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High Acuity Exam 1 Study Guide - 2

This document provides information on assessing and diagnosing myocardial infarction (MI). Key points include: - Signs of an MI include chest pain not relieved by rest and symptoms like sweating, shortness of breath, pain radiating to the arm. Diagnostic tests for MI include ECG, which can show ST elevation (STEMI) or elevated cardiac biomarkers without ST changes (NSTEMI). - Treatment priorities for a patient with chest pain are controlling pain with nitroglycerin and morphine if needed, obtaining an ECG, and assessing for complications of MI like heart failure, arrhythmias, or decreased cardiac output leading to shock. - A cardiac catheterization can diagnose structural heart issues and
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0% found this document useful (0 votes)
279 views12 pages

High Acuity Exam 1 Study Guide - 2

This document provides information on assessing and diagnosing myocardial infarction (MI). Key points include: - Signs of an MI include chest pain not relieved by rest and symptoms like sweating, shortness of breath, pain radiating to the arm. Diagnostic tests for MI include ECG, which can show ST elevation (STEMI) or elevated cardiac biomarkers without ST changes (NSTEMI). - Treatment priorities for a patient with chest pain are controlling pain with nitroglycerin and morphine if needed, obtaining an ECG, and assessing for complications of MI like heart failure, arrhythmias, or decreased cardiac output leading to shock. - A cardiac catheterization can diagnose structural heart issues and
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High Acuity Exam 1 Study Guide·

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.

What diagnostic tests can be definitive for STEMI/NSTEMI? Remember that


assessment findings aren’t necessarily diagnostic because they can be s/s of
other things as well. So, which are indicative versus diagnostic?

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

· Understand the complications of MI. What complications can occur due to


heart damage from an MI? How do you assess for those complications? (hint:
Valvular damage/failure, heart failure, decreased cardiac output leading to shock,
renal failure)
Complications include disruptions of rate and rhythm such as sinus bradycardia, sinus
tachycardia, atrial dysrhythmias, ventricular dysrhythmias, AV heart block.
Heart failure, which can lead to a decrease in cardiac output and can lead to shock
(cardiogenic shock). Pulmonary edema, thrombophlebitis, mitral valve insufficiency,
postinfarction angina, Dressler’s syndrome (see box 56-6 in sylvestri p. 774)
Systemic signs that we can see of organ damage is decreased urine output because
the kidneys are not being perfused.
Liver damage will show liver enzyme elevation
Ventricular aneurysm which is a stretching or bulging of a vessel because it is weak.
Ventricular septal rupture. A hole is now in the septum which creates an abnormal
communication between the right and left ventricles. This can happen as a result of
ventricular aneurysm causing a weak area that tears.
Papillary muscle rupture- the muscle that opens and closes the mitral valve ruptures.
Cardiac wall rupture- EMERGENCY
Pericarditis- inflammation around the pericardial sac
Valve problems which can also lead to HF:

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.

· What occurs during cardiac catheterization (PCI)?


Cardiac catheterization is used to diagnose structural and functional diseases of the
heart and great vessels. This is performed in the cath lab. Contrast agent is used to
visualize patency of coronary arteries and left ventricular function, so be sure to ask
about allergies prior to administering contrast. Catheter is inserted into a large vein or
artery. Fluoroscopy is used to guide the advancement of the catheters through the right
and left heart.
You need consent for this. Not done at the bedside. Will go to the cath lab. Will have
local anesthesia and a bit of relaxation meds. NOT put under GA bc they need to report
what they're feeling. Will insert cath in the radial or femoral artery and advance the cath
up to the blood vessels of the heart (vena cava). Will squirt dye and watch where the
blockage is. They can then use a balloon and leave a stent, or can squirt tPA, or can fish
the clot out. Once done, they will pull the sheath out and hold pressure for 10-20 mins
and then bandage up and send the patient back to the nurse.

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.

· Nursing considerations of administering nitroglycerine. What do you assess


for? What do you do about those assessment findings? How would you teach a
patient to take it at home? Pt can take one tab (up to 3 tabs) every 5 mins. If pain has
not subsided after the first tab, call 911. Assess for hypotension, HA, and dizziness. Do
not administer another one if systolic BP is under 90. Have the patient in a sitting
position when taking nitro and get up slowly to prevent orthostatic hypotension. Can
cause a headache because of vasodilation. Check expiration date. Keep the bottle away
from light. If after 3 times they still have pain, give morphine for pain and let the HCP
know the status. May need to be put on a nitro drip and a beta blocker
If at home and the first dose does not relieve the pain, they need to take another nitro
and call the ambulance
· Signs and symptoms of infective endocarditis. So if a patient is diagnosed with
endocarditis, what are your priority assessments?
Endocarditis- A microbial infection and Inflammation of the inner lining of heart and
valves. Could be bacterial staph or strep or fungal. Common among IV drug abusers.
Assess for fever, auscultate for a heart murmur, lesions, weakness, dizziness. A murmur
could lead to valve problems which can lead to decreased cardiac output. May also see
clusters of petechiae on the body, small painful nodules on pads of fingers and toes.
Irregular red or purple macules on palms, fingers, hands, toes and soles. Look at BP,
SOB on exertion
Modified Duke criteria
•Blood cultures
•Chest radiograph
•Echocardiogram
•Complications
Heart failure
Timely antimicrobial administration to resolve the infection, prevent complications,
provide patient and family education. Patients may need long term antimicrobial therapy
via a PICC line or other long term IV access device.

· Review nursing considerations for cardiomyopathy (GENERAL- not specific to


a certain type).
Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to
pump and causes a decrease in cardiac output. It causes structural and functional
abnormalities of the heart muscle. Patients may remain asymptomatic for years but as
the disease progresses, so do the symptoms. Symptoms are like those for HF.
Nursing Interventions- Rest when symptomatic, Assess O2 saturation at rest and
during activity, assure adherence to medication regimen to assure adequate cardiac
output. Assure the patient chooses food selections that are low in sodium. Check daily
weights and note any significant change. Assess for SOB after activity. Assess how
many pillows the patient needs to sleep with. Avoid dehydration. Have them anticipate
voiding every 4 hours while awake and if the urge is not present or the urine is deep
yellow, more fluid intake is necessary. Alternate rest and activity periods and teach the
patient to do this as well. Avoid strenuous activities, isometric exercises and competitive
sports. Eradicate or alleviate stressors. If the patient is awaiting a heart transplant, allow
time for the patient to discuss their feelings. Help with anticipatory grieving. Assist
patients and family with adjusting to lifestyle changes. Teach patients to read nutrition
labels and record their daily weights and symptoms when they go home. Teach family
CPR. Teach signs that should be reported to the HCP. Teach women to avoid
pregnancy.

· Prioritize assessments- to help you answer these questions, remember 1. Is the


assessment/symptom choice related to the diagnosis? and 2. Use your ABCs to
prioritize those assessments/symptoms.
· Prioritize patients- who do you see first? Again, ABCs, plus MASLOW.
Remember on these prioritization questions that you can’t add in your own
information. You can only take the assessment findings given to you and decide if
they could indicate a priority problem. DON’T assume anything! Review MASLOW,
you can use it to help with your prioritization. Remember physiological first then
if physiologically stable, you can treat psychological issues.

· 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.

· Signs and symptoms of decreased cardiac output. Prioritize those assessment


findings. For example, weight gain and dyspnea are both symptoms, but which
takes priority? (those are NOT the test question options, just an example of what I
mean)
Signs and Symptoms of Decreased Cardiac output- decreased peripheral pulses,
exercise intolerance, hypotension, lethargy, restlessness, irritability, oliguria, pale cool
extremities, tachycardia

· 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.

· Lab levels to know – Troponin, CK-MB, CBC (WBC), Potassium, prothrombin


(PT), BNP, LDL, (what do these labs test for? What are normal levels? What do
abnormal levels indicate?
Troponin - 0-0.4 ng/mL
CK-MB - 5-25 IU/L >25 indicates cardiac muscle injury/damage (2-5 mcg/L)
WBC - 5000 - 10000 (Elevated with MI and lasts up to one week)
Potassium - 3.5 - 5 mEq/L can cause dysrhythmias
PT - 11 - 12.5 seconds
BNP - <100
LDL - <100
INR- in healthy ppl a level of 1.1 is normal. In a patient taking Warfarin, a level of
2.0-3.0 is an effective therapeutic range

· Calculation – 5 questions: (microdrip rate: 60 drops per minute). Normal


questions just require you to do gtt/min

· Cardiac rhythm identification – 4 strictly identification questions

· 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.

Normal Sinus rhythm- normal P wave, QRS complex, T wave

Sinus Bradycardia- normal P wave, QRS complex, T wave

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.

Sinus Tachycardia- normal P wave, QRS complex, T wave

Rates higher than 100 to 180bpm. Treat underlying cause.


Atrial Flutter- sawtooth pattern. The pattern originates in the atria but not from the SA node so
they are F waves (flutter waves). Rates are 250-350. Need anticoagulants to prevent a
thrombus from forming. Use CCB’s, beta blockers

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 Tachycardia-ventricular rates of 140-250bpm. Can lead to cardiac arrest.


Administer O2 as prescribed, administer antidysrhythmic (amiodarone). Prepare for
cardioversion if symptomatic, defibrillation and CPR if the patient is pulseless

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)

· Medications to review (uses, major effects, nursing considerations) – Diltiazem,


Digoxin, Warfarin, Nesiritide, beta blockers

Diltiazem: pg 806 sylvestri

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

SIde/Adverse effects- Bradycardia, hypotension, reflex tachy, headache,


dizziness, lightheadedness, fatigue, peripheral edema, constipation, flushing,
changes in liver and kidney function.

Nursing considerations: orthostatic hypotension, monitor I&O and for symptoms


of HF, monitor EKG in hospital, do not discontinue med, teach how to take pulse,
do not chew or crush

Digoxin: Therapeutic range 0.5-2ng/mL

Uses: cardiac glycoside; It's an antiarrhythmic; treats HF, A fib, and A flutter

Major intended effects: positive inotrope (increases the force of myocardial


contractions), negative chronotropic so it also decreases HR. It is also negative
dromotropic so it slows the conduction velocity through the AV node. Therefore it
increases cardiac output, decreases preload and improves blood flow to the
periphery. Helps the heart beat stronger and with a more regular rhythm

Side Effects: anorexia, N/V, diarrhea, bradycardia, visual disturbances of any king,
HA, fatigue, weakness, drowsiness.

Toxicity signs- GI disturbances, HR abnormalities and then visual disturbances


Nursing considerations: monitor apical pulse for 1 min before administering,
withhold dose if pulse is less than 60 bpm. Monitor EKG. Monitor serum Dig
levels, electrolytes and renal fctn tests. Hypokalemia K+ can make Dig toxic. Eat
foods high in K+.

Tx for toxicity: stop infusion, administer K if electrolytes are whack. Antidote:


digamunifab (digibind)

Contraindicated in ventricular dysrhythmias and 2nd°/3rd° heart blocks.

Warfarin Sodium:

Uses: anticoagulant aka blood thinner; vit K antagonist so antidote is vit K;


prolongs clotting times so monitor by prothrombin time (normal PT is 11-12.5.
therapeutic range is 1.5-2x the control value) and INR (normal is 0.8-1.2); long term
use is to prevent PE. In healthy people an INR of 1.1 or below is considered
normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for
people taking warfarin for disorders such as atrial fibrillation or a blood clot in the
leg or lung. 3-4.5 for high dose therapy.

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)

Nesiritide: pg 807 Sylvestri

Uses: vasodilator so decreases workload; used for tx of decompensated HF

Major effects: hypotension, dizziness, confusion, dysrhythmias

Nursing: administer via IV. watch for falls, monitor vitals, monitor BP, cardiac
output, urine and body wt. Monitor for signs of resolving HF

Beta Blockers- end in lol: pg 805 sylvestri

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.

Major effects: hypotension, bradycardia, dizziness, hyperglycemia,


agranulocytosis
Nursing: don’t stop med bc rebound hypertension, rebound tachy or anginal
attack can occur. Use with caution in a patient taking other antihypertensives.
Monitor vitals, withhold med if pulse or BP is not within the prescribed
parameters. Monitor for signs of worsening HF. change positions slowly to avoid
orthostatic hypotension

Add ons- Things to remember


Pulse pressure- difference between systolic and diastolic pressure. Normal range is between 30-40
Stroke volume- the amount of blood the heart pumps per beat out of the left ventricle
Cardiac output- the volume of blood the heart pumps out per minute.
Signs and Symptoms of Decreased Cardiac output- decreased peripheral pulses, exercise
intolerance, hypotension, lethargy, restlessness, irritability, oliguria, pale cool extremities, tachycardia
Preload- The volume of blood in the left ventricle at the end of diastole
Afterload- the amount of pressure the heart has to work against to eject blood during systole. ACEI,
ARBS, beta blockers and diuretics help with this
Central Venous Pressure- the pressure in the right atria of the right ventricle at the end of diastole.
Heart Failure- the inability of the heart to maintain adequate output to meet metabolic demands of the
body as a result of impaired pumping ability

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