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What do you give if you have given nitro x3 and they still have chest pain? Why?
IV morphine
decreases pain, relaxes patient, decreases HR and BP and decreases oxygen need of heart
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Upon arrival to the ED, patient w/ACS or suspected MI will get this done in less than 10 min.
- VS
- O2 sats?
- IV access
- Brief hx
- Blood draw for cardiac markets and electrolytes
- chest x ray
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Immediate treatment for ACS/MI
- if O2 sats <94%=4L/min
- Nitro spray/sublingual
- aspirin up to 325mg
- IV morphine if nitro didnt work
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2 reperfusion therapies and goal times
- door to balloon (PCI) <90min
- door to needle (fibrinolysis) <30min
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Normal or non diagnostic ST change...what gets done?
- serial cardiac markers
- repeat ECG
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Non ST elevated MI..what do I do?
Possible PCI
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STEMI...what do I do?
thrombolysis or PCI or CABG prep
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Why are BB good?
decreasing the HR decreases the hearts O2 requirements
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What do Clopidogrel and Glycoproteins do?
platelet inhibition/atherosclerosis
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Rules for Fibrinolytic therapy....name drugs
- given w/in 6 hrs of chest pain
- ECG shows STEMI/MI
- 2 IV's....1 for this drug, the other for fluids
Activase/Streptase
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Contraindications for fibrinolytic therapy
- coagulopathy
- liver failure
- recent surgery
- stroke in last 3 months
- SBP>200
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Sign of reperfusion
washout phenomenon or PVC
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Signs of hypoperfusion
- decreased LOC
- oliguria
- lactic acidosis
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ACS vs. Angina
ACS has pain with inspiration and expiration and it doesnt decrease with position change
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How do you know fibrinolytic therapy has worked?
- no more chest pain
- ST elevation is normal
- See EXPECTED reperfusion PVC
**monitor patient for bleeding
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Beck's triad
- Hypotension
- Muffled heart sounds
- Narrowed pulse pressure
Is this right?
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S/S of Pericarditis?
- Sharp pain with inspiration
- shallow breathing
- leaning forward
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Interventions for pericarditis
- HOB at 45
- provide over the table for support
- manage pain with ASA, Tylenol, NSAIDS
- Steroids for inflammation
**dont breath deep or lay flat
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What causes rheumatic fever and then valvular dysfunction and how is it dx?
strep infection that wasnt taken care of
seen with an echo or chest x ray....patient will be tachy
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Treatment for rheumatic fever/valvular dysfunction
- antibiotics
- bed rest
- steroids
- NSAIDS
Valves replaced??
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How do you get pulmonary edema?
HF has L ventricle failure causing alveoli to get filled with fluid= crackles
Pulmonary edema occurs and will be seen with dyspnea, orthopnea, decreased O2 sats, bad ABG's, chest pain, cough and decreased CO
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End result of pulmonary edema?
cardiogenic shock
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What is cardiogenic shock and what is the goal of treatment
decreased CO....
want to decrease myocardial requirements and maximize CO
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What meds decrease pre load
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What med decreases after load?
nitro
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What medication will dilate the coronary arteries
CCB
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What medication improves heart contractility
dopamine
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Meds given based on SBP
- <70=norepi
- 70-100 w/ signs of shock=dopamine
- 70-100 w/out signs of shock=dobutamine
- >100=nitro
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What does an intra-aortic balloon pump do?
improves myocardial perfusion and decreases afterload and facilitates LV emptying
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Calculate MAP
1systolic + 2 diastolic / 3
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What is used to dx a blockage in the heart
angiogram
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Post op care after a CABG
- Chest tube-how much, color
- epicardial wires to help w/arrhythmias
- radial artery line
- foley
- Monitor:
- UO, blood glucose, dysrhythmias
watch temp...hypothermia will make them shiver, then vasoconstrict=HTN
watch for hypovolemia (blood loss)
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CK-MB
- shows heart muscle damage
- takes 3 hours to elevate
- back to normal in 3 days
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Troponin
- tells if person is having/had MI
- takes 4 hours to elevate
- back to normal in 14 days
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BNP and levels
shows heart failure
- <100= possible/no HF
- 100-300= slight HF
- 900=severe HF
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What will find clots on a person with A fib?
echo
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Tech Prophosphate
damaged heart tissue will show as hot spots
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Thallium
damaged heart tissue will show as cold spots
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Electrophysiology Study....who gets it and how's it done
V tach and V fib
- d/c anti arrhythmics and be NPO
- stim arrhythmia
- defib to terminate arrhythmia
- start patient on new regime
- take back to lab and see if working by stimulating arrhythmia
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Percutaneous Coronary Interventions/Stent....
what do I check prior to procedure?
opens occluded artery
do they have kidney disease? post treatment they will have lots of fluids to flush the dye...watch BUN and creatinine
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Manage during PCI/Stent placement
watch patients response by taking VS, watching EKG and ask if they are having chest pains
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Nursing management after PCI/Stent placement
- check under dressing q15min for 2 hrs for blood
- IV fluids to flush dye
- check distal pulses
- *HOB 20
- *straight leg
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Pressure dressing applied at femoral site can cause...
vagal response....brady down....give atropine
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