Chapter 23 Management of Patients with Coronary Vascular Diseases Flashcards
What is the leading cause of death in the United States?
Cardiovascular Disease
Which type of cardiovascular disease is most prevalent in disease?
Coronary artery disease (CAD)
Non-modifiable Risk Factors for CAD
Family Hx
Gender (Assigned at Birth): Onset of disease is earlier in males than in females
Age
Male: > 45 y.o
Female: > 55 y.o.
Race: Greater genetic risk in African-Americans than in Caucasians
Primary (genetic) Hypercholesterolemia
Modifiable Risk Factors for CAD
Hyperlipidemia (LDL) and/or Low HDL
Elevated triglycerides
Smoking/tobacco use
HTN
Diabetes mellitus
Obesity
Physical Inactivity
Metabolic Syndrome: Combo of 3 modifiable physiological factors
Chronic Inflammatory Conditions: Rheumatoid arthritis, lupus, HIV/AIDS, etc
Chronic Kidney Disease (CKD)
(T/F) True or False: CAD is a progressive disease process
True
Early Stages of CAD
Atherosclerosis & Stable Angina (pain associated w/MI)
Atherosclerosis
Abnormal accumulation of lipid deposits & fibrous tissue w/in arterial walls & lumen
Atherosclerosis Process
1) Starts w/ injured vessel
2) Injured tissue can no longer produce antithrombotics & vasodilation agents
3) Inflammatory response begins and leads to a build-up of cells and lipids in the vessel (fatty streak)
4) Decreased blood flow in vessel due to narrowed opening
Atheromas
Lipid deposits/ plaques that protrude in the arterial lumen
Vulnerable Plaque
When the fibrous cap becomes thin with ongoing inflammation
Myocardial Infarction (MI)
AKA Heart Attack
Occur when there is occlusion of the coronary artery that leads to ischemia or necrosis of the myocardium
THIS IS AN EMERGENCY!!!
Additional Risk Factors for Atherosclerosis
Diabetes Mellitus
Peripheral Artery Disease (PAD)
Abdominal Aortic Aneurysm (AAA)
Carotid Artery Disease
Presence of disease in other body arteries presents a high likelihood that there is disease in the coronary arteries as well
Dangers of Atherosclerosis
Progressive and can lead to ischemia due to narrowing in the coronary arteries
Can lead to extensive myocardial damage and scarring; later causing angina/heart failure/heart attacks, or even sudden cardiac death
Ischemia
Insufficient tissue oxygenation
Clinical Manifestations of Atherosclerosis
May be nothing/chest pain
Epigastric pain
Pain in jaw, shoulder, or arm
Clinical Manifestations of Atherosclerosis in Women
Indigestion
Nausea
Palpitations & numbness
SOB
Angina pectoris
Refers to chest pain that is brought about by myocardial ischemia
- Usually characterized by pain or pressure
Angina Pectoris Clinical Manifestations
Vice-like pain in the chest (weight on chest, crushing)
Pts w/ DM may have neuropathy & feel less pain
Older patients may not have pain due to diminishing tissue sensation from aging
Chest/neck/jaw/shoulder/arm pain
Changes in: BP, N/V, pallor, tachycardia, tachypnea, vasoconstriction
Do the symptoms improve w/ NTG?
Atypical Angina Clinical Manifestations in Women
Chest pain, discomfort, pressure or squeezing (like there’s a weight sitting on you)
Unusual upper body pain/discomfort in one or both arms, back, shoulder, neck, jaw or upper portion of stomach
Breaking out in a cold sweat
Lightheadedness or sudden dizziness
Nausea
Unusual fatigue
SOB
Cause of Angina Pectoris
Usually caused by significant coronary atherosclerosis
- ANY reduction of blood flow to the heart (coronary spasm, extreme cold, hypotension)
Common Causes of Angina Pectoris
Atherosclerotic disease-> obstruction in at least 1 of the coronary arteries
Myocardial Ischemia: Insufficient tissue oxygenation (can lead to damage)
Any reduction of blood flow to the heart (coronary spasm, hypotension, extreme cold…)
Stable Angina
Can be managed w/lifestyle changes
Predictable/constant w/exertion
Relieved by rest and/or NTG
Common Exacerbating Factors of Stable Angina
Exercise: Increases O2 demand
Extreme cold: Vasoconstriction will decrease blood flow
High-stress situation: Increase in BP, HR, & cardiac work
Substances: Tobacco, caffeine, some illicit drugs
Unstable Angina
AKA preinfarction angina or crescendo angina
Occurs w/ sudden reduction in coronary blood flow likely from a ruptured atherosclerotic plaque, the vessel is not necessarily occluded
Unstable Angina (Symptoms)
Symptoms increase in frequency/severity
Unrelieved by rest and/or NTG
Not related to usual causes, often an indicator of impending MI
HEALTH EMERGENCY! ACT QUICKLY!
Variant Angina (Prinmetal’s angina)
Pain at rest w/ reversible ST-segment elevation
- Thought to be caused by coronary artery vasospasm
Silent Ischemia
Objective evidence of ischemia (such as ECG changes w/ stress test), but patient reports no pain
Intractable/ Refractory Angina
Severe incapacitating chest pain
Angina Pectoris Treatment Goal
Balance the O2 supply & demand
Nitroglycerin (NTG)/Imdur Action on the Heart
Vasodilator to increase blood flow to the myocardium
Patient Education on NTG Administeration
Instruct the patient to make sure that their mouth is moist, the tongue is still, & saliva is not swallowed until the NTG tablet dissolves
- If pain is severe: Can crush tablets between teeth to hasten sublingual absorption
Advise the patient to carry this med at ALL times
- Should be carried in its original container
- Tablets should NEVER be removed & stored in metal or plastic containers
Inactivated by heat, moisture, air, light, & time
- Instruct patient to renew every 6 months
Should be taken in anticipation of any activity that may produce pain
Recommend patient logs how much time it takes for NTG to alleviate symptoms
- If pain persists after taking 3 tablets at 5-min intervals, call 911 IMMEDIATELY!!
Discuss possible side effects: flushing, throbbing headache, hypotension, & tachycardia
Advise patient to sit down after taking a tablet to avoid hypotension & syncope
Beta-Blocker Action on the Heart
Decrease O2 demand of myocardium (monitor vitals & ECG)
Ca+2 Channel Blocker Action on the Heart
Decrease workload by lowering HR & systemic BP & increases O2 supply by dilating smooth muscle of coronary arteries
Meds to Prevent Platelet Aggregation
PO: Aspirin, Plavix, Effient
IV - Heparin, Integrilin
Angina Pectoris Patient Education
Exercise regimen
Smoking cessation if indicated
Diet changes (follow AHA/ Mediterranean Diet)
-Plant-based protein & whole grain bread/carb
- Low saturated fat; high in fiber
- Lower calories if indicated
Med Knowledge & Compliance
- One of the side effects of NTG is a headache
- Dizziness & hypotension w/BP meds
- Take tablets 5 mins apart
ID appropriate support resources
Help clients to ID one’s individual needs
Sudden Cardiac Death
Abrupt cessation of effective heart activity
Symptoms and severity are determined by…
…vessel location and amount of narrowing in the vessel
Prevention & Treatment of Atherosclerosis
Focus on modifiable risk factors:
-Cholesterol/triglyceride levels
-Tobacco use
-HTN: Take meds on time (low Na diet)
-Diabetes Mellitus: Take meds on time (low-carb diet)
-Activity
-Weight
Nursing Education Considerations for Atherosclerosis
Education should focus on the modifiable risk factors:
Cholesterol/triglyceride levels (see pg.
729)
Tobacco use
Hypertension
DM
Activity
Weight
Nursing Interventions for Atherosclerosis
Educate the pt
Monitor lab values/know your ranges
Encourage routine follow-up labs
Nutrition guidance
Tobacco cessation education
Encourage activity/cardiac rehab
Medication compliance and education
Acute Coronary Syndrome
Spectrum includes unstable angina, NSTEMI, & STEMI
Acute Coronary Syndrome Clinical Manifestations
CV: Chest pain, jugular vein distension, high/low BP, pulse changes, ECG changes
Resp: SOB, dyspnea, tachypnea
GI/GU - N/V, indigestion, decreased UO
Skin- cool, clammy, diaphoretic, pale
Neuro - Restlessness, dizziness
Psych - Fear, anxiety, denial, “impending doom”
Order of CAD Progression
Atherosclerosis-> Angina-> Acute Coronary Syndrome-> MI
Diagnostics Used in the ACS Spectrum: 12-lead ECG
Changes to ST segment and T wave, development of a pathologic (abnormal) Q wave
Should be obtained within 10 minutes of arrival to ED or complaint of pain
Diagnostics Used in the ACS Spectrum: Cardiac enzymes/biomarkers
Troponin
- Trop T and I, “Normal” Trop range = 0 - 0.03
CK-MB is cardiac-specific and will peak within 24 hours of the MI
Myoglobin is less specific, negative MG can be used as a “rule-out”
Normal Troponin Range
Normal: 0-0.03
Anything that exceeds 0.4 -> high likelihood it could be MI
Diagnostics Used in the ACS Spectrum: Echocardiogram
Check ventricular function and wall function
Diagnostics Used in the ACS Spectrum: Stress Test
May identify areas of CAD
Diagnostics Used in the ACS Spectrum: Cardiac catheterization w/ PCI
Visually identify coronary vessels & repair blockages
Left Heart Catheterization: Performed in Cath Lab
MD uses Radial or Femoral artery to insert a catheter, catheter is guided to the coronary arteries and contrast is injected
- Depends on which method the MD has been trained in
- Sometimes in patients w/ narrow shoulders, they will go femoral route
Under fluoroscopy the MD can see where the vessels narrow or are blocked
Angioplasty/stent placement vs medical management
- More than 70% occlusion = stent
- Less than 70% occlusion = medical management
Left Heart Catheterization: Returning to the Acute Floor
Assess vitals, groin/wrist, extremities
- Avoid risk for infection, bleeding, excess clotting
- Hold pressure for bleeding
- Patients w/ Metformin cannot undergo this procedure (must wait at least 48 hrs after to take it-> due to interaction)
Maintain hydration to promote renal flushing
- This procedure is caustic to the kidneys
- Assess renal function BEFORE procedure
Maintain bedrest for 4-6 hours (per MD order)
- Those w/ radial catheterization have at least 30 mins of rest
Left Heart Catheterization: Patient Education
Activity limitations
- Based on which body part was accessed
* Wrist = no lifting
* Groin = no bending, squatting, or stooping
- To avoid increasing pressure on procedure site
Signs of infection
- Watch out for redness, swelling, fever
ST-segment Elevation
Injured myocardial cells depolarize normally but repolarize faster than normal cells, causing the ST segment to rise at least 0.04 sec (1mm) above the isoelectric line
May return to normal after reperfusion
ST-segment Depression
At least 0.04 sec (1mm) below the isoelectric line
Typically associated with ischemia, not necessarily an infarct
T-wave Inversion
Typically the earliest change on ECG, may be permanent
Caused when myocardial repolarization is altered/damaged
Pathologic Q-wave
0.04 seconds or longer and 25% of R wave depth
Last change to occur (1-3 days after MI)
No depolarization can happen in the necrotic cells
NSTEMI Diagnosis
Shows abnormal biomarker, but no changes in ECG
STEMI Diagnosis
Shows abnormal biomarkers & ST changes in at least 2 leads
Highest Risk
-LAD occlusion: “Widow-maker”, anterior wall MI, person just drops dead
-RCA occlusion: Most common, inferior wall MI
Acute Coronary Syndrome Treatment Goal
Reestablish blood flow & decrease ischemic damage
Med Regiment for ACS: MONA
Same as angina, but also ACE-inhibitor (decrease O2 demand) & statin (help cholesterol level) should be added
Morphine
O2
Nitroglycerin
Aspirin
Nursing Interventions for ACS
Position the patient safely and implement bedrest
Administer MONA if indicated/MD ordered
Call for help from charge nurse or MET/MRT/RRT
Notify primary provider as quickly as possible
Call for stat EKG per protocol/MD order
Call for stat labs per protocol/MD order
STEMI Protocol
Act fast! Reperfusion needs to happen within 12 hours Preferred treatment is PCI
Door-to-balloon time is 60 minutes (arrival at ER to time PCI is performed)
-AHA suggested time is 90 mins
Thrombolytics within 12 hrs of symptom onset if PCI is not possible/indicated
-W/in 30 mins of onset shows best patient outcomes
USA Diagnosis
Shows symptoms, but diagnostics are negative for acute ischemia
The nurse is evaluating a 12-lead ECG of their patient who is experiencing an inferior wall MI. While discussing w/ the healthcare team, which of the following ECG changes has the nurse correctly identified:
A) Notched T wave & prolonged QTc
B) Inverted P wave & prolonged PR interval
C) ST segment elevation & inverted T wave
D) Irregular QRS complexes & no P wave
C) ST segment elevation & inverted T wave
ST elevation & T wave inversion both indicated damage to the myocardium, ST elevation indicates that it is acute (new) & this is the most life-threatening type of myocardial event
Rationale for Incorrect Choices:
A) is incorrect. These signs are more related to chronic (long-term) cardiac damage or medication use; although a prolonged QTC can be dangerous, this is not as imminently threatening as an ST elevation
B) is incorrect. These signs relate more to chronic atrial disease & are not as imminently threatening as ST elevation
D) is incorrect. These are characteristics of A-fib; while this can have dangerous complications, this is not as imminently threatening as ST elevation
A female patient is admitted to the ED c/o indigestion & nausea, in addition to pressure in her chest & shoulder. The patient also appears to be anxious, dyspneic, & diaphoretic. Which doctor’s orders should the nurse anticipate?
A) Keep NPO; draw labs: CMP, liver enzymes, abdominal CT
B) Keep NPO; draw labs: troponin, CK-MB, myoglobin, EKG & echo
C) Chest & shoulder MRI
D) Head CT
B) Keep NPO; draw labs: troponin, CK-MB, myoglobin, EKG & echo
- Rationale: The symptoms of the female patient could indicate a possible cardiac event. After ruling out a cardiac event, the provider may direct the focus to the GI system.
* Address symptoms of ABC’s FIRST!!!*
The nurse is taking care of a patient diagnosed w/ angina. Which of the following is the primary treatment goal?
A) Reversal of ischemia
B) Reversal of infarction
C) Reduction of stress & anxiety
D) Reduction of risk factors
A) Reversal of ischemia
Rationale: Angina is the pain associated w/ ischemic (impaired) cardiac tissue. All nursing care is aimed at reversing this damage before it becomes necrotic & is done by increasing O2 supply & decreasing O2 demand
The nurse is caring for a patient being admitted to the cardiac telemetry floor following a LT heart catheterization w/ PCI via femoral approach. Upon initial assessment, the nurse notes there is a large amount of blood under the patient’s buttocks. What is the nurse’s priority action?
A) Call Rapid Response for help
B) Assess your patient’s vital signs & call the doctor
C) Ask the client to raise their hips so you can assess underneath
D) Assess the client’s groin site
D) Assess the client’s groin site
Rationale: The blood could just be from the procedure, but it could also be an active bleed. The only way to know if this is an active bleed is to assess the groin site for bleeding. The priority action in an active bleed is to hold pressure, but the nurse cannot do this until they assess (ABC’s)
The nurse is assigned to a new patient being admitted to the cardiac telemetry floor for chest pain. The nurse assesses the patient’s medical history & current physical status. Which statement from the patient indicates a misunderstanding in the way to use nitroglycerin tablets?
A) “I can take up to 3 tablets before calling 911”
B) “I let it sit under my tongue instead of swallowing them whole”
C) “I only use them when I have chest pain”
D) “I keep a couple of the tablets in my general pill organizer for quick access”
D) “I keep a couple of the tablets in my general pill organizer for quick access”
Rationale: This is an INCORRECT understanding because the pills should be kept in their original pharmacy bottle (labeled for safety & dark to protect them from light exposure)
The nurse is completing a PQRST pain assessment on a patient c/o substernal chest pain. Which patient statement would indicate this pain is most likely stable angina?
A) “The pain began while I was watching television”
B) “The pain resolved after taking my NTG tablets”
C) “The pain is radiating to my LT arm”
D) “The pain started this morning & has lasted all-day”
B) “The pain resolved after taking my NTG tablets”
Rationale: This is predictable & when chest pain is resolved w/ rest it is considered stable
The nurse is caring for a 50 y.o. male patient w/ a family hx of CAD who has been prescribed Atorvastatin for the management of his cholesterol levels. The patient is concerned about the side effects of this medication, so the nurse tells him which of the following statements:
A) “This medication has no side effects; you should not worry about that”
B) “Because this medication directly impacts your normal cardiac function, the doctor will monitor your labs routinely”
C) “Because this medication directly impacts your normal liver function, the doctor will monitor your labs routinely”
D) “ A heart attack is worse than any side effect you may have, & because it is so important you should just take what the doctor ordered”
C) “Because this medication directly impacts your normal liver function, the doctor will monitor your labs routinely”
Rationale: The nurse should present factual information that addresses the patient’s concern & reassure the patient that care will be ongoing.
The nurse on the telemetry unit has just finished report & is reviewing their assignment. Which patient should be seen first?
A) The patient who was admitted last night at 2100 w/ chest pain that was unrelieved by their home NTG & showed a troponin level of 0.05 (@2100) & then 0.3 (@0700)
B) The patient that had a MI 2 days ago & has questions about going home today.
C) The patient who was admitted this morning at 0500 w/ chest pain that decreases w/NTG ointment & has a troponin of 0.04 (0500)
D) The patient who had a LT heart catheterization w/ stents yesterday at 0800 & has a resolving hematoma in their LT groin.
A) The patient who was admitted last night at 2100 w/ chest pain that was unrelieved by their home NTG & showed a troponin level of 0.05 (@2100) & then 0.3 (@0700)
Rationale: This patient is showing clinical changes that indicate worsening cardiac damage (unrelieved chest pain & increasing troponin level)
* Unstable angina can progress into a MI!!!**
A patient who experienced a MI received a thrombolytic agent rather than having a PCI. Which nursing intervention is most important during the next 24 hrs?
A) Assess for bleeding
B) Monitor K+ levels as ordered by the MD
C) Monitor the patient in a supine position
D) Encourage PO intake of fluid
A) Assess for bleeding
Rationale: A thrombolytic agent is meant to break up clots & prevent further clotting, bleeding is a SERIOUS side effect & can impact C(irculation) of the ABC’s.
The nurse is caring for a patient in the cardiac acute care floor who was admitted yesterday for chest palpitations. The patient calls to the desk stating they are having 10/10 pain in their chest & neck. Upon assessment the nurse determines normal S1 & S2, no adventitious breath sounds, & no GI abnormalities. They check the vitals which are HR 105, RR 22, BP 140/95, O2 91%, and temp 97.8F. Which intervention should the nurse do next?
A) Call the patient’s emergency contact
B) Assist the patient to safe positioning if needed & provide MONA interventions per hospital protocol
C) Page the MD
D) Complete a full head-to-toe assessment of the patient
B) Assist the patient to safe positioning if needed & provide MONA interventions per hospital protocol
Rationale: There is enough assessment to determine an action
The nurse is caring for a patient on the cardiac acute care floor. The patient was admitted overnight for recent periods of chest pain. Upon assessment of the patient, the nurse finds they are experiencing pain at a rating of 10/10. The nurse assesses the patient’s vitals & fins them to be HR 95, RR 24, BP 88/55, O2 93%, temp 98.2 F. Which intervention should the nurse do next?
A) Call the patient’s emergency contact
B) Assist the patient to safe positioning if needed & provide MONA interventions per hospital protocol
C) Page the MD
D) Complete a full head-to-toe assessment of the patient
C) Page the MD
Rationale: The doctor should be called since the assessment includes abnormal findings & the protocol is unsafe to proceed with. The nurse needs to communicate the findings & get new orders to work with.
