NSG6001 Midterm Study Guide LATEST VERSION 2019

NSG6001 Midterm Study Guide LATEST VERSION 2019 NSG 6001 - ANP 1 – Study Guide for MIDTERMETT – Exercise Tolerance Testing – Stress Test1. Primary goal of ETTThe primary goal of the ETT is to increase workload incrementally to induce ischemia or until a predetermined workload is reached.2. A negative ETT (Exercise Tolerance Test) – this is the most common and east invasive test for CAD diagnosis and detection.a. Negative – if patient able to (A) exercise to at least 85% of the maximum heart rate without ischemia (B) means that there is no underlying heart problem present, or at least nothing serious.b. Positive – (A) if patient able to complete the exam without ischemia and (B) it means the test is inconclusive for CAD and but requires further diagnostic tests (C) chest pain is not indicative of CAD.3. Can ETT results correlate with the artery or arteries with CADRecent American College of Cardiology (ACC) guidelines give some guidance about noninvasive testing and markers for asymptomatic CAD based on an individual patient’s risk for CAD. ACC guidelines have as a class I recommendation (suggested) based on class B evidence (limited populations studied) that health care providers ascertain risk for cardiovascular disease in asymptomatic individuals by use of a global assessment such as the Framingham score. The ACC guidelines use the level of risk determined by these scores to evaluate the evidence and to classify recommendations for the use of various testing modalities in the investigation and determination of subclinical cardiovascular disease. For example, the ACC guidelines suggest that C-reactive protein can be used in asymptomatic men older than 50 years and women older than 60 years with low-density lipoprotein cholesterol 160 mg/dL to determine if statin therapy is indicated and in asymptomatic intermediate-risk men older than 50 years and women older than 60 years to assess risk of cardiovascular disease. Anklebrachial index assessment is acceptable for intermediate-risk individuals to determine their risk for subclinical cardiovascular disease. And with risk factors of DM and HTN.4. How would the inability to exercise reduce the sensitivity and specificity of the routine ETT and understand the term: Sensitivity and an exercise echocardiography 2DEA. ETT’s lack of sensitivity is derived from the limitations of the surface electrocardiogram related to the spatial distribution of the electrical abnormalities that occur in ischemia. The ETT is more sensitive for the detection of severe disease.B. With an overall sensitivity of 67% and specificity of 72%, exercise stress testing can be a cost-effective strategy for evaluation of CAD.C. Because the interpretation of the test is based primarily on the development of characteristic ischemic ST-segment and T-wave changes, it is not surprising that resting ECG abnormalities can lead to a reduction in test sensitivity and specificity. The specificity of the routine ETT is reduced if the patient has had a prior myocardial infarction or if the patient has a resting bundle branch block conduction abnormality, paced rhythm, preexcitation syndromes, or inability to exercise because this produces persistent ST-segment and T-wave abnormalities.D. Ischemia that is confined to the posterior and or lateral segments of the left ventricle can be difficult to detect by ETT.E. The development of characteristic ischemic ST-segment and T-wave changes, it is not surprising that resting ECG abnormalities can lead to a reduction in test sensitivity and specificity. The specificity of the routine ETT is reduced if the patient has had a prior myocardial infarction or if the patient has a resting bundle branch block conduction abnormality, paced rhythm, preexcitation syndromes, or inability to exercise because this produces persistent ST-segment and T-wave abnormalities. A number of other factors can interfere with the sensitivity of the exercise test in detecting CAD. Because an increase in coronary blood flow is related to an increasing heart rate and systolic blood pressure, clearly the sensitivity of the test is effort dependent. The standard is the peak heart rate achieved during exercise.F. Although the 12-lead ECG is useful in localizing the region of myocardial ischemia, it is limited in both the sensitivity and the specificity and shows ischemic changes during or immediately after an ETT needed to distinguish the culprit coronary artery.5. Location of the J point in relation to the QRS after an exercise stress testThe ECG response of normal hearts is maintenance of an "isoelectric" ST segment during exercise and recovery. By standard criteria, a positive test result for CAD is defined by the development of horizontal or downsloping ST-segment depression of 1 mm measured 80 msec after the J point of the QRS complex (the junction between the QRS complex and the ST segment). ECG changes such as upsloping ST segment (elevation) or isolated T-wave downsloping (depression) have not demonstrated significant predictive value.In many healthy individuals, some degree of ST-segment elevation, especially in the precordial leads (V2 to V5), may be noted on the routine ECG. In most people, the degree of elevation is minimal; however, it can vary from 1 to 4 mm in height. This phenomenon has been attributed to early ventricular repolarization. It can be differentiated from the ST-segment elevation of an acute MI by the following: an upward concavity of the ST segment, an elevated takeoff of the ST segment at the J point (the junction of the end of the QRS complex and the beginning of the ST segment), and a distinct notching or slurring on the downstroke of the R wave.6. Physiological changes that occur during a routine ETTIn a stress test or ETT, patients are asked to perform incremental exercises that result in positive chronotropic (rate) and inotropic (strength of contraction) stimulation of the cardiovascular system, which in turn increases myocardial oxygen demand. Increases in oxygen demand obligate an increase in myocardial blood flow. The fundamental pathophysiologic change in CAD is a limitation of the ability of the coronary arterial circulation to vasodilate appropriately. As a result, the ability to increase coronary blood flow in the face of increased myocardial oxygen demand is limited, leading to an imbalance between oxygen supply and demand and resulting in myocardial ischemia.7. Significance of ischemic changes on the ECG during exerciseCirculatory beds in the body, the coronary circulation allows maximum oxygen extraction from the blood when the body is at rest. In a stress test or ETT, patients are asked to perform incremental exercises that result in positive chronotropic (rate) and inotropic (strength of contraction) stimulation of the cardiovascular system, which in turn increases myocardial oxygen demand. Increases in oxygen demand obligate an increase in myocardial blood flow. The healthy coronary circulation can increase flow approximately five times above the baseline level. The fundamental pathophysiologic change in CAD is a limitation of the ability of the coronary arterial circulation to vasodilate appropriately. A second important predictor of more advanced CAD is exercise-induced hypotension (i.e., a fall in systolic blood pressure of at least 20 mm Hg at any point during exercise).8. Test performed on a patient before recommending an exercise routine12-lead ECG and ECHO (Echocardiogram)9. The agent most commonly used to administer an ETTThe most widely available pharmacologic agents for stress testing are dipyridamole (Persantine), adenosine, regadenoson (Lexiscan), and dobutamine. However, the US Food and Drug Administration (FDA) warns against the use of adenosine and regadenoson in patients with signs or symptoms of unstable angina or cardiovascular instability.10. The meaning of an ST segment elevation during an exercise stress testAcute STEMI. STOP THE TEST!11. Changes that occur in an ECG that demonstrate ischemia late in the ischemic cascade.ST segment and T-wave changes that are central to demonstration of ischemia occur relatively late in the ischemic cascade.12. (A) The meaning of left ventricle wall thinning and there is some hyperkinesias of the ventricular wall during an echocardiogram exercise test and (B) define a positive exercise echocardiogramA positive exercise echocardiogram is defined by stress- induced decrease in regional wall motion, decreased wall thickening, or regional compensatory hyperkinesis. A limitation of the test is that it is dependent on the operator’s experience. Test results can also be altered by obesity, lung disease, and tachycardia.13. Stress-induced ischemiaMany of these women have evidence of stress-induced cardiac ischemia, which is likely to be related to endothelial dysfunction of the microvasculature.ECHO – Echocardiogram14. Difference of an echocardiogram exercise testing and a thallium stress testingThe 2DE evidence for ischemia includes an abnormal left ventricular ejection fraction (LVEF) response to exercise or the development of regional wall motion abnormalities.The exercise is performed with a bicycle or treadmill, and dobutamine is the most common pharmacologic agent used simultaneously with the echocardiography imaging. The image quality may be enhanced by the injection of echogenic microbubbles.As previously demonstrated in thallium imaging, the sensitivity of the 2DE technique for CAD detection is enhanced in patient subsets with multivessel CAD or prior myocardial infarction. In addition, the sensitivity of exercise echocardiography is decreased in patients with resting wall motion abnormalities.15. How does an echocardiogram enhance a standard ETTCurrent data suggest that adjunctive echocardiographic imaging enhances the sensitivity and specificity of CAD detection to an extent comparable to that provided by nuclear techniques.16. The effect of an ultrasound echocardiography on a morbidly obese patientNon-invasive cardiac imaging may suffer from poor image quality in morbidly obese individuals.Woman and heart disease (Coronary Artery Disease)17. Women and assessing by procedures for CADAlthough cardiovascular disease is the leading cause of death in women, this disorder often is not diagnosed expeditiously. Unfortunately, studies investigating women and cardiovascular disease are limited. Women are more likely to have nonobstructive or single-vessel disease compared with men, which decreases the diagnostic accuracy of stress testing.18. Women and limitations of certain tests for CADLimitations based on the size of the woman’s breasts and size of coronary arteries.Women are more likely to have nonobstructive or single-vessel disease compared with men, which decreases the diagnostic accuracy of stress testing. Single-photon emission CT imaging is technically limited in women because breast tissue and smaller coronary artery size.19. Women and symptoms of CADLeading cause of death (cardiovascular, heart disease including CAD in women) but a considerable body of research has demonstrated that women have different patterns of CAD and different responses to cardiac testing than their male counterparts do.20. Guidelines found from what source to support the prevention of future heart disease in a patient. All patients, even if asymptomatic, require risk stratification according to the Framingham risk score (low, intermediate, or high) to identify CAD risk equivalents. At present, the ACC/AHA guidelines do not recommend stress tests for asymptomatic patients, unless the patient (men 45 years or older, women 55 years or older) is sedentary and wishes to begin exercising aggressively. For women who are symptomatic and have known CAD, an abnormal resting ECG recording, questionable exercise tolerance, or coronary risk factors (e.g., diabetes, peripheral arterial disease), stress test imaging is recommended.21. Stress testing and women as compared to menWomen are more likely to have nonobstructive or single-vessel disease compared with men, which decreases the diagnostic accuracy of stress testing.Other22. A strategy to improve healthcare practices: Improvements in the delivery and management of healthcare are necessary if we are to improve the overall health of the nation’s population. Which of the following are identified in your readings as strategic in the movement to improve the healthcare system? Management of the population and healthcare practices.23. Term used for the encouragement of patients to be active in their own healthcareAutonomy, Ownership, Partnership, Self-management24. Medicare Part A, or "hospital insurance," covers inpatient hospital services as well as some post-hospital nursing care and home health care. Part A is paid for through federal payroll taxes.25. Medicare will not reimburse NPs for services considered to be exclusive to nursing.26. Medicaid and the way it is delivered by each state, a federal program administered by each state, provides health care coverage to low-income families, to women and children and elders who qualify on the basis of poverty or age, and to those with short-term disabilities.27. Adherence to the principle of fidelity mandates that health care providers honor their commitments; adherence to veracity compels health care providers to tell the truth and not to be deceptive.28. Collaboration between patient and healthcare providerThe best part of collaboration is between the health care provider (i.e. nurse practitioner) and the patient because if the patient doesn’t have faith in the HCP/NP, the relationship is doomed and true collaboration will not take place.29. Chronic disease management statistics: according to the World Health Organization (WHO); know the statistics and percentage of preventable deaths and disabilities: 67%.