Week 1 part 2Chapter 23: Management of Patients with Coronary Vascular Disorders Flashcards
Coronary Atherosclerosis
Atherosclerosis is the abnormal accumulation of lipid
deposits and fibrous tissue within arterial walls and
lumen
In coronary atherosclerosis, blockages and
narrowing of the coronary vessels reduce blood flow
to the myocardium
Cardiovascular disease is the leading cause of death
in the United States for men and women of all racial
and ethnic groups
Coronary artery disease (CAD) is the most prevalent
cardiovascular disease in adults
Clinical Manifestations of Atherosclerosis
Symptoms are caused by myocardial ischemia
Symptoms and complications are related to the
location and degree of vessel obstruction
Angina pectoris (most common manifestation)
Other symptoms: epigastric distress, pain that
radiates to jaw or left arm, SOB, atypical symptoms
in women
Myocardial infarction
Heart failure
Sudden cardiac death
Risk Factors for Coronary Artery Disease
(CAD)
Refer to Chart 23-1
o Four modifiable risk factors cited as major
(cholesterol abnormalities, tobacco use, HTN,
and diabetes)
Elevated LDL: primary target for cholesterol-
lowering medication
Framingham risk calculator
Metabolic syndrome
hs-CRP (high-sensitivity C-reactive protein)
Prevention of CAD
Control cholesterol
Dietary measures
Physical activity
Medications
Cessation of tobacco use
Manage HTN
Control diabetes
Cholesterol Medications
Six types of lipid-lowering agents: affect the lipid
components somewhat differently (Table 23-1)
o 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-
CoA) (or statins)
o Nicotinic acids
o Fibric acids (or fibrates)
o Bile acid sequestrants (or resins)
o Cholesterol absorption inhibitors
o Omega-3 acid-ethyl esters
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
Types of angina
o Refer to Chart 23-2
Assessment and Findings for Angina
Assessment and Findings for 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
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!
Gerontologic Considerations for Angina
Diminished pain transition that occurs with aging
may affect presentation of symptoms
“Silent” CAD
Teach older adults to recognize their “chest pain–
like” symptoms (i.e., weakness)
Pharmacologic stress testing; cardiac catheterization
Medications should be used cautiously!
Treatment of Angina Pectoris
Treatment seeks to decrease myocardial oxygen
demand and increase oxygen supply
Medications
Oxygen
Reduce and control risk factors
Reperfusion therapy may also be done
Medications for Angina
Nitroglycerin
Beta-adrenergic blocking agents
Calcium channel blocking agents
Antiplatelet and anticoagulant medications
Aspirin
Clopidogrel and ticlopidine
Heparin
Glycoprotein IIb/IIIa agents
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
Assessment of the Patient with Angina
Pectoris
Symptoms and activities, especially those that
precede and precipitate attacks (Chart 23-4)
Risk factors, lifestyle, and health promotion
activities
Patient and family knowledge
Adherence to the plan of care
Collaborative Problems of the Patient with
Angina Pectoris
ACS, MI, or both
Arrhythmias and cardiac arrest (see Chapters 22
and 25)
Heart failure (see Chapter 25)
Cardiogenic shock (see Chapter 11)
Planning and Goals for the Patient with
Angina Pectoris
Goals
o Immediate and appropriate treatment of angina
o Prevention of angina
o Reduction of anxiety
o Awareness of the disease process
o Understanding of prescribed care and adherence
to the self-care program
o Absence of complications
Nursing Interventions for the Patient with
Angina Pectoris
Treat angina
Reduce anxiety
Prevent pain
Educate patients about self-care
Continuing care
Nursing Intervention: Treat Angina
Priority
Patient is to stop all activities 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 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
Nursing Intervention: Preventing Pain
Identify level of activity that causes patient’s
prodromal S&S
Plan activities accordingly
Alternate activities with rest periods
Educate patient and family
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 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
Assessment of the Patient with ACS
Chest pain
o Occurs suddenly and continues despite rest and
medication
o Other S&S: SOB; C/O indigestion; nausea;
anxiety; cool, pale skin; increased HR, RR
ECG changes
o Elevation in the ST segment in two contiguous
leads is a key diagnostic indicator for MI
Lab studies: cardiac enzymes, troponin, creatine
kinase, myoglobin
Collaborative Problems of the Patient with
ACS
Acute pulmonary edema (see Chapter 25)
Heart failure (see Chapter 25)
Cardiogenic shock (see Chapter 11)
Arrhythmias and cardiac arrest (see Chapters 22
and 25)
Pericardial effusion and cardiac tamponade (see
Chapter 25)
Planning and Goals for the Patient with
ACS
Goals:
o Relief of pain or ischemic signs (e.g., ST-
segment changes) and symptoms
o Prevention of myocardial damage
o Maintenance of effective respiratory function,
adequate tissue perfusion
o Reduction of anxiety
o Adherence to the self-care program
o Early recognition of complications
Nursing Interventions for the Patient with
ACS
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 Management of the Patient with
ACS
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 #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 Management: Patient Requiring
Invasive Cardiac Intervention #2
Relieve pain
Maintain adequate tissue perfusion
Maintain body temperature
Promote health and community-based care
Cardiac-Specific Troponin:
Cardiac-Specific Troponin:
►Troponin T (cTnt): <0.1 ng/mL (>2.3 + cardiac injury)
►Troponin I (cTnI): <0.5 ng/mL
►Creatine Kinase MB (CK-MB): < 4%-6% total CK
►Myoglobin: 11.1 mcg/L – 91.2 mcg/L
Which result is the most important?
►Troponin T (cTnt)
►Why?
How do you differentiate between Unstable
Angina (UA) and Non-Stemi (NSTEMI)?
►ECG
►Serum Cardiac Biomarkers
What are your priority nursing interventions?
► Medications: Continue O2, Administer Nitroglycerin
and Aspirin
► Monitor: Continually assess patient: Airway,
breathing efforts, hemodynamic status, cardiac
arrhythmias
► Prepare for percutaneous coronary intervention (PCI).
► Would you wait for laboratory results prior to sending
patient to the cardiac catheterization lab? Why or
why not?
Cardiac Catheterization Lab:
Cardiac Catheterization Lab:
► Arterial Access: Radial or Femoral
► Percutaneous Coronary Intervention (PCI): An
endovascular procedure that is minimally invasive
where a small incision is made into a vessel using a
needle puncture, guidewire and sheath to provide
access to diagnose/treat.
► Percutaneous Transluminal Coronary Angioplasty
(PTCA): Locate and assess blockage and determine
extent of collateral circulation along with left
ventricular function.
► Balloon Angioplasty: Widening of blocked or narrowed
vessel by balloon catheter.
► Stent Placement: Bare Metal or Drug-Eluting
What medications are used
during a cardiac catheterization?
►Midazolam
►For Sedation
►Fentanyl
►For Pain Control
What are the benefits
of PCI over
Coronary Artery Bypass Graft (CABG)?
►Minimally Invasive
►Low Risk
►Quick Recovery
What is the goal of PCI?
►Quickly open up blocked
arteries to allow oxygen-rich
blood to circulate to the entire
heart muscle with minimal risk
and recovery.
What are your expectations s/p
reperfusion? -aka- What will you
frequently assess?
►No Chest Pain
►Normal ECG
►Normal Vital Signs
►Normal Neuro Status
►Normal Heart and Lung Sounds
►No Bleeding (External or Internal)
How often will you draw serum cardiac
biomarkers post PCI?
► Q 6 hours x 3
► What will happen to serum cardiac biomarkers s/p
reperfusion therapy?
► Early and rapid rise within three hours of reperfusion
therapy.
► Peaking within 12 hours.
► Why do these levels increase?
►Necrotic heart cells release proteins into circulation
after perfusion is restored to the area.
What are some PCI complications that can
lead to an emergent Coronary Artery Bypass
Graft (CABG).
► Dissection
► Rupture
► Acute Stent Thrombosis
► Restenosis (Reocclusion)
► Coronary Spasm
► Bleeding
► Stroke
► Infection
When would a patient receive a thrombolytic?
►No Cardiac Catheter Lab
►Thrombolytic Requirements:
►Chest Pain < 12 hours
►STEMI only
►No contraindications
What is the goal of Thrombolytic Therapy?
►Limit Infarction Size
►Get Patient to Cardiac Cath Lab ASAP
►Thrombolytic Therapy Risks?
►Bleeding
►Reocclusion of Artery
Absolute Contraindications:
► Intracranial Hemorrhage History
► Known Abnormalities
► Recent Stroke
► Recent Trauma
► Intracranial Cancer
► Severe Uncontrolled Hypertension
► Active Internal Bleeding
► Suspected Aortic Dissection
► Prior Treatment (Streptokinase)
► Recent Intracranial/Spinal Surgery
ACS Medications: Why do we give them?
►Dual Antiplatelet Therapy
►Nitroglycerin
►Morphine
►Beta Blocker
►Lipid-Lowering Drugs
►ACE/ARB
►Antidysrhythmics
►Stool Softeners
Dual Antiplatelet Therapy:
Antiplatelets stop platelets from clumping
together and forming blood clots. Dual antiplatelet therapy (DAPT) is
defined as the use of a P2Y12 receptor inhibitor (clopidogrel,
ticagrelor, and prasugrel) and aspirin. (Clopidogrel, Aspirin)
► Nitroglycerin:
A nitrate resulting in vasodilation to relieve angina
occurring when the heart muscle is deprived of blood/oxygen.
► Morphine:
A potent opioid providing analgesia along with vasodilation
and decreasing cardiac workload (decreases heart rate, blood
pressure and venous return). As a result, myocardial oxygen demand
is decreased.
► Beta Blocker:
Used to manage abnormal heart rhythms and for
patients with acute MI, beta blocker therapy reduces infarct size and
early mortality when started early and lowers the risk of death when
continued long term. (Atenolol, Metoprolol)
► Lipid-Lowering Drugs:
Decrease the levels of fats in the blood.
Lowering cholesterol levels that are too high lessens the risk for
developing heart disease and reduces the chance of a heart attack or
dying of heart disease, even if the patient already has it.ACE/ARB
(Atorvastatin, Simvastatin)
► Antidysrhythmics:
Used to reduce mortality in post MI patients with
ventricular ectopic activity which has an adverse effect on prognosis
post MI. (Amiodarone)
► Stool Softener:
Used to prevent straining during a bowel movement
which should be avoided after an MI or surgery. Straining can trigger
a vasovagal response where the vagus nerve sends a message to the
brain causing a sudden drop in blood pressure and heart rate which
can trigger a cardiovascular event, such as arrhythmia. (Docusate)
