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Critical care cardiovascular lecture notes
Management Of Health Care (NURS 485)
University of Louisville
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Cardiac Management
Coronary artery disease and MI refresher: o Three major coronary arteries: RCA- located on right side of heart and supplies blood to top part of right side of heart and posterior wall LAD (left anterior descending)- ascends straight down anterior wall of heart and supplies blood to anterior wall and septum Circumflex- supplies blood to lateral wall and some of posterior wall LMCA (left main coronary artery)- supplies blood directly to LAD and circumflex, basically all of left side “widow maker” is disease of left main coronary artery Infarctions are caused by blockages/stenosis in one or multiple coronary arteries o Coronary artery disease: Stable angina Occurs in early parts of disease, for example 50-75% blockage Pain occurring with activity and relieved with rest ACS: occurs in later parts of disease, for example >80% blockage Unstable angina o Unpredictable pain that can occur with both activity and rest o After 20 minutes of unstable angina, MI occurs, and cardiac cells die Myocardial infarction o No blood supply gets through the blocked artery, causes cardiac cell injury/death o Manifestations of CAD/MI: Chest pain that can radiate, SOA, diaphoresis, N/V, pallor o STEMI o Non-STEMI EKG appearance: Ischemia: o ST depression and/or T-wave inversion o 20 minutes until this ischemia turns into an infarction Myocardial infarction: o ST elevation (STEMI) o Active injury to cardiac tissue Necrosis:
o Irreversible cellular injury to cardiac tissue o Will see pathological Q-waves that indicate irreversible cardiac injury and an OLD STEMI o > or equal to 0 seconds or 1/3 height of R-wave o Big Q-wave, larger than normal o Q-waves will appear on the lead where the injury occurred in the heart o EKG readings/coronary arteries: Leads II, III AVF- likely effects RCA and corresponds to inferior wall Leads I, AVL, V5-V6- likely effects left circumflex and corresponds to lateral wall Leads V2-V4- likely effects LAD and corresponds to anterior wall Leads I, AVL, V1-V6- likely effects LMCA and corresponds to anterior lateral wall (bad) Leads V1-V2- likely effects LAD and corresponds to septal region Reciprocal leads V1-V3- likely effects to left circumflex or RCA and corresponds to posterior wall o STEMI vs NSTEMI: Both will have positive cardiac enzymes because both are infarctions (will not elevate for ischemia) STEMI: Will have ST elevation in corresponding leads Injury all the way through all layers of the heart wall Will develop Q-waves at the site of injury on subsequent EKGs NSTEMI: No ST elevation seen Injury not through all layers. Depends on site of MI and how deep the injury is No Q-waves seen on EKG, but may develop Q-waves later o Myocardial infarction clinical manifestations: Men: N/V Jaw/neck pain Chest pain Shortness of breath Women: Back pain Diabetic/elderly: Shortness of breath (d/t diabetic neuropathy) Risk factors for MI: Hypertension
o Can give: IIB/IIIA inhibitors Integrillin Reopro Clotting factors that inhibit platelet aggregation Given pre-op before a PCI to decrease risk of clot formation in stent Clopidogrel (Plavix) Antiplatelet given 24 hours before patient goes to cath lab to decrease risk of clot formation in stent Revascularization treatments: o The only way to actually treat, 1st and 2nd line treatments only buy more time o Thrombolytics (STEMI only) Types: tPA, streptokinase streptokinase has high incidence of anaphylaxis o if a patient has ever had streptokinase before, they CANNOT receive it because of the high risk of anaphylaxis if the patient has had a recent strep infection, they cannot receive streptokinase because of anaphylaxis risk Contraindications: Recent traumas/surgery (last 3 months) Uncontrolled HTN Pregnancy Vascular malformations Bleeding disorders History of hemhorragic stroke Must be given within 6 hours of onset of symptoms Must also give within 30 minutes of arrival (door to thrombolytic time 30 minutes) Reperfusion dysrhythmias: Can cause ventricular tachycardia o PCI (unstable angina, STEMI, NSTEMI) Must be done within 90 minutes of patient walking through door Must have angiography done first to determine if they need PCI or a CABG Types: angioplasty, stent placement, thrombectomy Nursing responsibilities Pre: IV access, should be NPO, screen for contrast allergies, assess kidney function, informed consent. If patient has contrast allergy, give IV Benadryl, IV steroid, and IV Pepcid (H antagonist). If patient has poor kidney function, give PO mucomyst (should mix with juice to mask flavor/smell)
Post: monitor site with each VS check, neurovascular checks with each VS check, must lay flat for prescribed amount of time, monitor intake/output, give fluid to flush contrast, assess kidney function o CABG (must have angiography first): Complications: Infection, bleeding, heart function (brain and kidney function to ensure perfusion), hemodynamic issues Nursing interventions Monitor for infection, bleeding, hemodynamic issues, kidney/brain function Discharge education Cannot lift anything heavier than 10 lbs Cannot drive for 6-8 weeks Teach incision care CAD discharge teaching (meds, diet, exercise, smoking cessation) o MI discharge education: Diet Low fat, low cholesterol, lean meats, fresh/frozen fruits and vegetables, low sodium < 2 grams Exercise 30 minutes of cardio/day Lifestyle modifications No smoking Reduced alcohol consumption Sexual activity Can have sex again when they can climb 2 flights of stairs with no pain May go home with NTG, do not take with erectile dysfunction meds Family teaching Teach family to recognize signs of ACS, when to call for EMS, teach CPR Long term pharm therapy: Statin (lowers cholesterol): will be put on even if they do not have high cholesterol ACEI: decreases work of heart and prevents ventricular remodeling after an MI ASA: lifetime drug, helps prevent future cardiac events Beta blockers: decreases blood pressure Will also be prescribed PRN NTG (call EMS after 2nd dose) If patient had a PCI, will take Plavix from 6 weeks-12 months
o Discharge education: Daily weights (report >2-3 lbs/day or 5 lbs/week) Low sodium diet (< 2 g/day) Conservative fluid intake Follow up with HCP Cardiomyopathy: o Types: Hypertrophic: muscle is too big, cannot relax Restrictive: too tight, cannot relax Dilated: chamber stretches too far and cannot contract Dilated cardiomyopathy is a common consequence of ischemic heart events 70% of patients diagnosed and without effective treatment die within 5 years o Causes: Hypertrophic and restrictive are typically idiopathic Dilated risk factors: Ischemic events (ACS) Genetics (family members may be at risk) Alcohol Viral infections such as influenza, COVID pregnancy o Diagnostics: TEE o Treatments: Remember that prognosis is poor and requires a lot of support Treatment depends on severity Meds to treat symptoms: furosemide, vasopressors End-stage treatments: Transplant: o 50% of transplants treat DCM o Post-transplant complications: Infection (from the immunosuppressants), organ rejections, hemorrhaging, hemolysis (clotting), emboli formation, multi-system organ failure o Patients that experience ACS after a heart transplant will NOT experience any symptoms of ACS because they will not have nerve endings to the new heart Left ventricular assist device (LVAD) o Discharge teaching***** article o Do not allow fluid to enter the LVAD. Shower carefully and avoid swimming, hot tubs, and baths. o Do not drive with an LVAD
Critical care cardiovascular lecture notes
Course: Management Of Health Care (NURS 485)
University: University of Louisville
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