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Acute Coronary Syndromes (MI-ST and Non ST, Unstable Angina) for Progressive Care Certified Nurse (PCCN)

Acute Coronary Syndromes (MI-ST and Non ST, Unstable Angina) for Progressive Care Certified Nurse (PCCN)

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Study Tools For Acute Coronary Syndromes (MI-ST and Non ST, Unstable Angina) for Progressive Care Certified Nurse (PCCN)

Acute Coronary Syndrome (ACS) (Cheatsheet)

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Outline

Acute Coronary Syndromes (MI-ST and Non ST, Unstable Angina ):

Definition/Etiology:

Acute coronary syndrome (ACS): the suspicion or confirmed
presence of acute myocardial ischemia caused by POOR
PERFUSION
Caused by clots, narrowed coronary arteries or vasospasms
and damages the myocardium (heart muscle)
Acute coronary syndrome may be further classified into the
following categories:
- Unstable angina
- NSTEMI
- STEMI

Pathophysiology:

Unstable Angina
- Partial Occlusion of coronary artery
- “Traffic cones in the road”
- No damage to myocardium
NSTEMI
- Partial occlusion of coronary artery
- “One lane closed in the highway”
- Damage to myocardium: inner layer only
STEMI
- Complete occlusion of coronary artery
- “All lanes washed away – no road!”
- Affects ALL layers of heart muscle

Noticing: Assessment & Recognizing Cues:

Assessment
- Pain (OLDCARTS or PQRST)
- Heart monitor
  - Tachycardia, arrhythmias, waveform changes
- Heart and Lungs sounds
  - symptoms of heart failure, murmurs
- Frequent Vitals
Subjective Cues
- PAIN (including at rest
  - <20 MINS Unstable Angina/NSTEMI
  - >20 mins STEMI
- SOB
- DIZZY
- Numbness
- Anxiety
- Nausea
- Palpitations
- Syncope
- IMPENDING DOOM
Objective Cues
- Pallor
- Vomiting
- Syncope
- Diaphoresis
- Dyspnea

Interpreting: Analyzing & Planning:

ECGS = ACS Type/Location
- ECG Timing
  - ECG within 10 minutes of ED arrival.
  - Repeat every 15 minutes or so
NSTEMI
- ST Depression
- T wave inversion
STEMI
- ST Elevation
- Hyperacute T waves
Priority Labs = Troponin
- Troponin Timing ‘Drawn Serially”
  - Higher the troponin = worse the damage
  - Starts rising 3-6 hours after an MI
  - Peak 16 hours
  - Normal in 2 weeks
    - “Normal” = 0.04 ng/ml
- Troponin determines ACS Type/Damage Extent
  - Unstable Angina = NEG Trop
  - NSTEMI = POS Trop
  - STEMI= POS Trop

Responding: Patient Interventions & Taking Action:

Priority Pharmacological Interventions
- Oxygen
  - If symptomatic
- Nitrates
  - 0.4 mg SL Q 5 mins x 3
- Aspirin
  - Platelets less sticky
- Morphine
  - Dosing = low & slow
Priority Non-Pharmacology
- IV Access
- Vitals
- EKG results = intervention
  - Unstable Angina = Heparin gtt
  - NSTEMI = Heparin gtt → Cath Lab
  - STEMI = CATH LAB
STEMI = Cath Lab
- PCI (stent) in 90 mins
  - Clot Busters if not available (if not contraindicated)
- GOAL = RESOLVE chest pain

Reflecting: Evaluating Patient Outcomes:

Continued Monitoring
- PCI?
  - Site monitoring
    - Radial vs Femoral
  - Retroperitoneal Bleed
    - Flank Pain, Hypotension, etc
  - Renal Panel
    - Procedure Dye
- Vitals
  - Consider Hypotension if nitrates used
  - Reduction of pain = BETTER PERFUSION
    - Pain return? STENT CLOSED. EMERGENCY
- Continuous bedside telemetry monitoring
  - ST Segment monitoring is vital
- Troponin Levels Q 3-6 hours
  - The Lower the better
- Continued IPharm
  - P2Y12 Inhibitors
    - Keep Stent open
  - Beta-Blockers
    - Start within 24 hours of PCI
  - STATINs
    - ↓ inflammation
  - ACE/ARBS
    - Prevents “remodeling”

Linchpins (Key Points):

Consider Perfusion: Time = Tissue
- MUST WATER GARDEN
Notice: Signs of Ischemia
Interpret: EKG within 10 minutes & Serial Troponin
Respond: ONAM (NOT MONA) & STEMI = Cath Lab
Reflect: NO PAIN = IMPROVED PERFUSION + WATCH ST segment monitoring

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Transcript

References:

Collet J-P, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020; 42(14):p.1289-1367. doi: 10.1093/eurheartj/ehaa575.
Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. J Am Coll Cardiol. 2021; 78(22): p.e187-e285.
Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2017; 39(2): p.119-177. doi: 10.1093/eurheartj/ehx393
Ralapanawa, U., & Sivakanesan, R. (2021). Epidemiology and the magnitude of coronary artery disease and acute coronary syndrome: A narrative review. Journal of Epidemiology and Global Health, 11(2), 169.
Wereski R, Kimenai DM, Taggart C, et al. Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction. Circulation. 2021; 144(7): p.528-538. doi: 10.1161/circulationaha.121.054302

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MS2EXAM1

Concepts Covered:

Study Plan Lessons

EKG Basics – Live Tutoring Archive

Dysrhythmia Emergencies

Electrical Activity in the Heart

EKG (ECG) Waveforms

The EKG (ECG) Graph

Normal Sinus Rhythm

Sinus Tachycardia

Sinus Bradycardia

Supraventricular Tachycardia (SVT)

Atrial Fibrillation (A Fib)

Premature Ventricular Contraction (PVC)

Ventricular Tachycardia (V-tach)

Ventricular Fibrillation (V Fib)

Procainamide (Pronestyl) Nursing Considerations

Sympatholytics (Alpha & Beta Blockers)

Verapamil (Calan) Nursing Considerations

Adenosine (Adenocard) Nursing Considerations

Amiodarone (Pacerone) Nursing Considerations

Diltiazem (Cardizem) Nursing Considerations

Dysrhythmias Labs

Dysrhythmias for Certified Emergency Nursing (CEN)

AV Blocks Dysrhythmias for Progressive Care Certified Nurse (PCCN)

Cardiogenic Shock For PCCN for Progressive Care Certified Nurse (PCCN)

Nursing Care Plan (NCP) for Myocardial Infarction (MI)

Electrolytes Involved in Cardiac (Heart) Conduction

Nursing Care Plan (NCP) for Cardiomyopathy

3rd Degree AV Heart Block (Complete Heart Block)

2nd Degree AV Heart Block Type 2 (Mobitz II)

1st Degree AV Heart Block

Nursing Care and Pathophysiology of Coronary Artery Disease (CAD)

Advanced Cardiovascular Life Support (ACLS)

Acute Coronary Syndrome (ACS)

Nursing Care and Pathophysiology of Acute Respiratory Distress Syndrome (ARDS)

Obstructive Heart (Cardiac) Defects

Heart (Heart) Failure Exacerbation

Nursing Care and Pathophysiology of Myocardial Infarction (MI)

02.09 12 Lead EKG- Leads 1, 2, 3, aVL, and aVF for CCRN Review

02.14 Shock Stages for CCRN Review

02.15 Hypovolemic Shock for CCRN Review

02.16 Cardiogenic Shock for CCRN Review

02.17 Septic Shock for CCRN Review

Disseminated Intravascular Coagulation (DIC)

Nursing Care and Pathophysiology for Sepsis

Nursing Care and Pathophysiology for Distributive Shock

Toxicity Sepsis- Signs and Symptoms Nursing Mnemonic (The 6 T’s)

Sepsis Concept Map

Ischemic (CVA) Stroke Labs

Nursing Care Plan (NCP) for Atrial Fibrillation (AFib)

Cardiopulmonary Arrest for Certified Emergency Nursing (CEN)

ACLS (Advanced cardiac life support) Drugs

Electrical A&P of the Heart

02.10 12 Lead EKG- Lead V1-V6 for CCRN Review

Nursing Care Plan (NCP) for Acute Respiratory Distress Syndrome

ARDS Case Study (60 min)

Acute Respiratory Distress Syndrome (ARDS) for Progressive Care Certified Nurse (PCCN)

Acute Respiratory Distress

Nursing Care Plan (NCP) for Respiratory Failure

Nursing Care and Pathophysiology for Arterial Disorders

Nursing Care Plan (NCP) for Arterial Disorders

Nursing Care and Pathophysiology for Cardiomyopathy

Nursing Care and Pathophysiology of Endocarditis and Pericarditis

Nursing Care and Pathophysiology for Heart Failure (CHF)

Restrictive Lung Diseases (Pulmonary Fibrosis, Neuromuscular Disorders)

Nursing Care and Pathophysiology for Thrombophlebitis (clot)

Venous Disorders (Chronic venous insufficiency, Deep venous thrombosis/DVT)

Rapid Sequence Intubation

Trach Suctioning

Myocardial Infarction (MI) Case Study (45 min)

02.12 Myocardial Infarction- Inferior Wall for CCRN Review

Acute Coronary Syndromes (MI-ST and Non ST, Unstable Angina) for Progressive Care Certified Nurse (PCCN)

02.13 Myocardial Infarction – Anterior Septal Wall for CCRN Review

Fluid Volume Deficit

Sodium and Potassium Imbalance for Certified Emergency Nursing (CEN)

Cardiomyopathies (Dilated, Hypertrophic, Restrictive) for Progressive Care Certified Nurse (PCCN)

02.02 Cardiomyopathy for CCRN Review

Valvular Heart Disease for Progressive Care Certified Nurse (PCCN)

Nursing Case Study for Rheumatic Heart Disease

06.04 Differentiating Ectopy and Aberrancy for CCRN Review

Coronary Artery Disease Concept Map

02.08 Cardiac Catheterization & Acute Coronary Syndrome for CCRN Review

Cardiac Surgery (Post-ICU Care) for Progressive Care Certified Nurse (PCCN)

Anti-Platelet Aggregate

Nursing Care Plan (NCP) for Cardiogenic Shock

Mixed (Cardiac) Heart Defects

Nursing Care and Pathophysiology of Angina

Nursing Care and Pathophysiology of Myocarditis

Nursing Care and Pathophysiology for Hypovolemic Shock

Nursing Care and Pathophysiology for Ischemic Stroke (CVA)

Nursing Care Plan (NCP) for Disseminated Intravascular Coagulation (DIC)

Nursing Care Plan (NCP) for Hypovolemic Shock

Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)

Nursing Care Plan (NCP) for Heart Valve Disorders

Nursing Care Plan (NCP) for Aortic Aneurysm

Nursing Care Plan (NCP) for Angina

Preload and Afterload

Nursing Care and Pathophysiology for Cardiogenic Shock

MI Surgical Intervention

Heart Failure for Certified Emergency Nursing (CEN)

02.05 Calculating PAWP on PEEP for CCRN Review

Heart Failure 2 – Live Tutoring Archive

Nitro Compounds

Cardiac/Vascular Catheterization (Diagnostic, Interventional) for Progressive Care Certified Nurse (PCCN)

Nursing Care and Pathophysiology for Valve Disorders

Cortisone (Cortone) Nursing Considerations

Dexamethasone (Decadron) Nursing Considerations

Famotidine (Pepcid) Nursing Considerations

Gastrointestinal (GI) Bleed Concept Map

Methylprednisolone (Solu-Medrol) Nursing Considerations

Nursing Care and Pathophysiology for Peptic Ulcer Disease (PUD)

Nursing Care Plan (NCP) for Anemia

Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

Nursing Care Plan (NCP) for Peptic Ulcer Disease (PUD)

Parasympathomimetics (Cholinergics) Nursing Considerations

Peptic Ulcer Disease Case Study (60 min)

Cholecystitis for Certified Emergency Nursing (CEN)

Nursing Care and Pathophysiology for Cholecystitis

Nursing Care Plan (NCP) for Cholecystitis

Cirrhosis Case Study (45 min)

Cirrhosis Complications Nursing Mnemonic (Please Bring Happy Energy)

Cirrhosis for Certified Emergency Nursing (CEN)

Esophageal Varices for Certified Emergency Nursing (CEN)

Hepatic Disorders (Cirrhosis, Hepatitis, Portal Hypertension) for Progressive Care Certified Nurse (PCCN)

Hepatitis for Certified Emergency Nursing (CEN)

Liver Function Tests

Nursing Care and Pathophysiology for Cirrhosis (Liver Disease, Hepatic encephalopathy, Portal Hypertension, Esophageal Varices)

Nursing Care and Pathophysiology for Hepatitis (Liver Disease)

Nursing Care Plan (NCP) for Encephalopathy

Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

Nursing Care Plan (NCP) for Hepatitis

Nursing Care Plan for Cirrhosis (Liver)

Nursing Care Plan for Liver Cancer

Bowel Obstruction Concept Map

Epispadias and Hypospadias

Nursing Care Plan (NCP) for Bowel Obstruction

Nursing Care Plan for Hiatal Hernia

Cirrhosis Case Study (45 min)

Colorectal Cancer (colon rectal cancer)

Encephalopathy Case Study (45 min)

Fluid Shifts (Ascites) (Pleural Effusion)

Hepatic Disorders (Cirrhosis, Hepatitis, Portal Hypertension) for Progressive Care Certified Nurse (PCCN)

Nephrotic Syndrome

Nephrotic Syndrome Case Study (Peds) (45 min)

Nursing Care and Pathophysiology for Cirrhosis (Liver Disease, Hepatic encephalopathy, Portal Hypertension, Esophageal Varices)

Nursing Care and Pathophysiology of Nephrotic Syndrome

Nursing Care Plan (NCP) for Hepatitis

Nursing Care Plan (NCP) for Nephrotic Syndrome

Nursing Care Plan for Cirrhosis (Liver)

Nursing Care Plan for Liver Cancer

Nursing Case Study for Hepatitis

Stomach Cancer (Gastric Cancer)

Nursing Care and Pathophysiology for Cholecystitis

Nursing Care Plan (NCP) for Cholecystitis

Risk Factors for Cholelithiasis Nursing Mnemonic (5-F’s)

Acute Abdomen for Certified Emergency Nursing (CEN)

Appendicitis for Certified Emergency Nursing (CEN)

Dialysis & Other Renal Points

Nursing Care and Pathophysiology for Diverticulosis – Diverticulitis

Nursing Care Plan (NCP) for Bowel Obstruction

Nursing Care Plan (NCP) for Constipation / Encopresis

Nursing Care Plan (NCP) for Diverticulosis / Diverticulitis

Peritoneal Dialysis (PD)

Peritonitis for Certified Emergency Nursing (CEN)

Cystic Fibrosis (CF)

Diabetes Mellitus (DM) Module Intro

Diabetes Mellitus & Those Dang Blood Sugars! – Live Tutoring Archive

Diabetes Mellitus Case Study (45 min)

Diabetes Mellitus for Progressive Care Certified Nurse (PCCN)

Diabetes Mellitus Type 1- Signs & Symptoms Nursing Mnemonic (The 3 P’s)

Diabetic Ketoacidosis (DKA) Case Study (45 min)

Hyperglycaemic Hyperosmolar Non-ketotic syndrome (HHNS)

Metabolic Acidosis (interpretation and nursing diagnosis)

Nursing Care and Pathophysiology of Diabetes Mellitus (DM)

Nursing Care and Pathophysiology of Diabetic Ketoacidosis (DKA)

Nursing Care Plan (NCP) for Chronic Kidney Disease

Nursing Care Plan (NCP) for Diabetes

Nursing Care Plan (NCP) for Diabetes Mellitus (DM)

Nursing Care Plan (NCP) for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Nursing Case Study for Diabetic Foot Ulcer

Nursing Case Study for Type 1 Diabetes

Renal Failure- Acute Kidney Injury (AKI), Chronic Kidney Disease (CKD) for Progressive Care Certified Nurse (PCCN)

03.02 Diabetes Insipidus for CCRN Review

Diabetes Insipidus Case Study (60 min)

Diabetes Insipidus Nursing Mnemonic (DDD)

Nursing Care and Pathophysiology for Diabetes Insipidus (DI)

Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)

Nursing Care Plan (NCP) for Diabetes Insipidus

03.04 DKA vs HHNK for CCRN Review

05.01 Pancreatitis and Large Bowel Obstruction for CCRN Review

09.05 Chronic Renal Failure for CCRN Review

Diabetes Management

Diabetes Mellitus Case Study (45 min)

Diabetes Mellitus for Progressive Care Certified Nurse (PCCN)

Diabetes Mellitus Type 1- Signs & Symptoms Nursing Mnemonic (The 3 P’s)

Diabetic Emergencies for Certified Emergency Nursing (CEN)

Diabetic Ketoacidosis (DKA) Case Study (45 min)

Diabetic Ketoacidosis for Progressive Care Certified Nurse (PCCN)

End-Stage Renal Disease (ESRD) for Progressive Care Certified Nurse (PCCN)

Gestational Diabetes (GDM)

Glipizide (Glucotrol) Nursing Considerations

Hyperglycaemic Hyperosmolar Non-ketotic syndrome (HHNS)

Hyperglycemia for Progressive Care Certified Nurse (PCCN)

Hyperglycemia Management Nursing Mnemonic (Dry and Hot – Insulin Shot)

Hypoglycemia for Progressive Care Certified Nurse (PCCN)

Injectable Medications

Insulin – Intermediate Acting (NPH) Nursing Considerations

Insulin – Long Acting (Lantus) Nursing Considerations

Insulin – Mixtures (70/30)

Insulin – Rapid Acting (Novolog, Humalog) Nursing Considerations

Insulin – Short Acting (Regular) Nursing Considerations

Insulin Mnemonic (Ready, Set, Inject, Love)

IV Infusions (Solutions)

IV Pump Management

Hyperthyroidism Case Study (75 min)

Nursing Care and Pathophysiology for Hashimoto’s Thyroiditis

Nursing Care and Pathophysiology for Hyperthyroidism

Nursing Care and Pathophysiology for Hypothyroidism

Nursing Care Plan (NCP) for Hashimoto’s Thyroiditis

Nursing Care Plan (NCP) for Hyperthyroidism

Nursing Care Plan (NCP) for Hypothyroidism

Adrenal and Thyroid Disorder Emergencies for Certified Emergency Nursing (CEN)

09.02 Acute Tubular Necrosis for CCRN Review

Burn Injury Case Study (60 min)

Burns for Certified Emergency Nursing (CEN)

Compartment Syndrome for Certified Emergency Nursing (CEN)

Electrolyte Imbalances for Progressive Care Certified Nurse (PCCN)

Nursing Care Plan (NCP) for Burn Injury (First, Second, Third degree)

Nursing Care Plan (NCP) for Urinary Tract Infection (UTI)

Nursing Care Plan for Gastritis

Wound Care – Assessment

Wound Care – Selecting a Dressing