Med Surge II - Test 2
Card Set Information
Med Surge II - Test 2
Acute Coranary Syndromes
What is the nursing diagnosis for CABG post-op?
Decreased cardiac output
What are signs of Mediastinitis?
Fever > 4 days
Signs of infection at suture site
What are signs of Postpericardiotomy syndrome?
Pericardial & pleural pain
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
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?
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?
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
How do you know if Thrombolytic Threapy has worked?
Resolution of chest pain
ST segment return to baseline
Rapid rise in cardiac enzymes
What does MOVE IT C stand for?
Chest x-ray within 30 min
CKMB normal level:
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
antiplatelets as ordered
What drug should you stop before having a CABG?