NRS-105: Coronary Vascular Disorders (Chpt. 27)

Prevention of CAD

-control cholesterol -dietary measures -physical activity -medications -cessation of tobacco use -manage hypertension -control diabetes

Gerontologic considerations

-diminished pain transition that occurs with aging may affect presentation of symptoms -"silent" CAD -teach older adults to recognize their "chest pain-like" symptoms (ex: weakness) -pharmacologic stress testing; cardiac catheterization -medications should be used cautiously

variant angina

(Prinzmetal's angina)due to a coronary artery spasm, often occurring during restusually happens in early morning hours when resting (sleeping)

Unstable angina

(preinfarction angina) occurs with exercise or emotional stress, but it increases in occurrence, severity, and duration over time-more frequent, more severe- not relieved by rest and NTG. Requires medical intervention!

Collaborative problems

-Acute coronary syndrome, Myocardial Infarction or both -dysrhythmias: disorder of the formation or conduction (or both) of the electrical impulse within the heart, altering the heart rate, heart rhythm, or both and potentially causing altered blood flow -Cardiac arrest: occurs suddenly and often without warning. It is triggered by an electrical malfunction in the heart that causes an irregular heartbeat (arrhythmia). With its pumping action disrupted, the heart cannot pump blood to the brain, lungs and other organs. -Cardiogenic shock: shock state resulting from impairment or failure of the myocardium

Nursing Process: The care of the patient with ACS-Diagnoses

-Acute pain related to increased myocardial oxygen demand and decreased myocardial oxygen supply -Risk for decreased cardiac tissue perfusion related to reduced coronary blood flow -Risk for imbalanced fluid volume -Risk for ineffective peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction -Anxiety related to cardiac event and possible death -Deficient knowledge about post-ACS self-care

Collaborative problems

-Acute pulmonary edema: fluid buildup in the lungs -Heart failure -Cardiogenic shock -Dysrhythmias and cardiac arrest -Pericardial effusion: buildup of extra fluid in the space around the heart -cardiac tamponade: compression of the heart caused by fluid collecting in the sac surrounding the heart.

Nursing Management: Patient requiring invasive cardiac intervention #1

-Assessment of patient -Reduce fear and anxiety -Monitor and manage potential complications -Provide patient education -Maintain cardiac output -Promote adequate gas exchange -Maintain fluid and electrolyte balance -Minimize sensory-perception imbalance

Nursing Intervention: Patient Teaching #1

-Balance activity with rest -Follow prescribed exercise regimen -Avoid exercising in extreme temperatures -Use resources for emotional support (counselor) -Avoid over-the-counter medications that may increase HR or BP before consulting with health care provider -Stop using tobacco products (nicotine increases HR and BP) -Diet low in fat and high in fiber

Nursing Process: The care of the patient with ACS-Assessment

-Chest pain .Occurs suddenly and continues despite rest and medication .Other S&S: SOB; C/O indigestion; nausea; anxiety; cool, pale skin; increased HR, RR -ECG changes .Elevation in the ST segment in two contiguous leads is a key diagnostic indicator for MI -Lab studies: cardiac enzymes, troponin, creatine kinase, myoglobin

Acute Coronary Syndrome (ACS) and Myocardial Infarction (MI)

-Emergent situation -Characterized by an acute onset of myocardial ischemia that results in myocardial death (i.e., MI) if definitive interventions do not occur promptly -Although the terms coronary occlusion, heart attack, and MI are used synonymously, the preferred term is MI

Nursing Intervention: Preventing pain

-Identify level of activity that causes patients prodromal S&S -Plan activities accordingly -Alternate activities with rest periods -Teach patient and family

Nursing Intervention: Patient Teaching #2

-Medication teaching (carry NTG at all times!) -Follow up with health care provider -Report increase in S&S to provider -Maintain normal BP and blood glucose levels

Nursing Management: ACS/MI

-Oxygen and medication therapy -Frequent VS assessment -Physical rest in bed with head of bed elevated -Relief of pain helps decrease workload of heart -Monitor I&O and tissue perfusion -Frequent position changes to prevent respiratory complications -Report changes in patient's condition -Evaluate interventions!

Invasive Coronary Artery Procedures

-Percutaneous transluminal coronary angioplasty (PTCA) -Coronary artery stent -Coronary artery bypass graft (CABG) -Cardiac surgery

Nursing Management: Patient requiring invasive cardiac intervention #2

-Relieve pain -Maintain adequate tissue perfusion -Maintain body temperature -Promote health and community-based care

Nursing Process: The care of the patient with ACS-Nursing Interventions

-Relieve pain and S&S of ischemia -Improve respiratory function -Promote adequate tissue perfusion -Reduce anxiety -Monitor and manage potential complications -Educate patient and family -Provide continuing care

Nursing Intervention: Reduce anxiety

-Use a calm manner -Stress-reduction techniques -Patient teaching -Addressing patient's spiritual needs may assist in allaying anxieties -Address both patient and family needs

Assessment and findings of angina

-may be described as tightness, choking, or a heavy sensation -frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left) -anxiety frequently accompanies the pain -other symptoms may occur: dyspnea or shortness of breath, dizziness, nausea and vomiting

Medications

-nitroglycerin -beta-adrenergic blocking agents -calcium channel blocking agents -antiplatelet and anticoagulant medications -aspirin -clopidogrel and ticlopidine -heparin -glycoprotein IIb/IIIa agents

Nursing Intervention-Treat angina

-priority -patient is to stop all activity and sit or rest in bed (Semi-Fowler positioning) -Assess the patient while performing other necessary interventions. Assessment includes VS, observation for respiratory distress, and assessment of pain. In the hospital setting, the ECG is assessed or obtained -Administer medications as ordered or by protocol, usually NTG. Reassess pain and administer NTG up to three doses -Administer oxygen 2 L/min by nasal cannula

Nursing Process: the care of the patient with Angina Pectoris-Diagnoses

-risk for decreased cardiac tissue perfusion -anxiety related to cardiac symptoms and possible death -deficient knowledge about the underlying disease and methods for avoiding complications -noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes

Nursing Process: the care of the patient with Angina Pectoris-Assessment

-symptoms and activities, especially those that precede and precipitate attacks -risk factors, lifestyle, and health promotion activities -patient and family knowledge -adherence to the plan of care

Clinical manifestations of coronary artery disease (CAD)

-symptoms are caused by myocardial ischemia (MI) -symptoms and complications are related to the location and degree of vessel obstruction -angina pectoris (most common manifestation) -myocardial infarction -heart failure -sudden cardiac death -other symptoms: epigastric distress, pain that radiates to jaw or left arm, shortness of breath (SOB), atypical symptoms in women

Nursing Process: the care of the patient with Angina Pectoris-Interventions

-treat angina -reduce anxiety -prevent pain -educate patients about self-care -continuing care

Treatment

-treatment seeks to decrease myocardial oxygen demand and increase oxygen supply -medications -oxygen -reduce and control risk factors -reperfusion therapy may also be done

3 types of angina

1. stable angina 2. unstable angina 3. variant angina

Risk factors for coronary artery disease (CAD)

1.) atherosclerosis begins as monocytes and lipids enter the intima of an injured vessel 2.)Smooth muscle cells proliferate within the vessel wall 3.) contributing to the development of fatty accumulations and atheroma 4.) as the plaque enlarges, the vessel narrows and blood flow decreases 5.) the plaque may rupture and a thrombus might form, obstructing blood flow

4 modifiable risk factors cited as major for CAD

1.) cholesterol abnormalities 2.) tobacco use 3.) hypertension 4.) diabetes -elevated LDL: primary target for cholesterol- lowering medication -Framingham risk calculator -metabolic syndrome -hs-CRP (high-sensitivity C-reactive protein)

Cholesterol medications

6 types of lipid-lowering agents: affect the lipid components somewhat differently 1.) 3-Hydroxyl-3-methylglutaryl coenzyme A (HMG- CoA) (or statins) 2.) nicotinic acids 3.) fibric acids (or fibrates) 4.) bile acid sequestrants (or resins) 5.) Cholesterol absorption inhibitors 6.) omega-3 acid-ethyl esters

The nurse is caring for a patient with hypercholesterolemia who has been prescribed atorvastatin (Lipitor). What serum levels should be monitored in this patient?

A. complete blood count (CBC) B. blood cultures C. Na and K levels D. liver enzymes; Atrorvastatin (Lipitor) is an HMG-CoA reductase inhibitor and is hepatotoxic. Therefore, liver enzymes should be monitored in patients taking this medication

The nurse is caring for a patient who has severe chest pain after working outside on a hot day and is brought to the emergency center. The nurse administers nitroglycerin to help alleviate chest pain. What side effect should concern the nurse the most?

A.) Dry mucous membranes B.) Heart rate of 88 bpm C.) Blood pressure of 86/58 mm Hg D.) Complaints of headache -Nitroglycerin dilates vessels in the body. Dilation of the veins causes venous pooling of blood throughout the body. As a result, less blood returns to the heart, and filling pressure (preload) is reduced. If the patient is hypovolemic, the decrease in filling pressure can cause a significant decrease in cardiac output and blood pressure. This patient was working outside on a hot day, and the possibility of dehydration and hypovolemia should be considered.

The nurse is caring for a patient after cardiac surgery. Which nursing intervention is appropriate to help prevent complications arising from venous stasis?

A.) Encourage crossing of legs B.) Use pillows in the popliteal space to elevate the knees in the bed C.) Discourage exercising D.) Apply sequential pneumatic compression devices as prescribed -Sequential pneumatic compression devices should be used when prescribed to help prevent venous stasis and clotting complications such as deep vein thrombosis and pulmonary embolism. Patients should be discouraged to cross their legs. Pillows should not be used in the popliteal space to elevate the knees; rather, this should be avoided. Exercises, passive and active, should be encouraged

Nursing Process: The care of the patient with ACS-Planning

Goals: -Relief of pain or ischemic signs (e.g., ST-segment changes) and symptoms -Prevention of myocardial damage -Maintenance of effective respiratory function, adequate tissue perfusion -Reduction of anxiety -Adherence to the self-care program -Early recognition of complications

Nursing Process: the care of the patient with Angina Pectoris-Planning

Goals: -immediate and appropriate treatment of angina -prevention of angina -reduction of anxiety -awareness of the disease process -understanding of prescribed care and adherence to the self-care program -absence of complications

Troponin

a cardiac muscle biomarker; measurement is used as an indicator of heart muscle injury

Metabolic syndrome

a cluster of metabolic abnormalities including insulin resistance, obesity, dyslipidemia, and hypertension that increase the risk of cardiovascular disease

Stent

a metal mesh that provides structural support to a coronary vessel, preventing its closure

Thrombolytic

a pharmacologic agent that breaks down blood clots; alternatively referred to as a fibrinolytic

Percutaneous coronary intervention (PCI)

a procedure in which a catheter is placed in a coronary artery, and one of several methods is employed to reduce blockage within the artery

High-density lipoprotein (HDL)

a protein-bound lipid that transports cholesterol to the liver for excretion in the bile; composed of a higher proportion of protein to lipid than low-density lipoprotein; exerts a beneficial effect on the arterial wall

Low-density lipoprotein (LDL)

a protein-bound lipid that transports cholesterol to tissues in the body; composed of a lower proportion of protein to lipid than high-density lipoprotein; exerts a harmful effect on the arterial wall

Coronary artery bypass graft (CABG)

a surgical procedure in which a blood vessel from another part of the body is grafted onto the occluded coronary artery below the occlusion in such a way that blood flow bypasses the blockage

Angina pectoris

a syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow -physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand

Percutaneous transluminal coronary angioplasty (PTCA)

a type of percutaneous coronary intervention in which a balloon inflated within a coronary artery to break an atheroma and open the vessel lumen, improving coronary artery blood flow

Contractility

ability of the cardiac muscle to shorten in response to an electrical impulse

Atherosclerosis

abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and the lumen

Sudden cardiac death

abrupt cessation of effective heart activity

Coronary atherosclerosis

blockages and narrowing of the coronary vessels reduce blood flow to the myocardium

Angina pectoris

chest pain brought about by myocardial ischemia

Stable angina

chest pain that occurs when a person is active or under severe stress; subsides with rest or NTG (nitroglycerin)

Myocardial infarction (MI)

death of heart tissue caused by lack of oxygenated blood flow

Atheroma

fibrous cap composed of smooth muscle cells that forms over lipid deposits within arterial vessels and protrudes into the lumen of the vessel, narrowing the lumen and obstructing blood flow; also called plaque

Ischemia

insufficient tissue oxygenation

Acute coronary syndrome (ACS)

signs and symptoms that indicate unstable angina or acute myocardial infarction

Cardiovascular disease

the leading cause of death in the United States for men and women of all racial and ethnic groups

Coronary artery disease (CAD)

the most prevalent cardiovascular disease in adults