CORONARY HEART DISEASE EXAM WITH WELL ANSWERED QUESTIONS VERIFIED BY AN EXPERT 2023/2024 L, Exams of Nursing

Download CORONARY HEART DISEASE EXAM WITH WELL ANSWERED QUESTIONS VERIFIED BY AN EXPERT 2023/2024 L and more Exams Nursing in PDF only on Docsity! Care of patients with Acute Coronary Syndromes CORONARY HEART DISEASE EXAM WITH WELL ANSWERED QUESTIONS VERIFIED BY AN EXPERT 2023/2024 LATEST UPDATED. o Coronary artery disease (CAD), AKA Coronary heart disease (CHD) or simply heart disease, is the single largest killer of American men and women in all ethnic groups. o A broad term that includes Chronic stable angina & Acute coronary syndromes. o It affects the arteries that provide blood, Care of patients with Acute Coronary Syndromes oxygen, & nutrients to the myocardium. When blood flow through the coronary arteries is partially or completely blocked, ischemia & infarction of the myocardium may result. o When the arteries that supply the myocardium (heart muscle) are diseased, the heart cannot pump blood effectively to adequately perfuse vital organs and peripheral tissues. o When perfusion is impaired, the patient can have life-threatening signs & symptoms and possibly death. o Over the past decade there has been a decrease in the death rate from CAD due to:  Increasingly effective treatment.  Increased awareness/emphasis on reducing Care of patients with Acute Coronary Syndromes moderate to prolonged exertion in a pattern that is familiar to the patient. o The frequency, duration, and intensity of symptoms remain the same over several months. o CSA results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. o It is usually relieved by: Nitroglycerin or Rest & often is managed with Drug therapy.  Rarely does CSA require aggressive treatment.  Unstable Angina Care of patients with Acute Coronary Syndromes Acute Coronary Syndrome (ACS) • Used to describe patients who have either Unstable angina or an Acute myocardial infarction. • In ACS, the atherosclerotic plaque in the coronary artery ruptures, resulting in: o Platelet aggregation (“clumping”) o Thrombus (clot) formation, & o Vasoconstriction. • The amount of disruption of the atherosclerotic plaque determines the degree of coronary artery obstruction (blockage) and the specific disease process. Care of patients with Acute Coronary Syndromes • The artery has to have at least 40% plaque accumulation before it starts to block blood flow. Unstable Angina (UA) • Chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. • An increase in the number of attacks & in the intensity of the pressure indicates UA. • The pressure may last longer than 15 minutes or may be poorly relieved by rest or nitroglycerin. • Unstable angina describes a variety of disorders, including new-onset angina , variant • (Prinzmetal's) angina, and pre-infarction angina. Care of patients with Acute Coronary Syndromes 1. Non- ST-Segment elevation MI (NSTEMI) • Patients typically have ST and T-wave changes on a 12-lead ECG. o This indicates myocardial ischemia. • Initially Troponin may be normal, but it elevates over the next 3 to 12 hours . • The combination of changes on the ECG & elevation in cardiac troponin indicates Myocardial cell death or necrosis. • Causes of NSTEMI : o Coronary vasospasm o Spontaneous dissection o Sluggish blood flow due to narrowing of the Care of patients with Acute Coronary Syndromes coronary artery. • Important to note that changes in ECG along with elevation of troponin should always be assessed in conjunction with the clinical presentation & history of the patient. • Patients with elevated troponin and ECG changes without typical symptoms of acute coronary syndrome (chest discomfort, shortness of breath, nausea) typically have a condition other than CAD (such as sepsis), causing the imbalance between myocardial oxygen supply & demand. 2. ST elevation MI (STEMI) Care of patients with Acute Coronary Syndromes • Patients typically have ST elevation in two contiguous leads on a 12-lead ECG. o This indicates MI/necrosis. • STEMI is attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation & thrombus formation at the site of rupture. • The thrombus causes an abrupt 100% occlusion to the coronary artery, is a MEDICAL EMERGENCY & requires immediate revascularization of the blocked coronary artery . Care of patients with Acute Coronary Syndromes • Potassium, Calcium, & Magnesium imbalances, as well as Acidosis at the cellular level, may cause changes in normal conduction and contractile functions. • Catecholamines (epinephrine and norepinephrine) released in response to hypoxia & pain may increase the heart's rate, contractility, and afterload. o These factors increase oxygen requirements in tissue that is already oxygen deprived.  May lead to life-threatening Ventricular Dysrhythmias. • The area of infarction may extend into the zones of injury and ischemia. Care of patients with Acute Coronary Syndromes • The actual extent of the zone of infarction depends on three factors: 1. Collateral circulation 2. Anaerobic metabolism 3. Workload demands on the myocardium. Care of patients with Acute Coronary Syndromes • Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted region appears blue and swollen. o These changes explain the need for intervention within the first 4 to 6 hours of symptom onset! • After 48 hours , the infarcted area turns gray with yellow streaks as neutrophils invade the tissue & begin to remove the necrotic cells. (“Most crucial time/risk for myocardial rupture Due to weakness of myocardium. • By 8 to 10 days after infarction, granulation tissue forms at the edges of the necrotic tissue. • Over a 2- to 3-month period , the necrotic area eventually develops into a shrunken, thin, Care of patients with Acute Coronary Syndromes o Patients with obstruction of the RCA often have Inferior wall MIs (IWMIs), causing significant damage to the right ventricle. Care of patients with Acute Coronary Syndromes o It is important to obtain a “right-sided” ECG to assess for right ventricular involvement.  Patient-Centered Care • Many women with symptomatic ischemic heart disease or abnormal stress testing DO NOT have abnormal coronary angiography. • Studies implicate Microvascular Disease or Endothelial Dysfunction or Both as the causes for risk for CAD in women. • Endothelial dysfunction : The inability of the arteries & arterioles to dilate due to lack of nitric oxide production by the endothelium. Care of patients with Acute Coronary Syndromes o Nitric oxide is a relaxant of vascular smooth muscle. • Women typically have smaller coronary arteries & frequently have plaque that breaks off & travels into the small vessels to form an embolus (clot). • Positive remodeling, or outward remodeling (Lesions that protrude outward), is more common in women. o This outpouching may be missed on coronary angiography. Care of patients with Acute Coronary Syndromes preventing complications.  Patients who have THREE of the following factors are diagnosed with metabolic syndrome. o Hypertension o Decreased HDL-C (usually with high LDL-C) o Increased Level of Triglycerides o Increased Fasting Blood glucose (caused by diabetes, glucose intolerance, or insulin resistance). o Large waist size (excessive abdominal fat causing central obesity). Care of patients with Acute Coronary Syndromes Indicators of Risk Factors for Metabolic Syndrome Care of patients with Acute Coronary Syndromes  Indicators of Risk Factors for Metabolic Syndrome (Chart of Table 38-1) 1. Hypertension  Either Blood pressure of 130/85 mm Hg or Higher OR Taking Antihypertensive drug(s) 2. Decreased HDL-C (usually with high LDL-C)  Either HDL-C < 45 mg/dL for Men or <55 mg/dl for Women OR Taking an Anticholesterol drug. 3. Increased Level of Triglycerides  Either 160 mg/dL or Higher for Men or 135 mg/dL or higher for Women OR Taking an Anticholesterol drug . 4. Increased Fasting Blood glucose (caused by diabetes, glucose intolerance, or insulin resistance).  Either 100 mg/dL or Higher OR Taking antidiabetic drug(s). 5. Large waist size (excessive abdominal fat causing central obesity).  40 inches (102 cm) or greater for Men or 35 inches (89 cm) or greater for Women . Care of patients with Acute Coronary Syndromes  Patient and Family Education: Preparing for Self-Management (Text of Chart 38-1)  Prevention of Coronary Artery Disease Smoking/Tobacco Use • If you smoke or use tobacco, quit. • If you don't smoke or use tobacco, don't start. Diet • Consume sufficient calories for your body to include: o5% to 6% from saturated fats. oAvoiding trans fatty acids. oLimit your cholesterol intake to less than 200 mg/day. oLimit your sodium intake as specified by your health care provider, or under 1500 mg/day, if possible. Care of patients with Acute Coronary Syndromes Cholesterol • Have your lipid levels checked regularly. • If your cholesterol and LDL-C levels are elevated, follow your HCP’s advice, including taking statin medications as indicated. Physical Activity • If you are middle-age or older or have a history of medical problems, check with your HCP before starting an exercise program. • Exercise periods should be at least 40 minutes long with 10-minute warm-up and 5-minute cool- down periods. • If you CANNOT exercise moderately 3 to 4 times each week, Walk daily for 30 Care of patients with Acute Coronary Syndromes minutes at a comfortable pace. (30 mins of walking/day) • If you CANNOT walk 30 minutes daily, Walk any distance you can (ex: Park farther away from a site than necessary; Use the stairs, Not the elevator, to go one floor up or two floors down). Diabetes Mellitus • Manage your diabetes with your HCP. Hypertension • Have your blood pressure checked regularly. • If your blood pressure is elevated, follow your HCP’s advice. • Continue to monitor your blood pressure at regular intervals. Obesity Care of patients with Acute Coronary Syndromes • When compared with men, women are usually 10 years older when they have CAD. • Only 56% of women are aware that heart disease is the leading cause • of death in women, and even fewer can identify the symptoms of a heart attack. • Women who have MIs have a greater risk for dying during hospitalization. • When they are older than 40 years , women are more likely than men to die within 1 year after their MI. oIf women do survive, they are less likely to participate in cardiac rehabilitation programs. Care of patients with Acute Coronary Syndromes  Incidence & Prevalence “ Heart Disease = leading cause of death in women. Only 56% know it’s #1 killer” • The average age of a person having a first MI is 65.1 years for men and 72 years for women. • Many patients who survive MIs are not able to return to work.  CAD is the leading cause of premature, permanent disability in the United States and the world. • 95 % of sudden cardiac arrest victims die before reaching the hospital, largely because of Ventricular Fibrillation (V fib). Care of patients with Acute Coronary Syndromes oTo help combat this problem, automatic external defibrillators (AEDs) are found in many public places, such as in shopping centers and on airplanes. oSome patients with diagnosed CAD have AEDs in their homes or at work. Care of patients with Acute Coronary Syndromes history and modifiable risk factors, including eating habits, lifestyle, & physical activity levels. o Ask about a history of smoking & how much alcohol is consumed each day. o Collaborate with the dietitian to assess current body mass index (BMI) & weight as needed. Care of patients with Acute Coronary Syndromes Physical Assessment/Signs and Symptoms • Rapid assessment of the patient with chest pain or other presenting symptoms is crucial. • Differentiate among the types of chest pain & identify the source. • Question the patient to determine the characteristics of the alterations in comfort. oPatients may deny pain & report that they feel “pressure.” • Appropriate Questions to Ask Concerning the Discomfort Include: oOnset oLocation oRadiation oIntensity Care of patients with Acute Coronary Syndromes oDuration oPrecipitating & Relieving factors. • If pain is present, ask the patient if the pain is in the chest, epigastric area, jaw, back, shoulder, or arm. • Ask the patient to rate the pain on a scale of 0 to 10, with 10 being the highest level of discomfort. • Some patients describe the discomfort as tightness, a burning sensation, pressure, or indigestion. Care of patients with Acute Coronary Syndromes  Key Features of Angina and Myocardial Infarction Angina Myocardial Infarction • Substernal chest discomfort: - Radiating to the left arm. - Precipitated by exertion or stress (rest in variant angina). - Relieved by nitroglycerin or rest. - Lasting less than 15 minutes. - Few, if any, • Pain or discomfort: - Substernal chest pain/pressure radiating to the left arm. - Pain or discomfort in jaw, back, shoulder, or abdomen. - Occurring without cause, usually in the morning. - Relieved ONLY by opioids. - Lasting 30 minutes or more. - Frequent associated symptoms: (“Catecholamines responsible for these”) Care of patients with Acute Coronary Syndromes associated symptoms.  Nausea/vomiting.  Diaphoresis.  Dyspnea.  Feelings of fear & anxiety.  Dysrhythmias.  Fatigue.  Palpitations.  Epigastric distress  Anxiety  Dizziness.  Disorientation/acute confusion.  Feeling of “short of breath”. Care of patients with Acute Coronary Syndromes • Assess Blood pressure & Heart rate. oInterpret the patient's cardiac rhythm and presence of dysrhythmias. oSinus tachycardia with premature ventricular contractions (PVCs) frequently occurs in the first few hours after an MI. • Next, Assess Distal peripheral pulses & Skin temperature . oThe skin should be warm with all pulses palpable. oIn the patient with Unstable angina or MI : Poor cardiac output may be manifested by cool, diaphoretic Care of patients with Acute Coronary Syndromes  Patient-Centered Care • The presence of associated symptoms without chest discomfort is significant. • In up to 40% of all patients with MI, primarily older women and patients with diabetes, chest pain, or discomfort may be mild or absent. oInstead they have associated symptoms. • Some older patients may think they are having indigestion & therefore not recognize that they are having an MI. • Others report Shortness of breath as the only symptom. • Because of the ambiguity of symptoms, older adults are more likely to wait before seeking Care of patients with Acute Coronary Syndromes treatment. • The major manifestation of MI in people older than 80 years: May be Disorientation or Acute confusion because of poor cardiac output and inadequate coronary perfusion. • In some older adults with MI, absence of chest pain may be caused by cognitive impairment or inability to verbalize pain sensation. oIn most cases it is probably the result of increased collateral circulation. • Silent myocardial ischemia increases the incidence of new coronary events & should be treated aggressively. Care of patients with Acute Coronary Syndromes Psychosocial Assessment • Denial is a common early reaction to chest discomfort associated with angina or MI. • On average, the pt. with an acute MI waits more than 2 hours before seeking medical attention. oOften he or she rationalizes that symptoms are caused by indigestion or overexertion. • Denial that interferes with identifying a symptom such as chest discomfort can be harmful. • Explain the importance of reporting any discomfort to the HCP. • Fear, Depression, Anxiety, & Anger are other common reactions of many pts. & Care of patients with Acute Coronary Syndromes release of enzymes from intracellular storage, & circulating levels of these enzymes are dramatically elevated. • Acute myocardial infarction (MI), AKA Acute coronary syndrome, can be confirmed by abnormally high levels of certain proteins or isoenzymes. • Troponin is a myocardial muscle protein released into the bloodstream with injury to myocardial muscle. • Troponins T and I are not found in healthy patients, so any rise in values indicates cardiac necrosis or acute MI. Care of patients with Acute Coronary Syndromes • Specific markers of myocardial injury, troponins T and I, have a wide diagnostic time frame , making them useful for patients who present several hours after the onset of chest pain. o Even low levels of troponin T are treated aggressively because of increased risk for death from cardiovascular disease (CVD). • These markers are evaluated in addition to clinical signs and symptoms and electrocardiogram (ECG) changes when identifying at risk patients. • Following initial troponin assessment, Care of patients with Acute Coronary Syndromes levels should be assessed again in 3 to 6 hours. • Before the development of highly sensitive troponin levels, providers relied on creatinine kinase (CK), its isoenzyme (CK-MB), and myoglobin to assist with diagnosis of acute myocardial infarction. o Use of these cardiac markers is no longer recommended Care of patients with Acute Coronary Syndromes subside when the ischemia is resolved & pain is relieved. oHowever, the T wave may remain flat or inverted for a period of time. o If the patient is not experiencing angina at the moment of the test , the ECG is usually normal unless he or she has evidence of an old MI. • When Infarction occurs , one of two ECG changes is usually observed: oST-elevation MI (STEMI) oNon–ST-elevation MI (NSTEMI).  Often presented with Women having an MI. Care of patients with Acute Coronary Syndromes oAn abnormal Q wave (wider than 0.04 seconds or more than one third the height of the QRS complex) may develop.  Depending on the amount of myocardium that has necrosed. Care of patients with Acute Coronary Syndromes oWomen having an MI often present with an NSTEMI. oThe Q wave may develop because necrotic cells do not conduct electrical stimuli. o Hours to days after the MI , the ST-segment and T-wave changes return to normal. oHowever, when the Q wave exists, it may become permanent. oThe Q waves may disappear after a number of years, but their absence does not necessarily mean that the patient has not had an MI. Care of patients with Acute Coronary Syndromes  Analysis: Interpreting  The patient with coronary artery disease (CAD) may have either Stable angina or Acute coronary syndrome (ACS) .  If ACS is suspected or cannot be completely ruled out, the pt. is admitted to a telemetry unit for continuous monitoring or to a critical care unit if hemodynamically unstable.  The Priority Collaborative problems for Most Patients with ACS: 1. Acute Pain due to an imbalance between myocardial oxygen supply and demand. 2. Decreased myocardial tissue perfusion due to interruption of arterial blood flow. Care of patients with Acute Coronary Syndromes 3. Decreased functional ability due to fatigue caused by the imbalance between oxygen supply & demand. 4. Decreased ability to cope due to the effects of acute illness and major changes in lifestyle. 5. Potential for dysrhythmias due to ischemia and ventricular irritability. 6. Potential for heart failure due to left ventricular dysfunction Care of patients with Acute Coronary Syndromes  Planning & Implementation • Astute assessment skills , timely analysis of troponin, & analysis of the 12-lead ECG (or 18- lead ECG for a suspected right ventricular infarction) are essential. • Important since the average time a patient waits before seeking treatmen t is over 2 hours. • This delay lessens the 4- to 6-hour window of opportunity for the most advantageous treatment with percutaneous intervention. Managing Acute Pain • Patients with diabetes mellitus and CAD Care of patients with Acute Coronary Syndromes  Nitroglycerin, Morphine sulfate, & Oxygen. Emergency Care of the Patient With Chest Discomfort (Text of Chart 38-3) • Assess airway, breathing, and circulation (ABCs). Defibrillate as needed. • Provide continuous ECG monitoring. • Obtain the patient's description of pain or discomfort. • Obtain the patient's vital signs (blood pressure, pulse, respiration). • Assess/provide vascular access. • Consult chest pain protocol or notify the HCP or Care of patients with Acute Coronary Syndromes Rapid Response Team for specific intervention. • Obtain a 12-lead ECG within 10 minutes of report of chest pain. • Provide pain relief medication & aspirin (non– enteric coated) as prescribed. • Administer oxygen therapy to maintain oxygen saturation ≥ 90%. • Remain calm. Stay with the patient if possible. • Assess the patient's vital signs & intensity of pain 5 minutes after administration of medication. • Remedicate with prescribed drugs (if vital signs remain stable ) & check the patient every 5 minutes. Care of patients with Acute Coronary Syndromes • Notify the provider if vital signs deteriorate. Drug Therapy • Nitroglycerin to relieve episodic anginal pain. o Patient may take it at home or in the hospital. • Aspirin 325 mg, an antiplatelet drug, may also be taken daily to prevent clots that further block coronary arteries. Care of patients with Acute Coronary Syndromes the pt. may be experiencing an MI. • When ischemia persists, the HCP may prescribe IV NTG for management of the chest pain. o Begin the drug infusion slowly, checking blood pressure & pain level every 3 to 5 minutes. o The NTG dose is increased until:  The pain is relieved  The BP falls excessively, or  The maximum prescribed dose is reached.  CRITICAL RESCUE • If the patient is experiencing an MI: o Prepare them for transfer to a specialized unit where close monitoring & appropriate Care of patients with Acute Coronary Syndromes management can be provided. o If the pt. is at home or in the community, Call 911 for transfer to the closest emergency department. DRUG ALERT: • Before administering NTG, ensure that the patient HAS NOT TAKEN any Phosphodiesterase Inhibitors for erectile dysfunction within the past 24 to 48 hours. o Sildenafil (Viagra, Revatio) o Tadalafil (Cialis) o Vardenafil (Levitra) Care of patients with Acute Coronary Syndromes • Concomitant use of NTG with these inhibitors can cause Profound Hypotension . Care of patients with Acute Coronary Syndromes  Morphine Sulfate (MS) • Morphine sulfate (MS) may be prescribed to relieve discomfort that is unresponsive to nitroglycerin. • Morphine: o Promotes comfort o Decreases myocardial oxygen demand o Relaxes smooth muscle o Reduces circulating catecholamines. Care of patients with Acute Coronary Syndromes • Usually administered in 1- to 5-mg doses IV every 5 to 30 minutes until: o The maximum prescribed dose is reached o The pt. experiences relief or o The pt. experiences signs of toxicity. • If Hypoxemia is present : The HCP may prescribe Oxygen at a flow of 2 to 4 L/min to maintain an arterial oxygen saturation of 90% or • Monitor for Adverse Effects of Morphine: o Respiratory depression o Hypotension o Bradycardia o Severe vomiting. • Treatment for Morphine Toxicity: o Naloxone (Narcan) 0.2 to 0.8 mg IV o Vasopressor drugs o IV fluids & o Oxygen therapy. Care of patients with Acute Coronary Syndromes higher.  The use of oxygen in the ABSENCE OF HYPOXEMIA has been shown to increase coronary vascular resistance, decrease coronary blood flow, & increase mortality. • Monitor pt's vital signs & cardiac rhythm every few minutes . • If the BP is stable : • Help pt. assume any position of comfort. • Placing the patient in Semi- Fowler's position often enhances comfort & tissue oxygenation. • A Quiet, calm environment & explanations of interventions Care of patients with Acute Coronary Syndromes Acute Coronary Syndrome (Nitrates, Beta Blockers, Antiplatelets) DRUG CATEGORY NURSING IMPLICATIONS Nitrates Common examples of nitrates: Monitor blood pressure (BP) and pay close attention to orthostatic changes because a decrease in BP occurs with vasodilation. + Sublingual tablets: Nitrostat, Nitroquick * Dizziness can occur with drop in BP. + Sublingual spray: Nitrolingual Monitor for headache because onsodilation is generalized. * Transdermal nitroglycerin: Minitran, Nitro Dur, Nitrek | Do not administer to patients taking drugs used to treat sexual dysfunction (e.,, sildenafil, tadalafil, vardenafil) because * Isosorbide dinitrate (Isordil, Iso-Bid) ery serious, possibly fatal mvteractions can occur. * Isosorbide mononitrate (Imdur) Always assess for pain relief because additional medication may be required. With sublingual tablets or spray: + Instruct patient to lie down when taking because the hypotensive response can be dramatic, + Tablets can be taken every 5 minutes for pain relief, up to 3 tablets. * Be sure to allow the tablet to dissolve because it is absorbed through the mucous membranes. * Check expiration date because the efficacy decrenses over time and should be replaced every 3-5 months. With transdermal nitroglycerin: + Apply the patch to a clean, dry, hairless area because the medication will be better absorbed. + Rotate application sites fo prevent skin irritation. # Remove the patch before defibrillation to prevent burs. « Remove patch after 12-14 hours each day to prevent drug tolerance, Beta Blockers Common examples of beta blockers: Assess HR and BP before administration because beta blockers case a decrease in HR anc cardiac output and suppress renin activity. * Carvedilol (Coreg, Coreg CR) * Donot administer if heart rate is <50-60 beats/min. * Hold for systolic <90-100 mm He. +e Les, Tp, ec (Observe for sins of eat alr such as cough, edema, shortness of breath, and weight gain bcs hs am ocur tha cardioselective beta-adrenergic blocker decease in adic et Assess for wheezing and shortness of breath because betay blocking effects in the lungs can cause bronchoconstriction, Antiplatelets Common examples of antiplatelets: Inform patients to report any unusual bleeding or bruising because bleeding is a side effect for all medications in this cafegory, vhost ss Avoid over-the-counter pain medications that contain additional aspirin. pm Goren ae 4 With aspirin therapy: * Clopidogrel Plavix) * Take with food because gustric irritation may occur, oie >a Eien) + Assess for ringing in ears beenuse this can be a sign of aspirin toxicity, Tica ee (Brin) * Teach patient that aspirin is an important cardiac medication that should not be stopped unless indicated by the provider as 5 : ee (Kengrea) studies indicate better survival rates for patients with CAD receiving aspirin, *?, ie Inhibitor With P2Y12 platelet inhibitors: * Take with food because drug can cause diarrhen and GI upset. * Vorapaxar sulfate (Zontivity) oDanel Plavix with Paxil  Care of patients with Acute Coronary Syndromes  Common Examples of Drug Therapy: Acute Coronary Syndrome (Nitrates, Beta Blockers, Antiplatelets) [ Text of Chart 38-4 ]  Nitrates  Nursing Implications:  Monitor blood pressure (BP) & pay close attention to orthostatic changes because a decrease in BP occurs with vasodilation. o Dizziness can occur with drop in BP.  Common Examples: o Sublingual tablets: Nitrostat, Nitroquick o Sublingual spray: Nitrolingual o Transdermal nitroglycerin: Minitran, Nitro Dur, Nitrek o Isosorbide dinitrate (Isordil, Iso-Bid) o Isosorbide mononitrate (Imdur) Care of patients with Acute Coronary Syndromes  Monitor for headache because vasodilation is generalized.  DO NOT administer to patients taking drugs used to treat sexual dysfunction (ex: Sildenafil, Tadalafil, Vardenafil) because very serious, possibly fatal interactions can occur.  Always assess for pain relief because additional medication may be required.  With Sublingual Tablets or Spray: o Instruct patient to lie down when taking because the hypotensive response can be dramatic. o Tablets can be taken every 5 minutes for pain relief, up to 3 tablets. o Be sure to allow the tablet to dissolve because it is absorbed through the mucous membranes. o Check expiration date because the efficacy decreases over time & should be replaced every 3-5 months. With transdermal nitroglycerin: Care of patients with Acute Coronary Syndromes  Antiplatelets  Nursing Implications:  Inform patients to report any unusual bleeding or bruising because bleeding is a side effect for all medications in this category.  Avoid over-the-counter pain medications that contain additional aspirin.  Common Examples: o Aspirin (Ecotrin, Asaphen ) o P2Y12 Inhibitors o Clopidogrel (Plavix) o Prasugrel (Effient) o Ticagrelor (Brilinta) o Cangrelor (Kengreal) o PAR-1 Inhibitor o Vorapaxar sulfate (Zontivity) Care of patients with Acute Coronary Syndromes  With Aspirin Therapy: o Take with food because gastric irritation may occur. o Assess for ringing in ears because this can be a sign of aspirin toxicity. o Teach pt. that aspirin should not be stopped unless indicated by the provider. - Studies indicate better survival rates for patients with CAD receiving aspirin.  With P2Y12 platelet inhibitors: o Take with food because drug can cause diarrhea & GI upset . o DO NOT CONFUSE Plavix with Paxil. Care of patients with Acute Coronary Syndromes  Increasing Myocardial Tissue Perfusion Expected Outcome: • The primary outcome is that the patient will have increased myocardial perfusion. o As evidenced by an adequate cardiac output, normal sinus rhythm , & vital signs within normal limits. Interventions: • Restoring perfusion to the injured area often limits the amount of extension & improves left ventricular function. o Within 4 to 6 hours for NSTEMI & o 60 to 90 minutes for STEMI.  Complete, sustained reperfusion of coronary Care of patients with Acute Coronary Syndromes Glycoprotein (GP) IIb/IIIa inhibitors • Abciximab (ReoPro) • Ptifibatide (Integrilin) • Tirofiban (Aggrastat) • May be administered IV to prevent fibrinogen from attaching to activated platelets at the site of a thrombus. • These medications are used in Unstable Angina and NSTEMI.  DRUG ALERT: • Dual antiplatelet therapy is suggested for all patients with ACS. • Incorporating Aspirin and either Clopidogrel (Plavix) or Ticagrelor (Brilinta). • The major side effect for each of these agents is bleeding. • Observe for bleeding tendencies (nosebleeds or blood in the stool). • Medications will need to be discontinued if evidence of bleeding occurs. • Teach patients signs of bleeding and when to contact the health care provider. Care of patients with Acute Coronary Syndromes • Given Before and During Percutaneous Coronary Intervention (PCI) to maintain patency of an artery with a large clot. • Given with fibrinolytic agents after STEMI.  DRUG ALERT: • When giving GP IIb/IIIa inhibitors, assess the patient closely for bleeding or hypersensitivity reactions. • If either occurs, notify the HCP or Rapid Response Team immediately. • Monitor the platelet level 4 hours after starting the drug and daily thereafter . • Notify the cardiologist if the pt. experiences a significant decrease in platelet count per agency protocol. Care of patients with Acute Coronary Syndromes  Antiplatelet Therapy • Clopidogrel (Plavix) or Ticagrelor (Brilinta), also known as P2Y12 platelet inhibitors. o May be given with an initial loading dose followed by a daily dose for up to 12 months after diagnosis. • Prasugrel (Effient) o Only recommended in those undergoing Primary coronary intervention. o These oral agents work to prevent platelets from aggregating (clumping) together to form clots. • A newly approved antiplatelet agent (aka Protease-activated receptor inhibitor PAR-1),