1
Q
Stable Angina
A
predictable and consistent
pain with exertion
relieved by rest/Nitro/both
2
Q
Unstable Angina
A
“preinfarction”
episodes increase in frequency and severity, happens for no reason, may not be relieved by rest and Nitro
3
Q
Intractable/Refractory Angina
A
severe and incapacitating, nothing relieves it
4
Q
Variant (Prinzmetal) Angina
A
pain at rest due to coronary artery vasospasm
5
Q
Silent ischemia
A
objective EKG evidence of ischemia with no CP or other s/s
6
Q
s/s may accompany angina
A
anxiety, dyspnea/SOB, dizziness, n/v
7
Q
leads to collateral development
A
chronic ischemia, genetics
8
Q
atypical s/s of myocardial ischemia in these groups
A
elderly (maybe only dyspnea and fatigue d/t decreased SNS response)
Women (get more GI s/s)
DM (neuropathy)
9
Q
Three effects of smoking that make it a RF for CAD
A
increased CO2 decreases oxygenation
Nicotine stimulates catecholamines, which increase HR, BP, and demand on heart
Increased plt aggregation increases risk of thrombus
10
Q
elevated lipids are a well establish RF of
A
CAD
cholesterol over 200
TGA over 200
11
Q
Metabolic syndrome
A
cluster of metabolic abnormalities that are a major RF for CVD (3 more more) DM obestiy dyslipidemia HTN increased fibrinogen level
12
Q
4 things that increase injury to arterial endothelium
A
smoking
HTN
DM
genetics
13
Q
Coronary arteries are perfused at this time, so…
A
During diastole when resistance is low
So, and increased HR shortens diastole, which can decrease myocardial perfusion
Need diastolic BP of at least 60 for good perfusion
14
Q
Coronary arteries
A
Right CA
Left Main CA-branches into LAD and Circumflex
15
Q
leading COD in US, all ages and races
A
CVD
16
Q
leading cause of CVD
A
CAD
17
Q
HR is determined in the heart by
A
myocardial cells with fastest firing rate
SA node : 60-100
AV node: 40-60 some ppl will show s/s, some not
Ventricular pacemaker sites: 30-40 too slow
18
Q
PNS influences HR
A
via vagus nerve
slows HR by affecting SA node
19
Q
SNS influences HR
A
increases HR by increasing circulating catecholamines from adrenal gland
20
Q
HR is controlled by (4)
A
ANS
CNS
baroreceptors
pacemakers
21
Q
Specialized nerve cells in aortic and carotid arches that are sensitive to increased BP
A
Baroreceptors
when stimulated by increased BP they signal the medulla to increase PNS stimulation of heart, which inhibits SA node and inhibits SNS influence, lowering HR and BP
22
Q
Three factors that affect Stroke Volume
A
Preload
Afterload
Contractility
23
Q
Preload
A
Degree of stretch in ventricular muscle fibers at the end of filling (diastole)
Determined by volume of blood in LV
24
Q
Frank-Starling Law
A
As volume of blood returning to heart increases, muscle stretch increases, resulting in a stronger contraction and greater SV
increased stretch=increased degree of shortening
As preload increases, SV increases
UNTIL physiologic limit is reached
25
Base of heart is at the
top
26
Apex of heart is at the
bottom
27
normal SV
70 ml/beat
28
normal CO
5L/min
29
atrial and ventricular systole are not simultaneous because
this allows ventricles time to fill passively and receive "atrial kick" prior to ejecting blood
30
the only veins that carry oxygenated blood
pulmonary veins
31
apical impulse (PMI) is located
5th intercostal space and left midclavicular line
32
These valves are open during diastole and close in response to contraction
AV valves:
Tricuspid (Rt)
Mitral (Lft)
33
These valves open during systole
Pulmonic and Aortic valves
34
Heart uses the % of O2 delivered
80%, most organs use 25%
35
If HR rises above this level, increase risk MI due to shortened diastole
100, especially in CAD pt
36
Two cell types in heart
Electrical--initiate and conduct impulse
| Mechanical--contract in response to stimulation
37
Job of AV node
coordinates incoming impulse from atria and after a slight delay relays impulse to ventricles
38
Impulse relayed to ventricles from AV node to
Bundle of His (AV bundle) to
Right and Left Bundle Branches, to
Purkinje fibers
39
Purkinje fibers are specialized to
rapidly conduct impulse through thick wall of ventricles
40
In Resting state of myocytes, ions distribution
K higher inside cell (--- charge)
| Na higher outside cell (+++)
41
Repeated cycle of depolarization and repolarization of cardiac myocytes
Cardiac Action Potential
42
Depolarization
Na and Ca enter cell, make inside cell more +++
| K goes out of cell, makes outside more ---
43
Repolarization
Ions revert to resting state
| must be complete before cell can depolarize again correctly (refractory period)
44
Effective refractory period
cell is completely unresponsive, cannot depolarize early
45
Relative refractory period
if impulse is stronger than normal, cell may depolarize prematurely
early depolarization of atria cause premature contractions and dysrhythmias
46
Why is Vfib or Vtach dangerous
not enough time for ventricles to fill properly or eject, blood pools, clots form, decreased perfusion, can lead to asystole
47
PVC + myocardial ischemia can trigger
Vtach or Vfib
48
P wave signifies
atrial depolarization
49
QRS complex signifies
Ventricular depolarization (atrial repolarization is hidden under wave)
50
T wave signifies
Ventricular repolarization (relaxation and filling)
51
chamber pressures are measured in
hemodynamic monitoring
52
Cardiac Output
Volume of blood pumped out of heart in L/min
| =SV x HR
53
to increase preload, you need to
increase blood return to the heart
54
Afterload
resistance of ejection of blood from the ventricle
55
As afterload increases, SV
decreases
56
Contractility
force generated by contracting myocardium; ability of muscle fibers to shorten in response to electrical impulse; related to number and state of myocardial cells
57
Contractility is increased by
circulating catecholamines
SNS influence
certain meds
58
Contractility is decreased by
```
hypoxemia
acidosis
certain meds (Beta Blockers)
```
59
Percentage of End Diastolic Volume ejected with each beat; used as a measure of myocardial contractility and LV function
Ejection Fraction
| normal LV: 55%-65%
60
decreased LV function, heart failure are signified by EF of
less than 40%
61
s/s of CAD
```
CP
n/v
cool extremities
diaphoresis
xanthelasma
```
62
Cholesterol deposits around eyes often seen in CAD patients
xanthelasma
63
CP is caused by
myocardial ischemia
64
s/s fo myocardial ischemia besides CP
Dyspnea, exertional dyspnea, PND
weight gain and dependent edema
syncope
fatigue
65
Goal of angina treatment
Decrease demand on heart and increase O2 supply to heart, reduce other complications
66
myocardial injury
Reversible--increasing O2 and nutrients can save area, no intervention, area will become necrotic
ST segment elevation on EKG
67
myocardial ischemia
Still Reversible
| ST segment depression on EKG
68
Myocardial necrosis
Irreversible, dead heart tissue in area of infarct
| begins 20-30 min from time of occlusion
69
Nitroglycerin serves to
vasodilate coronary arteries
| decrease O2 consumption by myocardium
70
store nitro
in dark glass bottle, away from light and moisture
| good for 6 months from opening
71
touching nitro to skin can cause
HA and decreased BP
72
MI results from
reduced blood flow in a coronary artery, usually d/t both a plaque and a thrombus
73
Acute Coronary Syndrome includes
Unstable angina and MI (same process at different points on a continuum)
74
check thyroid tests with CP because
hyperthyroidism can cause CP
75
CK-MB
Creatine kinase
Enzyme in cardiac cells that is released when they die
no longer evident after 3-4 days
false + by exercise from skeletal muscle
76
Myoglobin
protein in cardiac cells, short lived and not always elevated
77
Troponin 1
protein in cardiac cells
| Top marker for acute MI, no longer evident after 7 days
78
Troponin T
protein in cardiac cells
| evident for up to 21 days
79
Beta Blockers overall function
reduce workload of heart
decrease HR and BP, and contractility
improved LV diastolic function
80
give morphine for acute MI because
helps relax heart and decrease CP
81
AE of nitroglycerin
HA, decreased BP, decreased HR
82
Acute MI treatment (
```
EKG in 10 minutes
O2
aspirin
nitroglycerin
morphine
beta blockers
ACE inhibitor in 24h
blood thinners
bed rest
stool softeners
```
83
These meds decrease risk of re-infarction after MI and increase survival rate after MI
Beta Blockers
84
why stool softeners after MI
avoid straining, increased pressure can signal baroreceptors to lower BP, cause syncope
85
Prevent a clot from becoming larger
antiplatelet meds
| aspirin, plavix
86
Inhibit new clot formation
Anticoagulants
| Coumadin, heparin
87
Angioplasty aka
Percutaneous Coronary Intervention
| balloon, place stents
88
After Cardiac Cath care
Watch bleeding at site, pressure dsg
Contrast dye can be lethal to kidneys, Mucomyst can protect kidneys from dye
Watch for dysrhythmias (from cardiac manipulation)
89
these veins often used for bypass graft procedures
Greater and lesser saphenous veins of leg
90
Triple vessel disease requires
open heart surgery, CABG
91
lipitor is best cholesterol reduction med but
can damage liver, need to watch liver function
92
What raises HDL?
Exercise, moderate alcohol consumption, estrogen (in women, cholesterol can begin to rise at menopause)
93
81 mg ASA
protective from MI, same as 325 mg
| minimum effective dose bc ASA can be hard on stomach lining
94
Fastest to slowest absorption for injections
IV, IM, SC
94
Omega 3
Provides essential fatty acids, decreases inflammation
95
Angles and gauge for typical SC
45, 3/8-5-8 inch
96
SC sites
Upper arms, abd, ant and lat thighs
97
Complication of sc injection
Sterile abcess
98
SC insulin
Insulin syringe
90 deg
28 gauge
99
To mix insulin
Draw up clear, then cloudy
100
Hold for 10 sec after insulin SC injection
To prevent hematoma and ensure absorption of viscous med
101
Lovenox dose is based on
Weight
102
Before giving heparin or lovenox you should know
Platelet count
103
Gauge and Needle length for IM injections
1 to 1 1-2 inches
| 20-23 gauge
104
Gauge selection depends on
Viscosity of medication
| Larger number, smaller bore
105
Tuberculin syringe used to
Measure doses less than 1 mL
106
Filter needle used when
Withdrawing fluid from and ampule
| Change before injecting
107
Main fluid will hang
Lower than minibag
108
Secondary solution set tubing is connected
At the Y port ABOVE the pump
109
Aortic area
Right side of sternum
| 2nd ICS
110
Pulmonic area
Left side of sternum
| 2nd ICS
111
Erb's Point
Left 3rd ICS
| Hear S1 and S2
112
Tricuspid area
Lower left sternal border
| 4th ICS
113
Mitral area
Left 5th ICS, medial to MC line
114
S1 "Lub"
Sound of AV valves closing
| Beginning of systole
115
S2 "Dub"
Sound of aortic and pulmonic valves closing
| Beginning of diastole
116
Murmurs caused by
Turbulent blood flow due to narrowed valves or other defect; or normal process (pregnancy, fever, hyperthyroid)
117
Difference between apical and radial pulses
Pulse deficit, signifies arrhythmia
118
CIWA
Clinical Intoxication Withdrawal Assessment
MD may have SO for benzodiazepines based on positive findings
119
Death can occur from abruptly stopping use of these drugs
Alcohol
Benzodiazepines
Barbiturates
120
Different drugs have a specific syndrome that results from their withdrawal, and the s/s are due to
Effect of the substance on the CNS
121
Alcohol absorbed by the
Mouth, stomach, and SI
122
Normal alcohol metabolism is 10 mL in
90 minutes
123
Metabolic tolerance
Increased drug-metabolizing enzyme in the liver
124
Sign of drug dependence
Tolerance/withdrawal
125
BA of .05% to .15
Disinhibition and impaired judgement, euphoria
| 1-2 drinks
126
Slurred speech, staggering gait, and double vision occur at BA of
.15 to .25
127
Severe respiratory depression and coma (alcohol poisoning) can result from BA of
.40-.50%
128
Why does alcohol affect Brain before spinal column? (Disinhibition before unsteady gait)
Alcohol rapidly crosses BBB
129
Women are more easily intoxicated than men, Asians more easily than other races, because?
They have less alcohol dehydrogenase
130
A person who fails to fulfill role due to Substance use, has legal problems and yet continues to use, and uses dangerously and yet has not met criteria for dependence, their problem is defined as
Substance abuse
131
Criteria for drug dependence
Tolerance and withdrawal
132
Drug tolerance
Need to use more to get same effect
133
Physical tolerance
Tissue adaptation
| Changes in cells of NS so more drug is needed
134
Cross tolerance
Need more of drugs like the drug you depend on also ex-alcohol dependence and benzodiazepines
135
Behavioral tolerance
Ability to mask behavioral effects of intoxication
136
Tolerance is never developed to
Effects of respiratory depression ( can stop breathi g I. Sleep)
137
Substance withdrawal
Substance specific syndrome due to cessation or reduction in use
138
Minor alcohol withdrawal
Hangover (6-12 hours after last drink)
| Irritable, agitated
139
Alcohol withdrawal
24 hours after last drink
Tachycardia, increased BP--can go very hi, needs treatment
Diaphoresis , n/v, hallucinations
140
Major alcohol withdrawal
48-72 hours after last drink
Seizures
Delerium tremens
141
Deletion tremens
Hallucinations from major alcohol withdrawal- bugs crawling over you, pt can be terrified
142
Nsg care during alcohol withdrawal
Monitor VS closely
| Safety
143
Management of alcohol withdrawal
```
Early detection
Safety
Fluids
Benzodiazepines
MgSO4 and Dilantin for seizures
B vitamin replacements
```
144
Why B vitamin supplements for alcohol withdrawal
Alcohol decreases B vitamins and PTA often don't eat we'll. needed for nerve conduction.
146
Wernicke-Korsakoff Syndrome
Irreversible alcohol encephalopathy
Amnesia, confabulation, peripheral neuropathy
more likely to develop in women
147
Wernicke Korsakoff syndrome results from
Poor nutrition, especially inadequate thiamin and niacin and from neurotoxicity of alcohol
148
physical effects of alcohol
CNS selective anesthetic and depressant, cytotoxic and toxic to organs (cirrhosis, cardiomyopathy, pancreatitis, gastritis, psoriasis, increased cancer risk)
```
kills brain cells, blackouts
auditory hallucinations
dementia
peripheral neuritis, muscle weakness, ataxia
delirium tremens
```
149
Delerium tremens
extreme motor agitation, visual and tactile hallucinations, and seizures
150
very dangerous to combine alcohol with
other CNS depressants (benzos, opiates)
151
FAS
Fetal Alcohol Syndrome: alcohol inhibits fetal development in first trimester.
Only preventable mental retardation
152
most addictive drug
cigarettes, then heroin
153
endorphin agonists that relieve pain and reduce anxiety
opioids: Morphine, oxycodone, heroin, Fentanyl, methadone, Demerol, diluadid, codeine
154
Heroin has highly addictive because
readily crosses BBB
155
death from opioid abuse is caused by
respiratory depression
156
AE of opioid use
```
resp depression
constipation
decreased GI secretions
reduced pupil size
Hypotension
```
157
opioid antidote
naloxone (Narcan) Blocks neuroreceptors affected by opioids. Give for suspected OD, wont hurt pt if its not an OD
158
Examples of stimulants
Cocaine, amphetamines (Meth), crack
159
Withdrawal from stimulants
physical withdrawal mild, not life threatening; psychological withdrawal is severe, with intense cravings
160
Mode of action of stimulants
deplete monoamine NTs associated with depression, are highly pleasurable
161
Due to difficult psych withdrawal from cocaine, pts are
high suicide risk
162
presentation and withdrawal very similar to alcohol
benzodiazepines
163
Examples of benzodiazepines
Versed, Ativan, valium, Xanax, Rohypnol
164
HIghes risk of inhalant abuse
kids and poor
165
Inhalant abuse causes
CNS depression
hilarity, asphyxiation
some lipid soluble, can have prolonged effect on brain
166
Examples of hallucinogens
marijuana, mescaline, mushrooms, LSD, PCP. Ecstacy
167
Effect of hallucinogens
altered sense of reality, hallucinations, panic, confusion, paranoia
No withdrawal but effects can last a long time
168
Effects of marijuana
sense of well being
altered perception
increase hunger, antiemetic (THC)
impaired balance
impaired short term memory and concentration
harms lungs, weakens heart contraction, immunosuppression, reduces sperm count
169
depression increases risk of poor outcomes in
cardiac disease due to decreased compliance
170
2 most prevalent causes of death and disability worldwide
CV disease and depression
171
To be a depressive illness, s/s have to last for at least
2 weeks
172
anhedonia
Hallmark of depression: loss of interest in things you used to enjoy
173
Depression-decrease in NTs
serotonin and NE
174
with physical illness, risk for MDD increases
50%
175
medications associated with depression
Beta Blockers and other anti-HTN meds
steroids
CNS depressants: benzodiazepines, alcohol, opioids
amphetamines, when coming down
176
depression in elderly probably arises from
multiple losses
177
this group is high risk for substance abuse and underreported depression
elderly
178
to asses a client with depression use
```
Mental Status Exam:
Appearance (Hygeine? eye contact? affect?)
Behavior (slowed?)
Mood (subjective-ask)
Thoughts (psychomotor retardation?)
Interactions (Isolative?)
Hx
```
179
Most common med for depression
SSRIs
| Celexa, Lexapro, Paxil, Zoloft, Prozac, Luvox
180
Tricyclic antidepressants-try to avoid due to
anticholinergic AEs
181
Danger of MAOI use
dietary restrictions (could cause Hypertensive crisis if eat aged cheese)
182
Bipolar Affective Disorder is characterized by
pathological mood swings from mania to depression
183
NT imbalance in Bipolar
decreased serotonin
| increased NE
184
Bipolar 1 disorder
alternate MDD to mania (at least one episode of each)
185
Bipolar II disorder
alternate MDD to hypomania
186
Mirror image of depression
mania
187
s/s of mania
intrusive, restless, frenzied, rapic speech, loose associations, irritable to hostile, delusional, graindiose, no fear, engages in risky behavior
188
drug of choice for bipolar
lithium
189
manic pt high risk for suicide due to
impulsivity and lows experienced after
190
Therapeutic zone for lithium
0.6-1.2 mEq/L
191
s/s of lithium OD
```
Diarrhea
Ataxia
Blurred vision
BAD
Higher--coma and death
```
192
Do not use lithium with these pts
cardiac diseases
renal diseases
pregnancy
hypothyroid
193
Anticonvulsant mood stabilizers
Tegretol, Depakote
194
Drugs for bipolar
Mood stabilizers:
1. Lithium
2. Anticonvulsants
3. Atypical antipsychotics
195
low lethality, low intent/planning, little physical damage
suicide gesture
196
Best place to hear s1 and s2
.
197
SAD PERSONAS
```
Sex
Age
Depression History
Past Attempts
Etoh
Rational Thinking Loss
Social supports lacking
Organized plan
No spouse
Availability of means
Sickness
```
198
CAP-color and agent
Strep Pneumoniae
| Rust colored sputum
199
HAP-color and agent
yellow-green sputum
| Staph, Klebsiella, Pseudomonas
200
latent TB infection
test positive by ppd but do not have active tb disease because immune system fights it off
201
bronchiectasis often results from
chronic repeated respiratory infections, pneumonias, and CF
202
lung abcess often secondary to
aspirations
203
occupation lung disease r/t dust particle inhalation
pneumoconiosis
204
lung cancer with poor prognosis, linked to smoking, occurs centrally in lungs
small cell
| oat cell
205
fluid in pleural space
pleural effusion
206
inflmn of both layers of pleura
pleurisy
207
alveolar collapse due to sticky secretions and mucus plugs
atelectasis
208
dx of chronic bronchitis
productive cough for 3 months each year for two consecutive years
209
flattened diaphragem and barrel chest
emphysema
210
often first sign of emphysema
DOE
211
often first sign of asthma
chest tightness
