Med Surge II - Test 2
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What is the nursing diagnosis for CABG post-op?
Decreased cardiac output
What are signs of Mediastinitis?
- Fever > 4 days
- Boggy sternum
- Signs of infection at suture site
- Elevated WBC
What are signs of Postpericardiotomy syndrome?
- Pericardial & pleural pain
- Friction rub
- Fever, elevated WBC, dysrythmias
A patient has just underwent a CABG and there was a sudden cessation of previously heavy CT output, what should the nurse suspect?
What are signs of Cardiac Tamponade?
- Sudden cessation of CT output
- JVD with clear lung sounds
- Muffled heart sounds
- Diminished peripheral pulses
- Pulsus paradoxus
What should be immediately reported to a MD after a CABG?
Chest tube outputof >150ml/hr
Healthy Triglyceride levels in men?
Healthy Triglyceride levels in women?
Healthy Cholesterol levels?
- < 200
- LDL (0-130) - lower the better
- HDL (>40) - higher the better
T/F: Men have a greater chance of CAD until women reach menopause
Chronic stable angina?
- Chest discomfort precipitated by stress/exertion
- *Relieved by rest and/or NTG*
- Less than 15 min of duration
Chronic Unstable angina?
- chest pain > 15 min. duration
- Poorly relieved by rest or NTG
If someone is having a heart attack what should they do?
Chew 325mg of Aspirin, rest & call 911
How often can you administer NTG sublingually?
Every 5 minutes - up to 3 times
When should you notify position after taking NTG?
If BP <100 mm HG or drop of 25 mm Hg - & lower head of bed and call doctor
NTG Patch teaching?
Remove 8-10 hours everyday to prevent tolerance
Expected side effect of NTG?
- Headache (back of head)
NTG tablet patient teaching?
- replace pills every 3-5 days
- Store in dry, dark place
When would you want to hold a Beta-Blocker and notify physician?
- HR < 60 bpm
- BP < 100 mm Hg
If a patient comes in with chest pain what actions should the nurse take?
- Pt. should be placed on a stretcher with HOB at level of comfort & do MONA
- -Morphine (contraindicated in low BP & bradycardia)
- -Oxygen 4L (>95% O2 sat)
- -Aspirin (chew 325mg)
ST Depression represents what?
ST elevation represents what?
What assessment finding would indicate thrombolytic therapy is needed?
- ST Elevation
- Continuous chest pain > 30 min unrelieved by NTG
(most effective within 6 hrs of onset)
What is the exclusion criteria for thrombolytic therapy?
- Any condition predisposing hemorrhage
- Active bleeding
- Uncontrolled hypertension
How do you know if Thrombolytic Threapy has worked?
- Resolution of chest pain
- ST segment return to baseline
- Reperfusion dysrhythmias
- Rapid rise in cardiac enzymes
What does MOVE IT C stand for?
- Vital Signs
- EKG Stat
- IV Access
- Chest x-ray within 30 min
What is the normal range for troponin?
What is the normal range for myoglobin?
An increase in cardiac enzymes is indicative of _______.
Non stemi/unstable angina or that the clot has been dissolved
If your pt's monitor is showing PVCs what do you need to watch for especially in the first hour?
What is a dysrhythmmia commonly follows an MI?
Nursing interventions for Post procedure-cardiac cath (PCTA):
- HOB 30 degree or less for 4-6 hr
- maintain pressure dressing
- avoid flexion of extremity for 12-24 hrs
Complications of MI?
S/S include: pericarditis with effusion, chest pain, dyspnea
What is the nursing diagnosis for STEMI?
ineffective tissue perfusion
Who are beta blockers CI in?
What would you monitor after adminstering thrombolytic therapy?
- Bleeding at IV site
- Occult blood in urine, feces, emesis, etc.
- neurological status (obtain baseline prior to adminstration)
Thromobolytic post infusion nursing interventions :
- bed rest for 6 hr
- pressure at site after catheter removal
- neuro checks
- antiplatelets as ordered
What drug should you stop before having a CABG?
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