week 5- angina Flashcards
Coronary Artery Disease
Also known as Coronary Heart Disease (CHD)
Most common form of heart disease
Atherosclerosis:
Build of plaque (fats, cholesterol) within the arterial wall
Leading risk factor for cardiovascular disease
Affects larger arteries (eg: coronary arteries, aorta, carotid arteries)
Arteriosclerosis:
thickening or hardening of the arterial wall, often associated with aging
Pathophysiology of chd
Exact cause Unknown
Thought to occur due to blood vessel damage that causes an inflammatory response
Intimal artery surface fatty streaks
Plaque formation causes partial or complete blockage of artery
Stable vs Unstable plaques:
Unstable plaque rupture leads to platelet adhesion and rapid thrombus formation
Blockage may be sudden or gradual
May result in ischemia (CELL DEATH BECAUSE OF NO O2)or infarction(NO O2 AND DAMAGE)
Heart disease and stroke are ___of the three leading causes of death in Canada
two
—% of all deaths caused by cardiovascular disease
29
Prevalence:
how many people in the population have the condition at a specific point in time (ie: 1.3 million Canadians)
Incidence:
the number of incidences of a certain condition, over a certain time period, in a specific population (70,000 MI’s annually)
Women and Heart Disease
New research suggests more similarities than differences between men and women Women may describe pain differently Fatigue **most predominant symptom Shortness of breath Indigestion Anxiety Frequently dismissed or misdiagnosed
Myocardial Infarction in Women
Number one killer of Canadian women
MI presentation more “typical” than angina
More likely to present with NSTEMI (non-ST-segment-elevation myocardial infarct)
More likely to reinfarct within 1 year
Poorer prognosis following acute MI
angina
Temporary imbalance between the coronary arteries’ ability to supply oxygen & cardiac muscle’s demand for O2 = Ischemia
Referred to as a vague sensation, a strange feeling, pressure, or ache in the chest
An unpleasant feeling described as constrictive, squeezing, heaving, choking, or suffocating sensation
Also caused by: anemia, hypoxia due to hypotension, dysrhythmias
Stable Angina
chest pain occurs intermittently over a long period of time with the same pattern of onset, duration and intensity
some ay deny feeling pain, often describe pressure or ache in the chest
Unpleasant feeling often described as constrictive, squeezing, heavy, choking, or suffocating sensation
**NB: rarely sharp or stabbing and usually does not change with position or breathing
Many c/o indigestion or a burning sensation in the epigastric region
Most c/o pain substernal, radiating to various locations see Lewis, Figure 36-5, p 904
Pain usually brief (3 to 5 minutes) and commonly resides when precipitant factor is relieved
- pain at rest unusual
EKG: usually transient ST segment depression, indicative of ischemia
relieved by nitroglycerin
Unstable Angina
pain that is new, occurs at rest, or has a worsening pattern
pain is easily provoked by minimal to no exertion, during sleep or rest
pain has progressed rapidly in past few hours, days or weeks
pain refractory to nitroglycerin
Stable Angina Triggers
Exertion (most common) ie raking, snow shoveling, lift heavy objects
Emotional stress
Exposure to very hot or cold temperatures
Heavy meals
Smoking
Sexual activity
Drug Therapy
Decrease O2 demand and/or increase O2 supply
Short-acting nitrates: Sublingual nitroglycerin
Long-acting nitrates: isosorbide dinitrate (Isordil)
β-adrenergic blockers: metoprolol
Calcium channel blockers if β-adrenergic blockers are poorly tolerated, contraindicated, or do not control anginal symptoms
Angiotensin-converting enzyme (ACEI) inhibitors
Angiotension Receptor Blockers (ARBs)
Low dose ASA (antiplatelet)
Short-acting nitrates: first-line therapy for angina
Action:
- dilate peripheral blood vessels -> decreased systemic vascular resistance, venous pooling, and decreased venous blood return to the heart.
- dilating coronary arteries and collateral vessels -> may increase blood flow to ischemic areas of heart
Usually relieves pain in approx. 3 minutes, duration 30 – 60 minutes.
Dose:
1 tablet or spray sublingually (directly under the tongue) allow tab to dissolve
NB: symptoms unchanged or worse in 5 minutes -> EMS
no tingling sensation and chest pain persists -> EMS
Patient ed.: - 1)proper use of nitro, 2)easy accessible to patient all times, 3)store in tightly closed dark glass bottle, 3) adverse effects – increase heart rate, pounding headache, dizziness or flushing, orthostatic hypotension 4) once bottle opened, get new meds in 6 months
Chronic Stable Angina-Diagnostic Studies
Health history*** Symptom Assessment: PQRST Physical exam Laboratory studies 12-lead ECG Chest x-ray Echocardiogram Exercise stress test
PQRST
SYMPTOM ASSESSMENT
P – precipitating events
Q- quality of pain (what the pain feel like?)
R – radiation of pain (where is the pain located? Does pain
radiate to other areas? If so, where?)
S – severity of pain ( how would you rate your pain on a
scale 0 – 10 10 being the most severe pain)
T – timing (when did the pain begin? Has the pain
changed since this time? Have you had this type of
pain before?)
ACS: Unstable Angina
May occur at rest
Responds poorly to SL nitroglycerin…or not at all
Requires morphine to manage pain
Difficult to differentiate from MI
ECG changes (ST depression) noted
No elevation of cardiac markers Troponin or CK-MB
Prinzmetal’s Angina (also called Variant Angina)
Due to vasospasm
Often occurs at rest
Infarction:
- results from sustained ischemia, causing
irreversible myocardial cell death
- within 20 minutes of sustained ischemia–cellS die
Manifestations OF AMI
- Pain – heaviness, pressure, tightness, burning
- Location – substernal, or epigastric area, radiate to neck, jaw, arms or back
- Timing– rest, asleep, or awake, commonly in AM
**Clients with diabetes more likely to experience silent (asymptomatic) AMI due to cardiac neuropathy
*Women may also have atypical presentation
May seek treatment for atypical symptoms
*Older Adults: change in mental status (confusion), shortness of breath, pulmonary edema, dizziness, or a dysrhythmia
*Skin- ashen, clammy, & cool to touch
*CV – BP & HR may be elevated initially, BP may drop d/t decreased CO, if severe – decreased renal perfusion & urine output. Crackles may be notes, JVD, hepatic engorgement, peripheral edema
*GI-Nausea & Vomiting
*Fever – temp may increase within first 24h up to 380C
Morphine sulfate –
decreases myocardial O2 demand, relaxes smooth muscle, reduces circulating catecholamine; 2 – 4 mg dose q 5 – 15min; adverse effects: resp depression, hypotension, bradycardia, severe vomiting
Interventions
A= evaluate chest & other pain, ECG, VS, ensure patency of IV, notify MD or 911
D= Acute Pain r/t biologic injury agents (imbalance b/w myocardial O2 supply & demand)
I =, Morphine sulfate, O2, Nitroglycerine, ASA
O2 – to increase amount of O2 avail to myocardial tissues, 2 – 4L/m by nasal cannula titrated O2Sat =/>95%
Nitroglycerin (NTG) “Nitro”
– increases collateral blood flow toward the subendocardium, and causes vasodilation redistributions of the coronary arteries.
Nitroglyerin: Nursing Considerations
When do you hold Nitro?
If BP is
Percutaneous Coronary Intervention (PCI)
Must have access to a centre capable of offering this tx
Must be administered within 4-6 hours of MI
Treats occlusion, improves perfusion
Goal: resolve ischemia, prevent greater area of necrosis
Diagnostics Tests
Electrocardiography: ischemic myocardium does not repolarize normally, ST segment elevation, T wave inversion, abnormal Q wave
Chest X-Ray: to determine HF, not diagnostic for MI
Stress Test: to assess for ECG changes consistent with ischemia, evaluate medical therapy
Cardiac Catheterization: may be performed to determine extent and exact location of obstructions of coronary arteries. Identifies those who might benefit from percutaneous transluminal angioplasty (PCTA) or Coronary artery bypass grafting (CABG)
What are common Nursing Diagnoses and Collaborative Problems?
Acute Pain r/t biologic injury agents
Ineffective Tissue Perfusion r/t interruption of arterial blood flow
Activity Intolerance r/t fatigue
Ineffective Coping r/t effects of acute illness & major changes in lifestyle
Potential for Dysrhythmias
Potential for Heart Failure
Potential for Recurrent Symptoms & Extension of Injury
Ineffective Tissue Perfusion r/t interruption of arterial blood flow
I = Complete, sustained reperfusion of coronary arteries in the first few hours post-MI = LOWERED mortality
Thrombolytic Therapy –
used to dissolve thrombi in coronary arteries and restore myocardial blood flow
Most effective within 6h
Continuous monitoring
Indications: CP >30m
Contraindication: recent abd surgery, stroke, internal bleeding, HI, bleeding disorders, pregnancy
Ineffective Tissue Perfusion
ASA – 80 – 325mg - to prevent platelet aggregation at the site of obstruction
Other meds:
Glycoprotein I IIb/IIIa Inhibitors – prevents fibrinogen from attaching to activated platelets at site of thrombus
Beta-blocker – slows HR and force of cardiac contraction (prolong period of diastole & increase myocardial perfusion while reducing the force of myocardial contraction)
Activity Intolerance r/t Fatigue
Cardiac Care: Rehabilitative
Acute Phase – (till d/c from Hosp) - promote rest & ensure limited mobility, assist with ADLs, promoting gradual independence, gradual ambulation, showering, bed rest and limited activity for 12 – 24h
Patients progress “at their own rate to increasing levels of activity dependant on clinical status, age, & physical capabilities”
Assess VS & fatigue with each higher level of activity (BP 20 mm Hg or HR 20 bpm or dyspnea or CP indicates intolerance of activity)
Ineffective Coping r/t effects of acute illness & major changes in lifestyle
Denial – anxiety, but results in acting out and refusing to follow treatment regmens
Anger – attempt to regain control of life
Depression – response to grief & loss of functions
Potential for Dysrhythmias
- Leading cause of death for people with MI occurring outside hospital
- 70 – 90% of pt’s with MI experience some abnormal cardiac rhythm
Dysrhythmias
Caused by any condition that affects the myocardial cell’s sensitivity to nerve impulses ischemia, electrolyte imbalances, & SNS stimulation
Intrinsic rhythm of the heart beat is disrupted, causing fast HR, slow HR, or an irregular HR
Life-threatening dysrhythmias occur most often with anterior wall infarction, HF, or shock
Potential for Heart Failure
Complication where pumping power of heart has diminished
Occurs initially with subtle signs of mild dyspnea, restlessness, agitation, or slight tachycardia
Pulmonary congestion on Xray, S3, S4, crackles, JVD
Potential for Recurrent Symptoms & Extension of Injury
Goal: Minimal angina while engaging in ADLs and an exercise program
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Coronary Artery Bypass Graft Surgery (CABG)
