Perfusion Flashcards
coronary artery disease CAD types
1) Atherosclerosis
- soft deposit of fat that HARDENING with age
2) Atheromas
- fat deposit form in coronary arteries
Causes of CAD
1) Major cause is atherosclerosis
- Inflammatory response causes injury to vascular endothelium
- which makes conditions right for thrombus and causes vasodilation problems
2) Atheromatous plague build up in artery - causes rupture of plaque
Lesions often form where vessels branch
- plague lesions can obstruct blood flow
Things that cause damage to vessel
- tobacco
- hyperlipidemia
- toxins
- diabetes
- elevated homocysteine levels
- infection
Development of CAD
- Is progressive (develops over many years)
* When the patient becomes symptomatic the disease process is usually well advanced.
Myocardial Ischemia
Inadequate blood supply to the heart due to impediment of blood flow. (Inadequate perfusion)
The heart is deprived of oxygen
The patient will be symptomatic
Myocardial Ischemia
If decrease In Blood supply is great/ long enough (or both) what happens
- irreversible damage and death of myocardial cells
- can lead to MI or sudden cardiac death
CAD (nonmodifiable) Risk Factors
- Family history / genetics
- > 45 men >55 women
- Men earlier
- African American
Coronary artery disease in women
- often 10y later than men
- more likely to die of MI
- tend to not recognize symptoms
- have smaller coronary artery
CAD modifiable Risk Factors
- hyperlipidemia (LDL)
- cigarette
- hypertension
- diabetes
- obesity
- physical inactivity
- substance use
- homocysteine levels
Major modifiable risk factors of CAD
High serum lipids
1) Cholesterol > 200
2) HDL > 40
- high HDLs prevent lipid accumulation in artery
3) LDL < 100
- high LDL increase atherosclerosis and CAD
- 70 target for high risk
4) fasting triglycerides > 150
- high levels increase risk for CAD
Major modifiable risk factor for CAD
Hypertension (stages)
1) elevated 120-129
- life style changes
2) stage 1 HTN 130-139 / 80-89
- HTN drugs
3) stage 2 HTN > 140/>90
- HTN drugs
What does elevated BP lead to
Endothelial injury leads to left ventricular hyper trophy and reduced stroke volume
- Left ventricular hypertrophy is a thickening of the wall of the heart’s main pumping chamber = poor pumping
- stroke volume is the volume of blood pumped from the left ventricle per beat
Major Modifiable Risk Factors (CAD)
Physical Inactivity/Obesity
Obesity stage
Need 30-60 min brisk walk 5 days a wk
Obesity =
- BMI > 30
- waist >40 men > 35 women
- Apple figure
Major Modifiable Risk Factors (CAD)
Psychologic States
-type A person (always stressed)
Health Promotion for CAD
•May prevent, modify, or slow disease progression
- Preventive measures - Promote lifestyle changes
FITT formula for CAD
“Frequency, intensity, type, and time”
-30 minutes most days plus weight training two days a week
Lifestyle changes
Physical Activity for CAD
- Brisk walking
- Hiking
- Biking
- Swimming
- Add weight training 2 days a week
- Dress appropriately (cold or warm), walk inside (mall walking, walking in large stores)
Lifestyle changes Control Lipid levels
When should lipids be tested ?
➢Complete lipid profile should be done every 5 years beginning age 20
➢Middle-aged adult should be screened every 1-2 years
➢ Need fasting lipid profile
CAD lipid lowering therapy
•Drug therapy is lifelong
- Reassess after 6 weeks; if high, change to alternate drug
•Concurrent diet change; weight loss and increased physical activity
CAD
Drugs that restrict lipoprotein production
Statins
1) Rosuvastain- cause liver damage
Niacin side effects
Treat high cholesterol
Flushing
Pruritus
GI
Orthostatic hypotension
Drugs that Decrease Cholesterol Absorption
Ezetimibe (Zetia)
•Decrease absorption of dietary and biliary cholesterol
•Combine with statin
CAD
Antiplatelet therapy
Aspirin 81 mg (not when bleeding)
Or
Clopidogrel
Dietary Changes for CAD
• fruits, vegetables, fiber and low-fat dairy products
•Reduce dietary sodium (1500 mg/day)
- Read labels for foods that contain less than 400 mg of sodium per serving (Will control blood pressure)
•Balance intake and exercise to maintain desirable weight
•Reduce fats
•Cholesterol should be less than 200 mg/day. Avoid the trans fats
Nutrition
Foods Recommended
•Include plant based foods
- olives, avocadoes, and canola, sun flower and peanut oils, nuts, seeds, fish, seed oils and oysters
•Omega-3 fatty acids: fatty fish foods twice a week( salmon, tuna, mackerel), soybean oils, canola, walnuts, and flaxeed
Nutrition
Foods to Avoid
- Saturated fats: solid at room temp (lard, butter, whole-milk products, fatty cuts of meat, bacon)
- Trans fats: Mainly in foods made with hydrogenated vegetable oils (those made with margarines and shortenings)
Lifestyle changes (modifiable)
What does smoking do?
• Raises HR and BP
- Cause coronary arteries to constrict
• Increases LDL
•Inhalation of smoke increases the blood carbon monoxide level and decreases the supply of oxygen to the heart
Tobacco cessation!
Myocardial Ischemia
- Occurs due to lack of oxygenation to the heart muscle (ischemia)
- There is reduced or blockage of blood flow to the coronary arteries
Angina
The sign that myocardial ischemia is occurring
Caused by either an increased demand for O2 or a decreased supply of O2
Angina symptoms
**Mild indigestion
**Choking/ heavy sensation in chest
•Severe feeling of impending death
•Pain behind the sternum
- May radiate to the neck, shoulders, inner aspects of the upper arms
•SOB
**Numbness in arms, wrists, and hands
**Pallor
•Diaphoresis
**Dizziness or lightheadedness
•Nausea and vomiting
•Feelings of tightness, strangling sensation (has viselike, insistent quality)
Symptoms may resolve once the episode of angina subsides
Chronic Stable Angina
•Due to chronic and progressive CAD
- chronic chest pain
•Intermittent chest pain that occurs over a long period with similar pattern of onset, duration(few mins) and intensity
**Predictable
**Provoked by: physical exertion, stress, or emotional upset
**Important to get an accurate assessment of the symptoms
•May deny pain; have pressure, heaviness, or discomfort in chest; may be accompanied by dyspnea or fatigue; no change with position or breathing
Chronic Stable Angina control
- rest , calm down, sublingual nitroglycerin
Unstable Angina (UA)
What is it and what will ECG show
** New onset; occurs at REST; or with increase in frequency, duration, or with less effort than chronic stable pattern
•Pain lasting > 10 minutes
*** Unpredictable; needs immediate treatment!!!!
•ECG shows ST depression and/or T wave inversion = ischemic changes
Patients who may Not Experience Pain with Angina
- Diabetics (Diabetic neuropathy dulls pain perception)
- Women (CV disease more diffuse in its distribution in the coronary arteries)
- Older adults ( Changes in neuroreceptors): Are often no symptoms. May exhibit as syncope or dyspnea.
Intervention for Angina
unless it is unstable angina
rest or administer nitroglycerin
Angina
Planning/goals
- Relief of pain
- Immediate and appropriate treatment
- Preservation of heart muscle if MI suspected
- Effective coping with illness-associated anxiety
- Participation in a rehabilitation plan
- Reduction of risk factors
Angina patient education- Reducing risk factors
- Diet
- Physical activity
- Medications
- Psychological support
Angina immediate Care in hospital
- Position upright; apply oxygen
- Assess: VS; heart, and breath
- Continuous ECG monitor; 12-lead ECG
- Pain relief—NTG; IV opioid if needed
- Obtain cardiac biomarkers
- Obtain chest x-ray
- Provide support; reduce anxiety
Chronic Stable Angina
Diagnostics
- 12-lead ECG
- cardiac biomarkers, lipid profile, CRP
- Chest x-ray
- Echocardiogram
- Stress test
- Electron beam computed tomography
- Coronary computed tomography angiography
- cardiac catheterization, coronary angioplasty
Stress Testing
- Stress testing evaluates the heart’s response to physical stress.
- Can set limits for exercise programs
- Exercise testing can be used for persons who can walk unassisted or use a bicycle. Treadmill or exercise bike (if unable to use treadmill).
- May have to use IV pharmacological agents if unable to do exercise testing. Agents include adnenosine, dobutamine dipyridamole or regadenoson (Lexiscan)
- ECG and BP are monitored throughout the exercise periods for signs of cardiac stress (angina, shortness of breath
Stress Testing Preparation
Wear comfortable clothing and shoes
•Hold beta blockers and caffeine x 24 hours before the test
•Refrain from smoking, or strenuous exercise 3 hours before the test.
•Obtain baseline vital signs and 12-lead ECG
Procedures to Improve Perfusion to the Heart
- Percutaneous transluminal coronary angioplasty (PTCA)
- Intracoronary stents
- Coronary Artery By-Pass (CABG) surgery
Angina drug therapy - Short-acting nitrates
Dilate peripheral and coronary arteries and collateral vessels
•Sublingual nitroglycerin
•Give 1 tablet or 1 to 2 metered sprays
•Relief in 5 minutes; duration 30 to 40 minutes
•May repeat every 5 minutes × 3 doses
•If no relief, call EMS
•May cause: HEADACHE , DIZZINESS, flushing, orthostatic HYPOTENSION
•Prophylactic use
Nitroglycerin (Standard Treatment)
What’s it’s main side effect?
•Potent vasodilator •Decreases the myocardial oxygen requirements •Relief of angina symptoms •Can cause HYPOTENSION - Avoid if SBP is less than 90
Long-acting nitrates
•To reduce frequency of angina
•Methods of administration
- Oral
- Nitroglycerin (NTG) ointment
- Transdermal controlled-release NTG
- Patches applied in the morning and removed at night to allow nitrate free period and prevent the development of toleranceNitroglycerin Sublingual tablets (Acute Episodes)
•Can be self administered
•Place one tablet under the tongue (make sure mouth is moist and tongue is still, do not swallow saliva until tablet dissolves)
• one tablet q 5-minute X3. If pain persists then emergency services should be called
**Sit down for 15-20 minutes after to avoid faintness, hypotension
•Advise patient to carry medication at all times
•Is very unstable. Should be carried securely in its original container (capped, dark, glass bottle). Tablets should never be stored in metal or plastic pillboxes
•Store away from light, heat sources (including the body heat)
•Patient must renew supply q6 months
•NTG increases tolerance for exercises and stress when taken prophylactically. Should be taken in anticipation of any activity that may produce pain
Impairment of Perfusion to The Heart
Assessment and questions to ask
●Assess skin color and mucous membranes
●Ask questions about the patient’s symptoms
●Ask questions about the patient’s activities
●Assess risk factors for CAD
Impaired Myocardial Perfusion
Outcomes
- Immediate and appropriate treatment
- Reduction of anxiety
- Awareness of the disease process
- Understanding of the prescribed care
- Adherence to the self-care program
- Absence of complications
Promote Perfusion to the Heart during Angina Episodes
- Have the patient stop all activities
- Sit down or rest in bed
- Loosen clothing
- Semi-Fowler’s position (reduces O2 demand)
- Administer O2 at 2L
- Monitor pulse oximetry (should be 95% or above)
- Monitor rate and rhythm of respirations
- Monitor EKG for T-wave and ST segment changes
- Administer nitroglycerin sublingually (monitor BP and relief of chest pain)
- Reduce anxiety
Patient Information on
Measures to Improve Myocardial Perfusion
• Balance activity with rest periods
- walking, playing golf (consult with HCP)
•Medications
•Lifestyle changes: diet, exercise, rest periods, stop smoking, weight loss
•Identify symptoms and know what to do. Any pain unrelieved within 15 minutes by the usual method, including NTG should be treated at the closest ED; call 911
•Keep follow up appointments
Acute myocardial infarction
What is it and cause and how long does it develop
- Ischemia then necrosis of the myocardium due to prolonged ischemia from COMPLETE occlusion of a coronary artery.
- Causes: plaque rupture, thrombus formation, vasospasm, decreased oxygen due to blood loss, ingestion of cocaine, rapid heart rate, thyrotoxicosis.
- develops over minutes to hours
Myocardial infarction problems
Decreased contractility
Tachycardia
Arrhythmia
Clinical Manifestations of MI
** Severe chest pain not relieved by rest, position change, or nitrate
** Heaviness, pressure, tightness, burning, constriction, or crushing in substernal or epigastric
- May radiate to neck, lower jaw, arms, back
• Diaphoresis
•Vasoconstriction of peripheral blood vessels
** Skin: ashen, clammy, and/or cool to touch
•increased HR and BP, then reduced BP
•Decreased renal perfusion leads to decreased urine output
** Crackles (LV dysfunction)
•Jugular venous distention, hepatic engorgement, peripheral edema (RV dysfunction)
** Abnormal heart sounds (S3 or S4)
- New murmur
•Watch for signs of CHF pulmonary edema
•Nausea and vomiting
** Fever
- 100.4° F first 24 to 48hr; up to 4 to 5 days
Myocardial Infarction
Clinical Manifestations
Psychological
- Anxiety
- Fear
- Feelings of impending doom
- Denial that anything is wrong
Measure degree of MI
- Length of exposure to ischemia
- Size of the infarct.
- Collateral circulation
- The degree of functional impairment of the heart ( How good is the heart able to function?)
Myocardial Infarction
Diagnostic Tests
- EKG
- Echocardiogram
- Cardiac Biomarkers
- Cardiac catheterization
Myocardial Infarction
Diagnostic Tests/Assessment Findings
NSTEMI
- The artery is only PARTIALLY blocked.
- NO elevation in the ST segment on EKG
- elevated cardiac biomarkers but no definite EKG evidence of a MI
Myocardial Infarction
Diagnostic Tests/Assessment Findings
STEMI
- The coronary artery is COMPLETELY blocked off.
- Elevated cardiac biomarkers
- Because of the complete blockage a relatively large amount of heart muscle damage is occurring
Cardiac Biomarker
Troponin I and T
- The most cardiac SPECIFIC biomarkers of cardiac injury.
- Not normally found in the blood stream
- Released in blood stream with cardiac injury.
- ANY ELEVATION indicates myocardial necrosis or injury.
- Begin to elevate within hours of myocardial injury and remains elevated for days or 2-3 wk
Cardiac Biomarker
Creatinine kinase-MB
- CK-MB is an isoenzyme found in cardiac muscle
- Elevation of the CK value with the presence of MB indicates cardiac necrosis and reflects that an MI has occurred.
- Released within a few hours of myocardial injury.
- Remains elevated for 48-72 hours after injury.
Cardiac Biomarker
Myoglobin
- Found in cardiac AND skeletal muscle.
- RAPIDLY released with heart damage and last 1-3 hours after an MI.
- Valuable because it is the FIRST to rise after an MI
- Results not real specific but will rule out an MI if negative
Myocardial Infarction
Initial Management if happen outside hospital
•Transfer to hospital
** Bedrest 12-24 hours
** Supplemental oxygen immediately
• meds (MONA)
- Aspirin
- Nitroglycerin
- Morphine sulfate (reduce preload and afterload)
- Beta blocker (for tachycardia, dysrhythmias). Hold if signs if severe CHF. Prescribed at discharge from hospital
- ACE Inhibitors for left ventricular systolic dysfunction
- Heparin
Acute Coronary Syndrome
When chest pain from ischemia is prolonged and not immediately reversible
symptoms signaling myocardial ischemia and then infarction if help does not arrive. Is an emergent situation!
•May die if they do not reach the hospital
Acute Care: Thrombolytic Therapy (ASE)
➢Given IV
➢Opens blocked arteries by lysis of thrombus/clot, allows reperfusion
➢Avoid using if active bleeding, known bleeding disorder, history of hemorrhagic stroke, uncontrolled hypertension, recent major surgery
➢Inclusion criteria:
●Chest pain less than 12 hours AND 12 lead shows STEMI
●No absolute contraindications
Myocardial Infarction
Inpatient Management
- Transfer to a cardiac ICU
- Monitor for dysrhythmias, another MI, cardiogenic shock, ventricular aneurysm
- Continue drug therapy
- Monitor urine output, serum sodium, potassium, and creatinine levels
- Smoking cessation (nicotine patches and smoking cessation counseling )
Nursing care following an MI
- Assess the patient’s symptoms
- Establish 2 IV lines for patients when experiencing ACS to insure that an IV line is available emergency medications
- Relieve pain and other signs of ischemia.
- Administer oxygen
- Monitor vital signs
- Bed rest with the head of the bed elevated or in a supportive chair
Nursing care following an MI when stable
And continuing education
•Manage pain
-Administer morphine
- Assess for hypotension, decreased mental/ RR
*Encourage deep breathing, change position frequently
*Bed or chair rest
*Avoid Valsalva Maneuver: Prevent straining, laxatives and stool softeners, place needed objects within close reach
*Reduce anxiety
•Monitor heart, BP, chest pain, R, skin color/temp, mental status, lab values
•Patient education about heart healthy living, cardiac rehabilitation
- Home care nurse assists with scheduling and keeping follow-up appointments and adhering to the prescribed cardiac rehabilitation, home oxygen
- Sexual activity Resumes General when can walk 1 city block without symptoms
- Return to work: depends
Cardiac Rehabilitation
Phase I
- Begins with when the patient is admitted to the hospital for ACS.
- At the patient’s bedside.
- Emphasizes early mobilization, patient education ( signs that indicate need for 911, medication regimen, rest-activity balance, and follow-up appointments with the provider).
- Establish individual goals with the patient based on the patient’s functional ability (age, extent of disease, course of hospitalization and complications)
- Range of motion exercises included
Cardiac Rehabilitation
Phase II
- Occurs after discharge.
- attends sessions 3 times a wk for 4-6 wks or for as long as 6 months
- Supervised
- ECG monitored
- Exercise training: Tread mill or stationary bike. The patient must stop and rest if symptomatic (dysrhythmias, chest pain, etc.)
- Assess for the effectiveness of and adherence to the treatment
- Educational sessions for patients and families given by cardiologists, exercise physiologists, dietitians, nurses, and other health care professionals
- Patients taught to check their own pulse.
Cardiac Rehabilitation
Phase III
- Long-term outpatient program that focuses on maintaining cardiovascular stability
- Patient is self-directed during this phase
- Includes mall walking
Hemodialysis for stage 4 CKF (<15% GFR)
- fluid restrictions (I&O)
- may need anti hypertension drug bc not getting it out ( higher blood pressure could have damaged kidneys or blood sugars)
- diuretic if can use the bathroom
- low sodium so body doesn’t swell ( don’t take supplements that’s are going to push things over board like too much iron or potassium)
- will have a low H&H bc of damaged kidneys not making enough RBC (normally gets blood with dialysis)
- HOLD MEDS before going
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