Cardiovascular Health 1. Describe the signs and symptoms of Acute Coronary Syndrome?

ACS is a spectrum of clinical presentations ranging from ST-segment elevation myocardial infarction (STEMI) NonST-segment elevation myocardial infarction (NSTEMI) Unstable angina. The symptoms of ACS are often the same as those of myocardial infarction Chest pain (angina) that feels like burning, pressure or tightness and lasts several minutes or longer Pain elsewhere in the body, such as the left upper arm or jaw (referred pain) Nausea Vomiting Shortness of breath (dyspnea) Sudden, heavy sweating (diaphoresis) If you're having a heart attack, the signs and symptoms may vary depending on your sex, age and whether you have an underlying medical condition, such as diabetes. Some unusual heart attack symptoms include: Abdominal pain Pain similar to heartburn Clammy skin Lightheadedness, dizziness or fainting Unusual or unexplained fatigue Feeling restless or apprehensive

2. Describe how an MI is diagnosed (using the WHO definition)

Category A Myocardial Infarction- Biomarkers such as troponin present Category B Myocardial Infarction- ECG changes present with inconclusive biomarkers Category C "Probable" Myocardial Infarction- All signs and symptoms of a MI, with inability to access healthcare to receive ECG and/or inconclusive biomarkers.

3. Describe how anginine is administered to a patient with acute chest pain and explain the protocol for administering this drug.
Administering Anginine. high hepatic first-pass effect (96% metabolized by the liver) sublingual (under the tongue) buccal (cheek lining)tablet form - 0.6mg 5 to 10 minutes prior to the activity of a known trigger acute relief, - in a sitting position one tablet is placed in position and allowed to dissolve without chewing or swallowing.

After 5 minutes, if the pain has not improved a second tablet can be used after a further 5 minutes if pain persists. No more than 3 doses can be given and only one dose at a time. A quarter of the tablets can be taken if blood pressure drops causing dizziness No pain relief indicates acute myocardial Infarction If pain desists the portion of tablet not dissolved can be removed Relief generally occurs within two minutes and is effective up to 30 minutes. Unused tablets shelf life three months once the container seal has been broken Also available in a sublingual spray (Nitrolingual) which has a two year shelf life transdermal patches, not suitable for an acute attack are used to prevent symptoms. also used in critical care through intravenous infusions with polyethylene tubing common side effects migraine-like headaches, orthostatic hypotension (sitting to standing), syncope (fainting), nausea, flushing face and neck, burning/tingling under the tongue and reflex tachycardia (increased heart rate) dizziness and lightheadedness are more evident in older adults placing them at increased risk of falls. overdose symptoms Bradycardia, blurred vision, severe nausea/vomiting, diaphoresis, cold/clammy skin and cyanosis contraindication Hypersensitivity, acute Myocardial Infarction severe anemia Caution history of MI, CHF, alcohol use, increased intracranial pressure (ICP) such as head trauma or cerebral hemorrhage (stroke),

increased intraocular pressure (IOP), hyperthyroidism, hypertrophic Cardiomyopathy (HOCM) which is a genetic condition where heart muscle has become thick, postural hypotension, volume depletion low systolic BP and pregnancy. It is also an unknown factor if Anginine passes into breast milk

Possible fatal interactions may occur if GTN is used with sildenafil (Viagra) tadalafil (Cialis) or vardenafil (Levitra) used to treat erectile dysfunction. serious contraindicated drugs (alternatives actions are recommended), bromocriptine, cabergoline, dihydroergotamine, ergoloid mesylates, ergonovine, ergotamine, methylergonovine and methysergide. Arginine should be closely monitored ethanol requires minor monitoring Tolerence to GTN develops within 24 to 28 hours of its use; therefore intermittent therapy over continuous therapy is preferable. Rebound myocardial ischemia is possible during the nitrate-free periods 4. Explain the pathophysiology of myocardial infarction (discuss atherosclerosis). 5. Define the risk factors and discuss the prevalence of Coronary Heart Disease (CHD) disease. 1. Define thrombolytic therapy and discuss why it is administered to patients who have had a STEMI? (types, indications and contra-indications, risks). 2. Discuss the care of a patient with Acute Coronary Syndrome in the first 24 hours (admission, observations, cardiac monitoring, activity, hygiene, elimination, social). Admission into the Coronary Care Unit (QLD Health CCU Admission Policy) QLD Health requires that a patient has at least one of the following admission criteria:

1. 2. 3. 4. 5. 6.

Continuous Cardiac Monitoring Central Venous Pressure Monitoring Arterial Pressure Monitoring Administration of nitrates, beta blockers, vasodilators and fibrinolytic agents Temporary Cardiac Pacing Pulmonary Artery Wedge Pressure Monitoring

Additionally the patient needs to meet the following prior to admission to CCU: Emergency Department staff notify the CCU Consultant and discuss the suitability of the admission Nurse Unit Manager is notified of the admission and the patients full name, age, diagnosis, UR number and estimated time of arrival Patient is escorted to CCU with at least a nurse or medical team if appropriate Detailed handover from the nurse or doctor caring for the patient will be given on arrival to CCU The Nurse in CCU will want to know the answers to these questions: 1. Refer to Patient Handover ED-CCU 2. As well as Isaacs LOC and that he has a IV cannula insitu Assessment of Patient with ACS Assessment of a patient with ACS needs to be rapid and frequently because it has a significant impact upon health outcomes Baseline Physical Assessment Baseline Physical Assessment determines Isaacs initial condition and can be compared against further assessments to determine responses to treatment. Integument: Inspect Isaacs skin for signs of Pallor, which is an abnormal paleness of the skin usually evident in the conjunctiva, oral mucous membranes, nail beds, palms and soles of the feet due to inadequate circulating blood. Also assess for cyanosis which is bluish tinge of the nail beds and lips (King, Hawley, & Weller, 2008). Inspect legs and feet for oedema. If oedema is present ask Isaac about development and duration of the oedema. Elevate the legs and see if it is relieved (Berman et al., 2010). Cardiovascular: Pulse: assess the rate of Isaacs pulse, rhythm and strength using the radial pulse. Strength is graded on a scale of 0-3. 0= absent 1=weak 2=normal 3=strong/bounding. Take a pulse of each arm and compare (Kucia & Quinn, 2010)

Blood Pressure: take Isaacs blood pressure on both arms and compare Cardiac Auscultation: listen to Isaacs heart sounds Respiratory: Does Isaac have signs of dyspnoea? If so establish whether it occurs at rest or on exertion. Positioning Isaac in semi fowlers will encourage easier breathing Observe Respiratory Rate, duration of inspiratory/expiratory cycle, respiratory sounds and if there is any use of accessory muscles during breathing (Berman et al., 2010). Cardiac Monitoring The RN has prepared a monitored bed for Isaac, what does this include? Telemetry: Is continuous electrocardiographic monitoring that sends radio transmission of ECG signals to a central monitoring system There are no wires connected to the central monitoring system, which allows the patient to move around Telemetry is the most appropriate cardiac monitoring in CCU due to the length of time the monitor has to stay on Telemetry monitoring systems can continually monitor arrhythmias, ischemia, blood pressure and pulse oximetry If there are abnormal signals the monitor will alarm Telemetry monitoring should occur for at least 24 hours post myocardial infarction or until ischemia is resolved (Kucia & Quinn, 2010) 3. Outline the pharmacological therapy for patients who have been diagnosed with a STEMI (beta blockers, daily aspirin). 4. Discuss the legal issues associated with medication administration. 5. Discuss the impact of culture on diet and obesity. 1. Explain the pathophysiology of heart failure. 2. Explain the action of ACE inhibitors and why they are prescribed for Coronary Artery disease. 3. Outline the pre and post procedure nursing management and the rationale for a patient undergoing a Cardiac Catheter. 4. Outline the legal requirements for informed consent. 5. Outline the legal and safety parameters related to the student nurse administering medications.

6. Discuss the prevalence of heart failure and its impact on the health care system. 1. Explore Phase 2 Cardiac Rehabilitation programs and identify the Best Practice Guidelines recommended for these programs. 2. Discuss the principles of adult education in relation to in-patient education post MI. Provide an outline of a proposed teaching session titled: What is a Heart Attack? 3. Examine the psychosocial impact of CVD. 4. Identify relevant Cohort Studies that will enable a discussion of: The Effectiveness of Cardiac Rehabilitation Programs and their Impact on Quality of Life for Cardiac Patients. 5. Discuss the availability and utilization of Cardiac Rehabilitation Programs in Australia. RESPIRITORY HEALTH Outline the pathophysiology of Asthma including the triggers.

Discuss the initial assessment of severity of acute asthma in adults (National Asthma Council Guidelines for Emergency Management of Asthma). Outline the nursing interventions and rationales for a patient with acute asthma. Explain the rationale for administration of salbutamol, ipratropium bromide and IVI hydrocortisone administration (indication, mode of action, dosage, administration, side-effects, legal and safety aspects of medication administration). Explain the principles of oxygen administration including nursing interventions, mode of administration, dosage, legal and safety aspects etc Discuss the prevalence of and risk factors for respiratory related health problems in Australia, consider any specific cultural variances. Discuss pneumonia types, clinical manifestations, treatment. Outline the nursing interventions including rationales for a patient with pneumonia? Explain the use of oral cortico-steroids in asthma management including rationale (pathophysiology), types of drugs, methods of administration, side effects and legal/safety aspects.

Outline the components of an Asthma Action Plan. Explain the pathophysiological rationale for the use of preventers and relievers. Discuss the legislation related to smoking in public places and environmental health legislation. Discuss the pathophysiology of COPD (chronic bronchitis and emphysema) including risk factors. Discuss oxygen therapy as part of the treatment regime for COPD (include use of oxygen in hospital and home oxygen) Discuss the nursing interventions including rationales for a patient with COPD. Discuss illness behaviour theories including Parsons sick role. Discuss the Public Health issues relevant to the use of and the marketing of tobacco.
Outline the function, components, benefits and what health care professionals may be involved in a Pulmonary Rehabilitation Program. Devise a discharge plan for Bill outlining his plan of care and education needs. Explain the current health education and health promotion intervention strategies to target the risk factors for respiratory illness Outline and explain the issues that need to be discussed in a family conference with Bill and Sally. (self management principles Outline the psychosocial impact of COPD.