right sternal boarder

aortic location

second intercostal space; right of the sternal boarder

Gout diagnostics

serum uric acid blood draw, synovial joint aspiration

allens test

should always be done prior to the insertion in the radial artery by the person inserting the line. Determines the blood flow to the hand. Cannot do on a femoral artery. occlude both ulnar and radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar artery is good and you can carry on with ABG/radial stick as planned. ABGS.

Lipid-Lowering Drugs

should be started on all pt's with ACS (statins)

psoriatic arthritis treatment

splinting joint protection physical therapy NSAIDs given early in the course of the disease may help with inflammation DMARDs (methotrexate)

calcium channel blockers result in:

systemic vasodilation with decreased SVR, decreased myocardial contractility, coronary vasodilation and decreased HR

cardiac index

the measurement of cardiac output adjusted for body surface area (BSA) amount of blood pumped out of heart per minute per sq meter of body mass. normal ranges btwn 2.5 to 4.2 L/min/meter2

systemic vascular resistance (SVR)

the pressure in the peripheral blood vessels that the heart must overcome to pump blood into the system The resistance that blood must overcome to be able to move within the blood vessels. SVR is related to the amount of dilation or constriction in the blood vessel.

stroke volume

the volume of blood pumped out by a ventricle with each heartbeat

preload

the volume within the ventricles at the end of diastole

herbs point

third intercostal space left sternal boarder

anginal pain is often described as:

tight squeezing, heavy pressure, or constricting feeling in the chest. -The pain can radiate to the jaw, neck, or arm.

myocardial ischemia

tissue death; MI: is irreversible but ischemia is usually Reversible

3 diseases that may need an intra-aortic balloon pump:

unstable chest pain, certain abnormal heart rhythms, CHF)

steroids and prednisone

used for RA -use only in life threatening exacerbation or when symptoms persist after treatment with less potent anti-inflammatory drugs. Administer for limited time only. Tapering dose slowly; exacerbation of symptoms occurs with abrupt withdrawal of drug. Monitor BP, weight, CBC, and serum potassium. Limit sodium intake. Report signs of infection.

methotrexate

used for RA -monitor CBC hepatic renal function; report signs of anemia (fatigue, weakness); stay hydrated: due to tera tonic effects instruct female patients not to get pregnant (conception during and 3 months after treatment)

manifestation of RA:

usually insidious affects joints AND organ systems inflammation and fibrosis of the joint capsule can cause immobility and disability of the joints -redness, swollen, hot, stiff joints may last 60 min-hours

Epinephrine (adrenaline)

vasoconstrictor; raises BP; primary drug during a code

ACE inhibitors and ARBS result in:

vasodilation and reduced blood volume

central venous pressure

venous blood pressure within the right atrium that influences the pressure in the large peripheral veins

When V-tach is seen upon inserting the Swan Ganz; what do you do?

wait for the doctor to instruct you to inflate the balloon, which allows for advancement of the catheter, then deflate the balloon

EKG lead locations

white on right grass under snow (green under white) brown in middle smoke (black) over fire (red) on left

Thrombolytic therapy is indicated for pt's

with STEMI only -These drugs open the blocked artery by lysis of the thrombus -Contraindicated in pt's with other factors that could be made worse by thrombolytic therapy. See table 33-13 for detailed list (pg. 724). (EX: hemophilia, thrombocytopenia

drug therapy for SCD

with amiodarone (Cordarone) may be used in conjunction with an ICD to decrease episodes of ventricular dysrhythmias.

arterial line supplies

• 500ml NS • Pressure catheter tubing • Tegaderm • 10ml syringe • 10ml flush • Iodine or chlorohexidine prep for insertion of line

•Noninvasive Monitoring (still hemodynamic monitoring)

• continuous EKG (white on right; black on left; smoke over fire (red on bottom); green right bottom; brown in middle) •Heart rate •Respiratory rate •Oxygen saturation (finger or toes (rare); ear lobes) • Noninvasive Blood pressure device (arms or legs)

•Nursing Management of CADs -circulatory assist devices

•Frequent and thorough cardiovascular assessments •Measurements of hemodynamic parameters •Arterial blood pressure •Cardiac output •Cardiac Index •Systemic vascular resistance •Nursing Management of CADs • Auscultation of heart and lung sounds •Evaluation of electrocardiogram (EKG) •Rate •Rhythm •Evaluation of tissue perfusion •Skin color •Temperature •Mental status Observe for Bleeding •Monitor hemodynamic parameters and heart sounds for Cardiac tamponade (muffled heart sounds, REVIEW what you would find), ventricular failure •Monitor for signs and symptoms for infection (fever, increased WBC, increased HR, organ failure, lactic acid increase) •Monitor and treat dysrhythmias per standing protocols •Monitor for renal failure (less than 30cc/hr) •Monitor for hemolysis and Thromboembolism •Educate patient about the device and support equipment •Provide emotion support for the patient and family •Consult other intraprofessional social workers, clergy etc. as needed •Urine output •Evaluate tissue perfusion •Assessing the abdomen: inspection, Auscultate, percussion, palpation

indications for use of IABP therapy

•Refractory unstable angina (when drugs have failed) •Short term bridge to heart transplantation •Acute MI with any of the following: ventricular aneurysm accompanied by ventricular dysrhythmias, acute ventricular septal defect; acute mitral valve dysfunction, cardiogenic shock, refractory chest pain with or without ventricle dysrhythmias •Preop, intraop, and postop cardiac surgery: prophylaxis, failure to wean from bypass, left ventricular failure after bypass •High risk interventional cariology procedures.