chapter 27 heart acute
prevention of CDA medications
Lipid-lowering medications can reduce CAD mortality in patients with elevated lipid levels and in at-risk patients with normal lipid levels 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (or statins), fibric acids (or fibrates), bile acid sequestrants (or resins), cholesterol absorption inhibitors, and omega-3-acid ethyl esters. A new class of lipid-lowering medications known as proprotein convertase subtilisin-kexin type 9 (PCSK9) agents has recently been approved
Although the terms coronary occlusion, heart attack, and MI are used synonymously, the preferred term is ____
MI
Atherosclerosis patho
begins with injury to the vascular endothelium (may be initiated by smoking, hypertension, hyperlipidemia, and other factors. The endothelium undergoes changes and stops producing the normal antithrombotic and vasodilating agents.) immflammtion then bring on macrophages who inject lipids and becomes foam cells to put lipids on the arterial wall. Lipids then make fatty streaks and foam cells oxidize LDL Then a atheromas (fibrous cap) forms narrowing and obstructing blood flow The plaque may rupture and a thrombus might form, obstructing blood flow.
Nursing Care pre-op CABG
aspirin (eduction in perioperative morbidity and mortality), beta-blockers (reduce a.fib), and statins (Reduce MI, atrial fibrillation, neurological dysfunction, renal dysfunction, infection, and death) during the preoperative period, along with the assessment of hematocrit and glucose levels Patient history CBC, BMP, PT/INR, Blood type & cross match CXR, US of Carotid Arteries CHG wash or shower Clip hair as ordered Patient & Family education: Clarify the procedure, CVICU environment, mechanical ventilation, sedation Address and explore any concerns, fears, anxiety assess patient (preop testing, see coping, fears and concerns and understanding) reducing fear an anxiety (describe the sensations that the patient can expect) Monitoring and Managing Potential Complications (angina/ give nitroglycerin or oxygen) Providing Patient Education (shower with an antiseptic solution such as chlorhexidine gluconate. Hair removal with an electric clipper rather than a razor, expect monitors, several IV lines, chest tubes, and a urinary catheter, Most patients remain intubated and on mechanical ventilation for several hours after surgery. It is important for patients to know that this will prevent them from talking, nurse explains deep breathing and coughing, the use of the incentive spirometer, and foot exercises, the nurse practices these procedures with the patient. The benefit of early and frequent ambulation)
CABG requirements
at least a 70% occlusion, or at least a 50% occlusion if in the left main coronary artery
In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce ______ ______to the _______.
blood flow; myocardium
prevention of CDA
controls cholesterol abnormalities dietary measures Physical activity Medications Cessation of tobacco use Manage HTN Control diabetes
Angina Pectoris Most often attributed to ______ _________
coronary arteriosclerosis
Pathological Q-waves:
infraction (MI)
Elevated S-T segment:
injury
T-wave inversion:
ischemia (lack of blood/oxygen)
Silent ischemia:
objective evidence of ischemia (such as electrocardiographic changes with a stress test), but patient reports no pain
Variant angina (also called Prinzmetal's angina):
pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm
Stable angina:
predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin (exercise increases O2 demands of heart)
Ischemia
reduced blood flow to the heart
________ identifies the type and location of the MI, and other ECG indicators, such as a Q wave and patient history, identify the timing. An abnormal Q wave may be present without ST-segment and T-wave changes, which indicates an old, not acute, MI.
12-lead ECG
If S-T elevation MI, (STEMI) ED door-to-balloon (PIC) time should be <__ minutes
90 (book said 60)
prevention of CDA tobacco use
A person at increased risk for heart disease is encouraged to stop tobacco use through any means possible: educational programs, counseling, consistent motivation and reinforcement messages, support groups, and medications. Some people have found complementary therapies (e.g., acupuncture, guided imagery, hypnosis) to be helpful. nicotine patch (NicoDerm CQ, Habitrol), varenicline (Chantix), or bupropion (Zyban) used for a short time and at the lowest effective doses. secondhand smoke Nicotinic acid in tobacco triggers the release of catecholamines, which raise the heart rate and blood pressure and cause coronary artiers to constrict moking can increase the oxidation of LDL, damaging the vascular endothelium which causes platete adhearence and higher risks for clots Inhalation of smoke increases the blood carbon monoxide level and decreases the supply of oxygen to the myocardium
Collaborative Problems/ potential complicatons angina
ACS (acute coronary syndrom), MI, or both Dysrhythmias and cardiac arrest Heart failure Cardiogenic shock (heart suddenly can't pump enough blood to meet your body's needs)
Characterized by an acute onset of myocardial ischemia that results in myocardial death (i.e., MI) if definitive interventions do not occur promptly. Emergent situation. 12-lead EKG is priority
Acute Coronary Syndrome (ACS) and Myocardial Infarction (MI)
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
Nursing Process: The Care of the Patient With ACS—Planning
Adherence to the self-care program (rehab: cease activity if CP, SOB or palpitations) 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 Early recognition of complications
Nitrates Nitroglycerin (Nitrostat, Nitro-Bid)
Angina (2 major side effects? Headache, hypotension) other: flushing, throbbing headache, hypotension, and tachycardia. Short- and long-term reduction of myocardial oxygen consumption through selective vasodilation Sublingual: dont swallow untill fully dissolved but if in alot of pain can crush in teeth. Keep in original dark glass bottle. inactivated by heat, moisture, air, light, and time and change bottle every 6 months. take before pain inducing stuff like excersie. if pain persists after taking three sublingual tablets at 5-minute intervals, emergency medical services should be called. sit down for a few minutes to avoid hypotension and syncope. patches are applied in the morning and removed at bedtime allows for a nitrate-free period to prevent the development of tolerance. IV: It usually is not given if the systolic blood pressure is less than 90 mm Hg. Generally, after the patient is symptom-free, the nitroglycerin may be switched to an oral or topical preparation within 24 hours. A common adverse effect of nitroglycerin is headache, which may limit the use of this drug in some patients
Calcium Channel Blocking Agents Amlodipine (Norvasc) Diltiazem (Cardizem, Tiazac)
Angina Negative inotropic effects; indicated in patients not responsive to beta-blockers; used as primary treatment for vasospasm slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect). These effects decrease the workload of the heart. also increase myocardial oxygen supply by dilating the smooth muscle wall of the coronary arterioles; they decrease myocardial oxygen demand by reducing systemic arterial pressure and the workload of the left ventricle commonly prescribed for hypertension. Hypotension may occur after the administration especially IV Other side effects may include atrioventricular block, bradycardia, and constipation.
anticoagulants heparin
Angina prevents the formation of new blood clots The dose of heparin given is based on the results of the activated partial thromboplastin time (aPTT). Heparin therapy is usually considered therapeutic when the aPTT is 2 to 2.5 times the normal aPTT value. Because unfractionated heparin and LMWH increase the risk of bleeding, the patient is monitored for signs and symptoms of external and internal bleeding, such as low blood pressure, increased heart rate, and decreased serum hemoglobin and hematocrit. Bleeding precautions (Applying pressure to the site of any needle puncture for a longer time than usual, Avoiding intramuscular (IM) injections, Avoiding tissue injury and bruising from trauma like blood pressure cuff) if you start it you can turn it off and do a procedure in an hour
antiplatelets clopidogrel (Plavix), prasugrel (Effient), ticagrelor (Brilinta)
Angina may take a few days to achieve antiplatelet effects carry the risk of bleeding from the GI tract or other sites.
A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow (either need to open vessels or decrease demand ) the need for oxygen exceeds the supply. Coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand Physical exertion or emotional stress increases myocardial oxygen demand Exposure to cold ->vasoconstriction ->elevated BP Eating a heavy meal -> blood & O2 to gut
Angina Pectoris
Nursing Management: Patient Requiring Invasive Cardiac Intervention
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 Relieve pain Maintain adequate tissue perfusion Maintain body temperature Promote health and community-based care Pulse assessment: If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.
____________ is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen, forming plaques.
Atherosclerosis
3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (or statins):
Atorvastatin, Simvastatin ↓ Total cholesterol ↓ LDL ↑ HDL ↓ TGs Inhibit enzyme involved in lipid synthesis (HMG-CoA) Favorable effects on vascular endothelium, including anti-inflammatory and antithrombotic effects Frequently given as initial therapy for significantly elevated cholesterol and LDL levels Administer in evening Myalgia (muscle pain) and arthralgia (joint pain) are common adverse effects Myopathy and possible rhabdomyolysis are potential serious effects Monitor liver function tests Contraindicated in liver disease Check for drug interactions Indication for use now includes ACS and stroke
For that same patient, the nurse had identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What is the most effective intervention? A. IV fluid bolus B. Consistent deep breathing and coughing C. Cardiac rehabilitation D. Metered dose albuterol inhaler
B. Consistent deep breathing and coughing
Nursing Process: The Care of the Patient With Angina Pectoris—Interventions *patient teaching*
Balance activity with rest Diet low in fat and high in fiber Follow prescribed exercise regimen Avoid exercising in extreme temperatures Use resources for emotional support (counselor) Avoid OTC decongestant (cause they contrict)medications that may increase HR or BP before consulting with health care provider Stop using tobacco products (nicotine increases HR and BP) 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
Complications post-cath
Bleeding or hematoma at site (bleeding/swelling at site, pain with leg movement) Retroperitoneal bleeding: bleeding into retroperitoneal space (back/ab pain, hypotension) Pseudoaneurysm: bleeding collects in space btwn 2 outer layers of artery (swelling) Arterial occlusion of extremity: thrombus or embolus Abrupt closure of coronary artery: thrombosis or restenosis Acute kidney injury: from contrast or hypotension (you would see decrease in urine output (want 30ml/hr)
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
C. Blood pressure of 86/58 mm Hg
standard procedure cardiac cath
Cardiac Cath Radial Approach This is now standard procedure Radial preferred unless anatomy prevents passage of wires and catheters TransRadial (TR) Band applies pressure after procedure After 2 hours, gradually decrease air in band (2ml/15 min)
______________ disease is the leading cause of death in the United States for men and women of all racial and ethnic groups.
Cardiovascular
ACS/ MI symptoms
Chest pain that occurs suddenly and continues despite rest and medication is the presenting symptom chest pain, shortness of breath, indigestion, nausea, and anxiety. They may have cool, pale, and moist skin. Their heart rate and respiratory rate may be faster than normal.
CAD major modifiable risk factors
Cholesterol abnormalities (elevated LDL- primary target for cholesterol lowering medication) tobacco use hypertension diabetes obesity inactivity Hyperlipidemia metabolic syndrome (insulin resistance, obesity, hypertension, dyslipidemia (triglycerides more than 150 an HDL more than 40-50), chronic inflammation) Type 2 diabetes hs-CRP (high-sensitivity C-reactive protein) screening tool
Bile acid sequestrants (or resins):
Cholestyramine, Colestipol ↓ LDL Slight ↑ HDL Oxidize cholesterol into bile acids, which ↓ fat absorption Most often used as adjunct therapy when statins alone have not been effective in controlling lipid levels Taken before meals Side effects include constipation, abdominal pain, GI bleeding May decrease absorption of other drugs
Replace blocked arteries with new bypass grafts
Coronary artery bypass graft (CABG) Cardiac surgery
_____ _________ _______ is the most prevalent cardiovascular disease in adults.
Coronary artery disease (CAD)
The nurse is caring for a patient 3 days post 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.
D. Apply sequential pneumatic compression devices as prescribed.
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
D. Liver enzymes
Nursing Process: The Care of the Patient With ACS—complications
Dysrhythmias and cardiac arrest Acute pulmonary edema Heart failure Cardiogenic shock Pericardial effusion and cardiac tamponade
Cholesterol absorption inhibitors:
Ezetimibe ↓ LDL Inhibits absorption of cholesterol in small intestine Better tolerated than bile acid sequestrants Used in combination with other agents, such as statins Side effects include abdominal pain, arthralgia, myalgia Contraindicated in liver disease
Fibric acids (or fibrates):
Fenofibrate, Gemfibrozil ↑ HDL ↓ TGs ↓ Synthesis of TGs and other lipids Adverse effects include diarrhea, flatulence, rash, myalgia Serious adverse effects include pancreatitis, hepatotoxicity, and rhabdomyolysis Contraindicated in severe renal and liver disease Use with caution in patients who are also taking statins
Omega-3 acid-ethyl esters: F
Fish Oil ↓ TGs Inhibit TG production in liver May be used alone or in combination with other agents Side effects include GI distress, taste perversion, rash, and back pain
____ ___ _______ is a tool commonly used to estimate the risk for having a cardiac event within the next 10 years adults 20 years and older. The calculation is performed using the individual's risk factor data, including age, gender, total cholesterol, HDL cholesterol, smoking status, systolic blood pressure, and need for antihypertensive medication.
Framingham Risk Calculator
Nursing care post cath
Frequent vital signs Meds as ordered, esp. antiplatelet immediately after PCI (IV heparin or a thrombin inhibitor (e.g., bivalirudin) Positioning as ordered (femoral vs. radial) must stay still, radial is bette Frequent observation of sheath/insertion site (closure device, holding pressure, or wristband) Monitor for site bleeding, hematoma, or retroperitoneal bleeding Assessment and documentation of all peripheral pulses Patient & family education
Nursing Process: The Care of the Patient With Angina Pectoris—Interventions *preventing pain*
Identify level of activity that causes patients prodromal S&S Plan activities accordingly Alternate activities with rest periods (If the patient has pain frequently or with minimal activity) Teach patient and family (balancing activity and rest)
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
Nursing Process: The Care of the Patient With Angina Pectoris—Nursing Diagnoses
Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (underlined ) 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
Angina—Nursing Assessment/ Clinical Manifestations
May be described as tightness, choking, or a heavy sensation (get an idea of what kind of pain like sharp deep) Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left) Anxiety frequently accompanies the pain (severe apprehension and a feeling of impending death) Other symptoms may occur: weakness or numbness in the arms, wrists, and hands dyspnea or shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, nausea, and vomiting The pain of typical angina subsides with rest or NTG Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention! (heparin or abciximab (ReoPro) or eptifibatide (Integrilin) The patient with diabetes may not have severe pain with angina because diabetic neuropathy can blunt nociceptor transmission, dulling the perception of pain
Cardiopulmonary Bypass system
Mechanically circulates and oxygenates blood for the body while bypassing the heart and lungs Provides bloodless, motionless surgical field Venous blood removed from vena cava, filtered, oxygenated, cooled, warmed, and returned to aorta Heart is stopped by cardioplegia solution (high potassium) Heparin prevents clotting/Protamine reverses heparin at end of procedure cannula in the right atrium, vena cava, or femoral vein to withdraw blood from the body. The cannula is connected to tubing filled with an isotonic crystalloid solution. Venous blood removed from the body by the cannula is filtered, oxygenated, cooled or warmed by the machine, and then returned to the body. hypothermia is maintained at a temperature of about 28°C (82.4°F)
MONA
Morphine (vasodilation and pain relief) Oxygen Nitroglycerin Aspirin
The patient has elevated cardiac biomarkers (e.g., troponin) but no definite ECG evidence of acute MI. In this type of MI, there may be less damage to the myocardium.
NSTEMI
angina medications
Nitroglycerin, Beta-Adrenergic Blocking Agents, Calcium Channel Blocking Agents, Antiplatelet and Anticoagulant Medications
Nursing Management: ACS/MI
Oxygen and medication therapy Frequent VS assessment Physical rest in bed with HOB 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!
ACS/ MI Assessment and Diagnostic Findings
Patient history- family history/risk factors of heart disease and current systoms 12-lead: given within 10 minutes. finds location, evolution, and resolution of an MI can be identified Troponin: elevated shows MI (rises in a few hours and stays for 2 weeks) Creatine Kinase and Its Isoenzymes: Elevated CK-MB is an indicator of acute MI (rises in few hours and peaks in 24) Myoglobin: negative results rule out an MI (rise is 1-3 hrs and peaks in 12)
Invasive Coronary Artery Procedures Increase the size of the artery's lumen
Percutaneous Transluminal Coronary Angioplasty (PTCA) AKA Percutaneous Coronary Intervention (PCI) Coronary artery stent
Complications after CABG
Persistent bleeding (may cause cardiac tamponade) (give blood and Protamine sulfate) Hypovolemia (fluids)/Fluid overload (dieretics) Hypotension/Hypertension (Vasodilators) Hypothermia Dysrhythmias (Carotid massage) MI/Heart Failure (diuretics) Atelectasis (collapsed lung) Stroke Acute kidney injury (diuretics) Infection (antibiotics) Liver Failure
Cardiac Rehabilitation phases
Phase I begins with the diagnosis of atherosclerosis and admitted to hospital Phase II: after discharge for 3 times a week for up to 6 months. ECG-monitored, exercise training that is individualized. Phase III is a long-term outpatient program that focuses on maintaining cardiovascular stability
Several factors are associated with typical anginal pain:
Physical exertion, which precipitates an attack by increasing myocardial oxygen demand Exposure to cold, which causes vasoconstriction and elevated blood pressure, with increased oxygen demand Eating a heavy meal, which increases the blood flow to the mesenteric area for digestion, thereby reducing the blood supply available to the heart muscle; in a severely compromised heart, shunting of blood for digestion can be sufficient to induce anginal pain Stress or any emotion-provoking situation, causing the release of catecholamines, which increases blood pressure, heart rate, and myocardial workload
Nursing Process: The Care of the Patient With Angina Pectoris—Interventions *Treat angina*
Priority! (stop what your doing) Patient is to stop all activity and sit or rest in bed (semi-Fowler's positing). Assess the patient while performing other necessary interventions. asking questions to determine whether the angina is the same as the patient typically experiences. Assessment includes VS, observation for respiratory distress, and assessment of pain. In the hospital setting, the 12-lead 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 ACS—Nursing Interventions
Relieve pain and S&S of ischemia (oxygen, rest, raise head of bed) Improve respiratory function (monitors fluid volume status to prevent fluid overload and encourages the patient to breathe deeply and change position frequently) *Promote adequate tissue perfusion: balance myocardial oxygen supply with demand (Bed or chair rest, skin temp should be monitored) *Reduce anxiety: address patient's fears (quiet environment) Monitor and manage potential complications Educate patient and family (identify the patient's priorities) Provide continuing care
Three major coronary arteries
Right coronary artery Left anterior descending coronary artery Circumflex coronary artery
The patient has ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG. In this type of MI, there is a significant damage to the myocardium.
STEMI
Greater and Lesser ________Veins Are Commonly Used for Bypass Graft Procedures
Saphenous
Nursing Process: The Care of the Patient With Angina Pectoris—Assessment
Symptoms and activities, especially those that precede and precipitate attacks (ask when did this happen and what brought it on, discribe the pain, point to it, what helps it go away) Risk factors, lifestyle (do you smoke), and health promotion activities Patient and family knowledge Adherence to the plan of care 12 lead ECG (most import) Stress Test CT of coronary arteries Cardiac Catheterization
prevention of CDA dietary measures
Therapeutic Lifestyle Changes (TLC) diet, a diet low in saturated fat and high in soluble fiber the Mediterranean diet, another diet that promotes vegetables and fish and restricts red meat referral to a dietitian can help the patient in following the appropriate TLC diet. Other TLC recommendations include weight loss, cessation of tobacco use, and increased physical activity. strict vegetarian diets can significantly reduce blood lipids, blood glucose, body mass index, and blood pressure.
TLC diet
Total fat- 25-35% of total calories saturated fat- <7% of total calories carbs- 50-60% of total calories dietary fibers- 20-30 g/day protein- Approximately 15% of total calories
angina treatment
Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply Medications Oxygen (onset of chest pain in an attempt to increase the amount of oxygen delivered to the myocardium and to decrease pain. The therapeutic effectiveness of oxygen is determined by observing the rate and rhythm of respirations and the color of skin and mucous membranes.) Reduce and control risk factors peperfusion procedures may be used to restore the blood supply to the myocardium. These include PCI procedures (e.g., percutaneous transluminal coronary angioplasty [PTCA] and intracoronary stents) and CABG.
revention of CDA controlling diabetes
Treatment with insulin, metformin (Glucophage), and other therapeutic interventions that lower plasma glucose levels can lead to improved endothelial function and patient outcomes.
Nursing Process: The Care of the Patient With Angina Pectoris—Interventions *reducing anxiety*
Use a calm manner Stress-reduction techniques (guided imagery or music therapy) Patient teaching ( providing information about the illness, its treatment, and methods of preventing its progression) Addressing patient spiritual needs may assist in allaying anxieties Address both patient and family needs
causes of MI
Vasospasm (sudden constriction or narrowing) of a coronary artery, decreased oxygen supply (e.g., from acute blood loss, anemia, or low blood pressure), and increased demand for oxygen (e.g., from a rapid heart rate, thyrotoxicosis, or ingestion of cocaine) and plaque rupture
Nursing care pre-cath
Vital signs Continuous ECG monitoring Meds: ASA, Beta-blocker, others as ordered Labs: CBC, BMP, PT/INR Assessment and documentation of all peripheral pulses Patient & family education Remove undergarments Clip hair
Nursing Process: The Care of the Patient With ACS—Assessment
What is the patient's baseline? Chest pain Occurs suddenly and continues despite rest and medication, may also be jaw or back pain Other S&S: SOB; C/O indigestion; nausea; anxiety; cool, pale skin; increased HR, RR 12 Lead ECG changes ECG monitoring Lab studies: troponin, cardiac biomarkers, creatine kinase, myoglobin 2 IV lines are placed for emergency meds
Beta-adrenergic blocking agents: Metoprolol (Lopressor) Atenolol (Tenormin)
angina decrease O2 demand (how? They slow down the heart rate) reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is a reduction in heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility (force of contraction). Because of these effects, beta-blockers balance the myocardial oxygen needs (demands) and the amount of oxygen available (supply). The dose can be titrated to achieve a resting heart rate of 50 to 60 bpm Cardiac side effects and possible contraindications include hypotension, bradycardia, advanced atrioventricular block, and acute heart failure. If a beta-blocker is given IV for an acute cardiac event, the ECG, blood pressure, and heart rate are monitored closely after the medication has been given. Side effects include depressed mood, fatigue, decreased libido, and dizziness. Patients taking beta-blockers are cautioned not to stop taking them abruptly, Patients with diabetes who take beta-blockers are instructed to monitor their blood glucose levels as prescribed because beta-blockers can mask signs of hypoglycemia. contridicted in patients with chronic pulmonary disorders, such as asthma cause it casus branchoconstriction
Glycoprotein IIb/IIIa Agents abciximab (ReoPro) eptifibatide (Integrilin)
angina prevent platelet aggregation by blocking the GP IIb/IIIa receptors on the platelets, preventing adhesion of fibrinogen and other factors that crosslink platelets to each other and thus form intracoronary clots bleeding is the major side effect, and bleeding precautions should be initiated.
antiplatelets and anticoagulants Aspirin
angina prevents platelet aggregation and reduces the incidence of MI and death A 162- to 325-mg dose of aspirin should be given to the patient with a new diagnosis of angina and then continued with 81 to 325 mg daily. may cause GI upset and bleeding, the use of histamine-2 (H2) blockers or proton pump inhibiotors are recammended
CAD non-modifiable risk factors
family history (first-degree, 55-men, 65 women) age (45 men, 55 women) gender(men earlier) race (blacks more)
prevention of CDA controlling cholesterol abnormalities
goal is higher HDL and lower LDL When an excess of LDL is produced, LDL particles adhere to receptors in the arterial endothelium. macrophages ingest them, contributing to plaque formation. All adults 20 years and older should have a fasting lipid profile (total cholesterol, LDL, HDL, and triglycerides) performed at least once every 5 years Patients who have had an acute event (e.g., MI), a percutaneous coronary intervention (PCI), or a coronary artery bypass graft (CABG) require assessment of their LDL cholesterol level within a few months of the event or procedure, because LDL levels may be low immediately after the acute event or procedure. Subsequently, lipids should be monitored every 6 weeks until the desired level is achieved and then every 4 to 6 months. LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients) Total cholesterol less than 200 mg/dL HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females Triglyceride less than 150 mg/dL
prevention of CDA managing hypertension
lower salt intake, diet
ASC/ MI Medical Management
minimize myocardial damage, preserve myocardial function, and prevent complications. Use rapid transit to the hospital. Obtain 12-lead electrocardiogram to be read within 10 minutes. Obtain laboratory blood specimens of cardiac biomarkers, including troponin. Obtain other diagnostics to clarify the diagnosis. Begin routine medical interventions: Supplemental oxygen, Nitroglycerin, Morphine, Aspirin, Beta-blocker, Angiotensin-converting enzyme inhibitor within 36 hours, Anticoagulation with heparin and platelet inhibitors, Statin Evaluate for indications for reperfusion therapy: Percutaneous coronary intervention, Thrombolytic (fibrinolytic) therapy Continue therapy as indicated: IV heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux, Clopidogrel (Plavix), Glycoprotein IIb/IIIa inhibitor, Bed rest for a minimum of 12-24 hours, Statin prescribed at discharge. initial: immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine (hypotension or decreased respiratory rate for morphine) The patient with STEMI is taken directly to the cardiac catheterization laboratory for an immediate PCI Thrombolytics (Fibrinolytics): used when no cath lab. watch for bleeding and take precaturions (do not use B/P cuffs alot or IM injections) Inpatient Management: after PCI or thrombolytics, ICU observes. aspirin, a beta-blocker, and ACE inhibitors continue giving. Blood pressure, urine output, and serum sodium, potassium, and creatinine levels need to be monitored closely
Acute Coronary Syndrome (ACS) and Myocardial Infarction (MI) Goal is to ...
reperfuse cardiac muscle, either through PCI or thrombolytics (TPA) if no cath lab available
Intractable or refractory angina:
severe incapacitating chest pain despite max med Rx
CABG Indications
surgical procedure in which a blood vessel is grafted to an occluded coronary artery so that blood can flow beyond the occlusion Revascularization When PCI is not successful or too risky Left Main coronary artery Multivessel CAD Prevention of and treatment for MI, dysrhythmias, or heart failure Left Internal Mammary Artery graft(LIMA) Right Internal Mammary Artery graft (RIMA) Saphenous vein grafts (main vein for bypass) not for diabetes
CAD Clinical Manifestations
symptoms caused by ischemia (insufficient tissue oxygenation) Angina pectoris (chest pain that is brought about by myocardial ischemia) caused by significant coronary atherosclerosis. MOST COMMON sudden cardiac death (From a drease in blood supply) decreased blood supply for a long enough time can cause damage and death of myocardial cells. eventually become irreversible and replaced with scar tissue epigastric distress and pain that radiates to the jaw or left arm older with history of diabetes or heart failure will experience SOB
Unstable angina (also called preinfarction angina or crescendo angina):
symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin
prevention of CDA physical activity
the goal for most adults is to engage in moderate-intensity aerobic activity of at least 150 minutes per week or vigorous-intensity aerobic activity of at least 75 minutes per week, or an equivalent combination. In addition, adults should engage in muscle-strengthening activities on 2 or more days each week that work all major muscle groups. start slow and set realistic goals They should also be taught to exercise to an intensity that does not preclude their ability to talk; if they cannot have a conversation while exercising, they should slow down or switch to a less intensive activity. When the weather is hot and humid, patients should exercise during the early morning, or indoors, and wear loose-fitting clothing. When the weather is cold, they should layer clothing and wear a hat. Patients should stop any activity if chest pain, unusual shortness of breath, dizziness, lightheadedness, or nausea occurs. weight reduction and increased physical activity. Regular, moderate physical activity increases HDL levels and reduces triglyceride levels, decreasing the incidence of coronary events and reducing overall mortality risk.
angina Gerontologic Considerations
the older adult with angina may not exhibit a typical pain profile because of the diminished pain transmission that can occur with aging. Often the presenting symptom in older adults is dyspnea (SOB). Sometimes there are no symptoms ("silent" CAD) Teach older adults to recognize their "chest pain-like" symptoms (i.e., weakness) Pharmacologic stress testing; cardiac catheterization (excersie like the treadmill) Medications should be used cautiously because they are at increased risk for adverse reactions Invasive procedures (e.g., PCI) that were once considered too risky in older adults may be considered