Cardio

• Acute Coronary Syndrome


  Results from prolonged ischemia
• Types of Acute Coronary Syndrome

  • Stable angina
  • Unstable angina
  • Myocardial infarction (MI)
• Stable angina


  • Occurs with exercise/emotional stress—relieved by rest/nitroglycerin
• Unstable angina


  • Occurs with exercise/rest-- increases in occurrence, severity, duration over time
  • ONLY treated by NITROGLYCERIN
  • Give nitroglycerin to prevent MI
  • Nitroglycerin: 3 doses MAX every 5 mins
• Acute MI


  • Non-ST-segment elevation MI (NSTEMI): Least dangerous—not enough damage to heart to see EKG changes
  • ST-segment elevation MI (STEMI): Loss of impulses sufficiency—NOT GOOD
• Nonmodifiable risk factors for Acute Coronary Syndrome

  • Age (older adults)
  • Race
  • Gender (males)
  • Family history
• Modifiable risk factors for Acute Coronary Syndrome

  • Sedentary lifestyle
  • Tobacco use
  • Diet
  • Hyperlipidemia
  • Obesity
  • Hypertension
  • Stress
  • Type 2 diabetes
• Expected findings for Acute Coronary Syndrome

  • Anxiety, feeling of impending doom
  • Chest pain (tight squeezing, crushing, heavy/aching pressure, constricting feeling in chest, can radiate to neck, shoulder, arm, jaw, weakness/numbness in arms)
  • Indigestion, nausea
  • Dizziness
  • Females often report no pain—goes unnoticed (characterized by pain between shoulders, jaw, sensation of choking with exertion)
• Physical assessment findings for Acute Coronary Syndrome

  • Tachycardia/heart palpitations
  • Tachypnea/SOB (dyspnea)
  • Hypotension
  • Pallor, cool, clammy skin
  • Diaphoresis
  • N/V
  • Decreased LOC
• Stable angina


  Precipitated by exertion/stress, relieved by rest/nitroglycerin, manifestations last less than 15 min, NOT associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
• Myocardial infarction (MI)


  Can occur without cause, often in morning after rest, relieved ONLY by opioids, manifestations last more than 30 min, associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
• Troponin is the #1 indicator of cardiac tissue damage
• Any positive value of troponin indicates damage to cardiac tissue and should be reported
• Troponin value over 0.5 indicates heart trauma
• Electrocardiogram (ECG)


  1. Assess for changes on serial ECGs

  2. Angina: ST depression/T-wave inversion = presence of ischemia

  3. MI: T-wave inversion = ischemia; ST-segment elevation = necrosis

  4. NSTEMI: no significant ECG changes/persistent ST elevations

  5. STEMI: ST segment elevations in 2 separate leads
• Stress test


  1. Client exercises muscle by walking on a treadmill

  2. Provides info about the workload of heart

  3. Test is discontinued one HR reaches certain rate

  4. Fatigue/disability can prevent traditional exercise testing/test completion
• Stress test considerations


  • Pre-procedure: Instruct pt to fast 2-4hrs before procedure, avoid tobacco, alcohol, caffeine before test, instruct pt to get adequate rest the night before
  • Intra-procedure: Apply 12-lead ECG to monitor HR, monitor for dysrhythmias throughout procedure, instruct pt to report any chest pain, SOB, dizziness during procedure
  • Post-procedure: Check BP frequently until pt is stable, monitor pt by 12-lead ECG, provider reviews findings with pt
• MONA


  1. morphine, O- oxygen, N- nitroglycerin, A- aspirin
• Administer ASPIRIN upon arrival, beta-blocker within 24 hrs, thrombolytic within 30 mins
• Nitroglycerin


  • Use: angina and help control BP
  • Use cautiously with other antihypertensive meds
  • Monitor for orthostatic hypotension
  • Ensure pt has NOT taken phosphodiesterase inhibitor (Viagra) within 24-48hr = hypotension can result
• Client education for chest pain


  • Stop activity and rest
  • Place nitroglycerin tablet sublingually
  • If pain is unrelieved in 5 min, call 911 or be driven to ER
  • 3 doses MAX taken every 5 mins
  • Common adverse effect: headache
  • Change positions slowly
• Morphine


  • Treat moderate-severe pain
  • Use cautiously with pts with asthma/emphysema due to risk of resp. Depression
• Nursing actions for morphine

  • Assess pain every 5-15 mins
  • Watch for signs of respiratory depression, especially in older adults (if respirations are less than 12/min, STOP med, and notify provider immediately)
  • Monitor vital signs for hypotension and decreased respirations
  • Assess for N/V
• Client education for morphine

  • Notify nurse if N/V persist
  • Only pt is allowed to push PCA pump
• Metoprolol (beta-blocker)


  • Has antidysrhythmic/antihypertensive properties decreasing imbalance between myocardial oxygen supply/demand by reducing afterload and slowing HR
  • In an acute MI, beta-blockers decrease infarct size/improve short/long term survival rates
• Nursing actions for beta-blockers

  • HOLD medication if apical pulse is LESS than 60/min & notify provider
  • AVOID giving to pts who have ASTHMA
  • Use with caution in pts who have HF
  • Monitor for decreased LOC, crackles in lungs, chest discomfort
• Client education for beta-blockers

  • Change positions slowly
  • NOTIFY provider immediately of SOB, edema, weight gain, cough
• Aspirin


  • Prevents vasoconstriction
  • Antiplatelet agents can cause GI upset
• Nursing actions for aspirin


  • Use cautiously with pts who have a hx of GI ulcers
  • Tinnitus can be a manifestation of aspirin toxicity
• Client education for aspirin


  • Risk for bruising/bleeding while on this med
  • Choose enteric-coated form and take w food to minimize GI upset
  • REPORT ringing in ears
• Heparin/enoxaparin (anticoagulants)


  • Used to prevent clots from becoming larger/other clots from forming
• Nursing actions for anticoagulants

  • Assess for contraindications (active bleeding, peptic ulcer disease, hx of stroke, recent trauma)
  • Monitor platelet levels and bleeding times: PT, aPTT, INR, CBC
  • Monitor for adverse effects of anticoagulants (thrombocytopenia, anemia, hemorrhage)
• Client education for anticoagulants

  Risk for bruising/bleeding while on this med
• Acute MI


  • Complication of angina not relieved by rest/nitroglycerin
• Nursing actions for acute MI

  • Administer oxygen to maintain O2 of 90%+
  • NOTIFY provider immediately
• Heart failure/Cardiogenic shock


  • Serious complication of pump failure
  • Manifestations: tachycardia, hypotension, inadequate urinary output, altered LOC, resp. distress (crackles/tachypnea), cool, clammy skin, decreased peripheral pulses, chest pain
• Nursing actions for heart failure/cardiogenic shock

  • Administer oxygen. Intubation/ventilation can be required
  • Administer IV morphine, diuretics, nitroglycerin to decrease preload
  • Administer IV vasopressors/positive inotropes to increase cardiac output and maintain organ perfusion
• Nursing actions for dysrhythmias

  • Monitor ECG/vital signs
  • Administer oxygen
  • Administer antidysrhythmic meds
  • Prepare for cardiac pacemaker/implantable cardioverter defibrillator if needed
• Dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI
• Chest pain lasting longer than 15 min is an indication of unstable angina