METHODICAL INSTRUCTION FOR STUDENTS
OF THE BSN 4yr. PROGRAM 4 COURSE
Nursing Faculty
LESSON № 25 (PRACTICAL – 6 HOURS)
Theme. Acute coronary syndromes. Interventions for critically ill clients with acute coronary syndromes
Aim: students must be able to provide interventions for clients with acute coronary syndromes
Professional orientation of students: Heart disease and stroke are major killers of individuals in the United States, and minority cultural groups have disproportionately high losses. American Indians and Alaskaatives have a cardiac disease mortality rate twice than rate of general population. African Americans have a higher mortality and morbidity rate from coronary artery disease and stroke than the general population.
Methodology of Practical Class (9:00-12:00)
Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):
During examination of the patient students have to use such communicative algorithm:
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take complaints and anamnesis in a patient.
5. Explain to the patient results of his/her lab tests correctly and accessibly.
6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient, what examinations will be carried out and get his/her informed consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the examination.
7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).
8. Examination (demonstration of clinical skill).
9. Explain to the patient results of his/her lab tests correctly and accessibly.
10. Conversation accomplishment.
Estimation of laboratory and instrumental investigations
Informing about the results of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient results of his/her lab tests correctly and clearly.
5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).
Planning and prognosis the results of the conservative treatment
Friendly facial expression and smile.
1. Gentle tone of speech.
2. Greeting and introducing.
3. Correct and clear explanation of necessary treatment directions.
4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.
5. Conversation accomplishment.
Work 1. Acute coronary syndromes. Interventions for critically ill clients with acute coronary syndromes
Individual Students Program
After completing this theme, you should be able to:
1. Explain the pathophysiology of heart failure.
2. Compare and contrast left-sided and right-sided heart failure.
3. Perform a comprehensive assessment of clients experiencing heart failure.
4. Identify commoursing diagnoses and collaborative problems for clients with heart failure.
5. Evaluate the effects of interventions for reducing preload and afterload.
6. Describe special considerations for older adults with heart failure.
7. Discuss the prevention of complications for clients with heart failure.
8. Prioritize nursing care for clients experiencing heart failure.
9. Identify essential focused assessments used by the home care nurse for clients with heart failure.
10. Compare and contrast common valvular disorders.
11. Discuss surgical management for clients with valvular disease.
12. Develop a teaching/learning plan for clients with valvular disease.
13. Differentiate between common cardiac inflammations and infections—endocarditis, pericarditis, and rheumatic carditis.
14. Discuss the legal/ethical aspects related to heart transplantation, including cost of care.
Program of self training:
1. Classification of heart failure
A) Systolic versus diastolic dysfunction.
B) Left versus right ventricular failure.
C) Low-output versus high-output syndrome.
2. Etiology
3. Incidence/Prevalence
4. Collaborative management
Seminar discussion of theoretical issues (12:30-14:00)
Student’s Individual Work (14:15-15:00)
Students who have passed Moodle tests the day before class are free from test control during the class
Test evaluation and situational tasks
1. By what pathophysiologic processes does atherosclerosis contribute to the development of coronary artery disease (CAD)?
a. Atherosclerotic plaques cause spasm and subsequent narrowing of the coronary vessels.
b. Coronary vessels become inflamed and injured as a result of excess cholesterol and triglycerides.
c. Macrophages and T cells form a connective tissue matrix in the vessel intima where lipids accumulate.
d. Atherosclerosis causes coronary vessels to become stiff, limiting their ability to respond to increases in blood flow.
2. A client presents with a history of variant (Prinzmetal’s) angina. What symptoms would the nurse expect to be manifested in this client?
a. Chest discomfort that appears with exertion and is relieved with nitroglycerin
b. Chest pain occurring with minimal exertion that limits the client’s activity
c. A burning sensation in the chest wall that is relieved with rest
d. Chest pressure or tightness that radiates to the arm and jaw
3. The client with a history of stable angina states that he has recently experienced an increase in the number of attacks and the intensity of the pain. What should the nurse suspect?
a. The client continues to have stable angina
b. The client has developed unstable angina
c. The client has experienced an acute MI
d. The client has a subendocardial necrosis
4. Which of the following would be considered a modifiable risk factor for coronary artery disease?
a. Age
b. Gender
c. Smoking
d. Family history
5. An 82-year-old client is admitted with a suspected myocardial infarction. What specific clinical manifestation of myocardial infarction would the nurse expect to see in an older adult?
a. Exophthalmos
b. Posterior wall chest pain
c. Disorientation or confusion
d. Numbness and tingling of the arm
6. Which of the following statements made by the client with CAD serves to alert the nurse that the client may be experiencing difficulty in adapting to the illness?
a. “I usually wait about 2 hours after I feel chest discomfort before calling my doctor to be sure it is really angina.”
b. “I know I will have some chest discomfort with some activities, so I carry my nitroglycerin with me at all times.”
c. “When I was in the hospital last time for my heart attack, I felt afraid.”
d. “I feel a little anxious whenever I get chest discomfort.”
7. The client is diagnosed with acute myocardial infarction. Which laboratory test is most specific in diagnosing acute MI?
a. Myoglobin
b. Serum LDH
c. CK-MB isoenzyme
d. Troponin T
8. The client’s ECG reveals ST-segment depression and T-wave inversion in leads II, III, and aVF. What is the nurse’s interpretation of these findings?
a. The client is experiencing an anginal episode.
b. The client is experiencing variant angina.
c. The client is experiencing acute MI.
d. The client is experiencing cardiac arrest.
9. A client brought to the emergency room has been diagnosed with an acute myocardial infarction. The physician has ordered thrombolytic therapy with reteplase (Retavase). What is the indication for this therapy?
a. This therapy will reverse any myocardial damage if given within 2 hours of the event.
b. This therapy restores perfusion to the injured area, reducing the size of the infarct.
c. This therapy restores coronary reperfusion without risk of internal bleeding.
d. This therapy makes percutaneous transluminal coronary angioplasty (PTCA) unnecessary.
10. The client diagnosed with acute MI is to receive tenecteplase (TNKase). What is an advantage of this therapy over other fibrinolytic drugs?
a. TNKase restores perfusion to coronary arteries.
b. TNKase limits damage to the myocardium.
c. TNKase decreases mortality in clients with MI.
d. TNKase is administered in a single bolus over 5 seconds.
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.
(the instructor has tests & situational tasks)
Basic level:
Student must know:
II. Heart failure
1. Pathophysiology
A) Compensatory mechanisms
1) Increased heart rate
2) Improved stroke volume
3) Arterial vasoconstriction
4) Sodium and water retention
5) Myocardial hypertrophy
2. Classification of heart failure
A) Systolic versus diastolic dysfunction.
B) Left versus right ventricular failure.
C) Low-output versus high-output syndrome.
3. Etiology
4. Incidence/Prevalence
5. Collaborative management
A) Assessment
1) History
a) Left ventricular failure.
b) Right ventricular failure.
2) Physical assessment/clinical manifestations
a) Left ventricular failure.
b) Right ventricular failure.
3) Psychosocial assessment
4) Laboratory assessment
5) Radiographic assessment
6) Other diagnostic assessment
6. Analysis
A) Commoursing diagnoses and collaborative problems
B) Additional nursing diagnoses and collaborative problems
7. Planning and Implementation
8. Impaired gas exchange
A) Planning: expected outcomes.
B) Interventions.
1) Ventilation assistance.
9. Decreased cardiac output
A) Planning: expected outcomes.
B) Interventions.
1) Hemodynamic regulation.
2) Reducing afterload.
3) Reducing preload.
a) Diet therapy.
b) Drug therapy.
4) Enhancing contractility.
10. Activity intolerance
A) Planning: expected outcomes.
B) Interventions.
1) Energy management.
11. Potential for pulmonary edema
A) Planning: expected outcomes.
B) Interventions.
12. Community-based care
A) Case management
B) Health teaching
C) Activity schedule.
D) Indications of worsening heart failure.
E) Drug therapy.
F) Diet therapy.
G) Advance directives.
H) Home care management
I) Health care resources
J) Evaluation: outcomes
III. Valvular heart disease
1. Mitral stenosis
2. Mitral regurgitation (insufficiency)
3. Mitral valve prolapse
4. Aortic stenosis
5. Aortic regurgitation (insufficiency)
6. Collaborative management
A) Assessment
B) Interventions
1) Nonsurgical management.
2) Surgical management.
a) Reparative procedures.
– Balloon valvuloplasty.
– Direct, or open, commissurotomy.
– Mitral valve reconstruction.
b) Replacement procedures.
c) Preoperative care.
d) Postoperative care.
7. Community-based care
A) Health teaching
B) Home care management
C) Health care resourcesss
Answers
1. C
Atherosclerosis leading to CAD is the result of three processes: (1) the overgrowth of intimal smooth muscle cells with macrophages and T cells; (2) the formation of a connective tissue matrix in the vessel intima, and (3) the accumulation of lipids, which serve to narrow the vessel lumen.
2. B
Variant angina (Prinzmetal’s angina) is a form of unstable angina characterized by chest pain or discomfort occurring with minimal exertion and leads the client to reduce his or her activity. Chest discomfort relieved by nitroglycerin or rest is characteristic of stable angina, whereas symptoms of chest pressure or tightness that radiates to the arm or jaw is more characteristic of a myocardial infarction.
3. B
An increase in the number of anginal attacks and an increase in the intensity of pain characterize unstable angina. The chest pain or discomfort also occurs at rest or with minimal exertion, causing marked limitations on activity.
4. C
Modifiable risk factors can be altered or controlled. Cigarette smoking and a sedentary lifestyle are examples of behaviors that are modifiable. Nonmodifiable factors are personal elements that cannot be altered or controlled (age, gender, family history).
5. C
In older adults (younger than age 80), disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output.
6. A
Although fear and anxiety are common reactions to CAD, the nurse should stress that denial of symptoms can result in harm to the client, and such symptoms need to be reported and treatment instituted immediately to avoid myocardial damage or death.
7. C
CK-MB isoenzyme is found in myocardial muscle. CK-MB activity is most specific for MI and shows a predictable rise and fall over 3 days.
8. A
The ECG obtained during an anginal episode reveals ST-segment depression, T-wave inversion, or both. With variant angina, the ECG reveals ST-segment elevation; with acute MI, ECG changes include ST-segment elevation, T-wave inversion, and abnormal Q waves.
9. B
Thrombolytic therapy is indicated in MI to restore perfusion to the injured area, thereby limiting the size of the infarct. Establishing sustained reperfusion in the first few hours after an MI has resulted in a decreased incidence of mortality.
10. D
Tenecteplase has advantages over other fibrinolytic drugs including administration over 5 seconds, more specific targeting of clots, and overall less bleeding.
References:
А–Basic:
Required Textbooks:
1. Ignatavicius, D.D. (2012). Clinical Decision-making Study Guide for Medical-Surgical Nursing, (7th ed.) St. Louis: Elsevier
2. Ignatavicius, D.D. & Workman, M.L. (2012). Medical-surgical nursing: Patient centered collaborative care. (7th ed.) St. Louis: Elsevier
3. Potter, P.A. & Perry, A. G. (2013). Fundamentals of nursing, 8th ed.) St. Louis: Mosby/Elsevier.
4. Ackley, B.J. & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care, (9th ed.) St. Louis: Mosby/Elsevier.
5. Deglin, J. H., Vallerand, A. H., & Sandoski, C.A. (2013). Davis’s Drug Guide for Nurses, (13th ed.) Philadelphia: F. A. Davis.
Internet Resources:
1. http://intranet.tdmu.edu.ua/education.php
В – Additional:
Other Textbooks:
1. Ignatavicius, D.D. et.al. (2013). Clinical Companion for Medical-Surgical Nursing: for- Patient-Centered Collaborative Care. (7th ed) St. Louis: Elsevier.
2. Mosby’s Dictionary of Medicine, Nursing, and Health Professions, (2009). (8th ed.) St. Louis: Elsevier
3. Potter, P. A. et al. (2013). Fundamentals of nursing: Study guide, (8th ed.) St. Louis: Elsevier.
4. Pickar, G. & Abemethy, A.P. (2008). Dosage Calculations, (8ft.ed.). Clifton Park, NY: Thomson Delmar.
5. Venes, D. editor (2009) Taber’s Cyclopedia Medical Dictionary (21*ed.). Philadelphia: F A. Davis.
Methodical instruction has been worked out by: B. Lokay, MD, PhD, BSN
Methodical instruction was discussed and adapted at the Department sitting
June 12, 2013. Minute № 13
