High Acuity Exam 1 Study Guide - 2
High Acuity Exam 1 Study Guide - 2
For patients with chest pain, what assessment findings point towards MI?
Chest pain not relieved by rest. Diaphoresis, agitation, SOB, pain radiating to the arm,
and a doom feeling are classic signs of an MI. The pain feels more like pressure,
squeezing, fullness, crushing in the substernal area. Not a stabbing pain. Pain may
radiate to shoulders, one or both arms, jaw, shoulder, back or epigastrium. Women and
diabetic patients have different signs of an MI. (dizziness, syncope, nausea, back pain,
fatigue, flu like symptoms). Diabetics might have silent MI bc of the dead nerve cells
from years of high blood sugar.
Physical examination and presence of presenting symptoms alone are not enough to
diagnose a MI. ECG can assist in ruling out or diagnosing an acute MI. ECG changes
with an MI include T wave inversion, ST segment elevation and the development of an
abnormal Q wave. With necrosis, repolarization is delayed which is what causes the T
wave to invert.
In an NSTEMI (Non STelevation myocardial infarction) the cardiac biomarkers are
elevated but there is no definite ECG evidence of an acute MI. May have less damage to
the myocardium
In a STEMI (STelevation myocardial infarction) (this is worst) there is evidence of an MI
on the ECG. ST elevation means cardiac damage is occurring
Further diagnostic tests for MI include the cardiac enzyme biomarkers troponin, creatine
kinase CK, and myoglobin. Remember, these aren’t seen until hours later.
Not completely diagnostic but indicative of a MI, see below:
Troponin I and T-a protein found in myocardial cells. An increase in the serum level of
troponin can be detected within 3 hours of an acute MI and remains elevated for 2
weeks. This is specific to cardiac muscle injury or infarction.
Creatine Kinase- CK-MB is a cardiac specific isoenzyme. Elevated CK-MB is an
indicator of acute MI. It increases within 6 hours of an acute MI. CK-MB normal is 5-25.
Anything over 25 is indicative ischemia, or any other thing that damages cardiac muscle
Mitral valve stenosis, Mitral valve regurgitation, Aortic valve stenosis, Aortic valve
regurgitation
Tricuspid valve stenosis, Tricuspid valve regurgitation, Pulmonic valve disease, Mixed
valvular lesions
· What are your priority interventions for a patient with cardiac chest pain?
Control the pain which needs to be relieved at a level of 0. If pain continues, it means
ischemia is still occurring. EKG, MONA (morphine, oxygen, nitroglycerin, aspirin). Nitro
first x3, then morphine if pain not relieved, vitals and get an EKG done. Do ABCs: Start
with airway, if it is patent, then move to O2 (breathing), then nitro (for circulation), then
morphine, then aspirin.
Nursing process: assess then treat. Ex if someone walks in w chest pain, first thing is
vitals and EKG. These are the assessments.
So nursing priorities: look for bleeding, check vitals q 15 for an hour then q30, keep
leg/extremity extended and straight to prevent bleeding/hematoma. Will look at the groin
and feel for hematoma, check for bleeding, and tell pt not to bend the leg. Pt wont be
laying flat tho, will elevate HOB 15-30 degrees or can put bed in reverse trendelenburg.
What are your nursing considerations for a patient immediately after PCI?
Post care for a patient immediately after are to observe the catheter access site for
bleeding or a hematoma and assess for peripheral pulses in the affected extremity
(dorsalis pedis, posterior tibial pulse in lower extremity and the radial pulse in the upper
extremity). Every 15 mins check vitals and bleeding. Also monitor for bleeding by
evaluating orthostatic hypotension. Evaluate the temperature, color and cap refill, pain,
numbness, tingling sensations that indicate arterial insufficiency. Screen for
dysrhythmias. Maintain bed rest for 6 hours post procedure with the leg straight, and
HOB elevated no more than 15°- 30°. Monitor elevated serum creatinine levels for
contrast induced nephropathy. IV hydration to increase urine output to flush contrast out
of the system. Instruct the patient to ask for help when getting out of bed for the first
time.
· Signs and symptoms of heart failure. Left versus right. Prioritize those
assessments!
Right Sided Heart Failure
● Fatigue
● Peripheral venous pressure
● Ascites
● Enlarged liver and spleen (hepatomegaly, splenomegaly)
● Distended jugular veins
● Anorexia and complaints of GI distress
● Weight gain
● Dependent edema
Left Sided Heart Failure- (signs of pulmonary congestion)
● Paroxysmal Nocturnal Dyspnea
● Elevated pulmonary capillary wedge pressure
● Pulmonary congestion such as cough, crackles, wheezes, blood tinged sputum,
tachypnea
● Restlessness
● Confusion
● Orthopnea
● Tachycardia
● Exertional dyspnea
● Fatigue, decreased activity tolerance
● Cyanosis
● Left sided HF can lead to right sided RF
● Increased BP from fluid volume excess or decreased BP from pump failure
· Know the types of different central venous catheters and be able to describe
them. Know the principles of central line insertion and CLABSI prevention.
Reasons for needing/keeping a central venous catheter.
Tunneled, peripheral, non tunneled, implanted ports. Want to know why we use
each type. Tunneled and implanted ports are for long term use for caustic
meds/cancer pts, extended antibiotic administration. PICC line is also long term
but not months, maybe just a few weeks for pt needing ABX. Also for TPN, don’t
put TPN in regular vein. Has to go through the central line. If needed for months
then use tunneled.
Non tunneled, picc, tunneled, port is the order of most infectious to least
infectious.
When do we get rid of the central line? Check daily. IV for sepsis needs a central
line.
How to dec CLABSI: hand hygiene, aseptic technique when changing dressings,,
don’t access it a lot (scrub the hub for 15-20 sec each time you access), change
clear dressing every 7 days, if opaque then change q24 hrs. Head DOWN when
you’re about to remove a line to prevent a clot from going to the brain. Blue to sky
for biopatch. Assure tip is present after taking out. Hold pressure till bleeding
stops.
Nurse can remove picc or non-tunneled!! Tunneled has to be surgically removed
because it is tunneled into tissue and then into a vein.
· Review your delegation principles. What types of things can you delegate to a
CNA/UAP/student nurse? There will be questions related to the content that ask
you to delegate.
· Nursing actions for patients with particular cardiac rhythms (ex: a patient has
_______ rhythm with ______ symptoms. What is the most appropriate action?).
You may have to look at the strip to determine the rhythm and then choose the
most appropriate intervention.
Rates below 60bpm, if symptomatic, determine the cause. Administer oxygen, administer
atropine to increase the heart rate to 60. Monitor for hypotension. Depending on the cause and
if the atropine does not work, the patient may need a permanent pacemaker.
Atrial Fibrillation- disorganized rapid impulses in the atria. No definitive P waves. The atria is
quivering which leads to formation of clots (thrombi). May see palpitations, and manifestations
of heart failure Administer anticoagulants to avoid clots going to the brain and cause a stroke
and other parts of the body. Administer O2, administer cardiac meds as prescribed, prepare the
client for cardioversion.
What is atrial fibrillation? What are the complications of it? Treatment and patient
teaching? See the A-fib strip. Complications can be the formation of a thrombus which
can cause a stroke or clots going to other parts of the body. Risk for heart failure,
myocardial ischemia.
Tx for clots associated w A fib: slow HR and restore normal conduction in SA node,
prevent clots. Use anticoagulants like warfarin (watch INR 2.5-3.5). Do not inc or dec
green leafy veggies bc they have vit K which blocks warfarin's effectiveness. Also beta
blockers, cardiac ablation and cardiac glycoside aka digoxin. Never give dig if heart beat
is less than 60 bpm. Listen to apical pulse for full minute. Watch for dig toxicity…over
2.0. also watch for K toxicity. Can also do cardioversion.
Not sure if yall listened to the Klimek review about rhythms. He mentioned and Nehali
inquired with professor Hart that we can use his rule of thumb….for atrial dysrhythmias
use ABCD (adenosine, beta blocker, CCB and digitalis)
Ventricular Fibrillation- ventricular fires in a disorganized manner. Chaotic rapid rhythm where
the ventricles are quivering and there is no cardiac output. Rate is greater than 300bpm. No
atrial activity seen. Fatal rhythm if not successfully terminated within 3-5 mins. Cardiac arrest
and death are imminent if not corrected. Early defibrillation is critical to survival. Do CPR until
defibrillation is available.
PEA: see if question says pt is pulseless. How to treat: CPR, vasopressor
(vasoconstricts so BP goes up to try to restore cardiac function)
Uses: treatment of stable angina, CCB used for HTN, angina (including Prince
Metals aka spastic heartbeats), A fib or A flutter and STD so its also an
antidysrhythmic. Reduces contractility and workload of the heart and vessels;
promotes vasodilation and decreases BP
Uses: cardiac glycoside; It's an antiarrhythmic; treats HF, A fib, and A flutter
Side Effects: anorexia, N/V, diarrhea, bradycardia, visual disturbances of any king,
HA, fatigue, weakness, drowsiness.
Warfarin Sodium:
Major effects:
Nursing: longer than 30 s PT and INR greater than 3 for standard therapy then
initiate bleeding precautions. Also bridge therapy from heparin. Monitor PT and
INR, observe for bleeding, antidote is vitamin K (fitonadione)
Nursing: administer via IV. watch for falls, monitor vitals, monitor BP, cardiac
output, urine and body wt. Monitor for signs of resolving HF
Uses: treats diastolic heart failure, because they slow the heart rate(negative
inotrope) and allow more time for your heart to fill with blood. This allows the left
ventricle to fill more completely and increases the volume of blood that the heart
pumps with each heartbeat (ejection fraction). Used for angina, dysrhythmias,
HTN, and prevention of MI.