Chapter 23 Management of Patients With Coronary Vascular Disorders - Tagged.pdf

Management of Patients With Coronary Vascular Disorders slideshow pdf, nursing cardiology

1. Chapter 23
Management of Patients
with
Coronary Vascular Disorders

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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

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Pathophysiology of Atherosclerosis

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The Coronary Arteries

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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

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Risk Factors for Coronary Artery Disease
(CAD)
Refer to Chart 23-1
oFour 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)

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Prevention of CAD
Control cholesterol
Dietary measures
Physical activity
Medications
Cessation of tobacco use
Manage HTN
Control diabetes

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Cholesterol Medications
Six types of lipid-lowering agents: affect the lipid
components somewhat differently (Table 23-1)
o3-Hydroxy-3-methylglutaryl coenzyme A (HMG-
CoA) (or statins)
oNicotinic acids
oFibric acids (or fibrates)
oBile acid sequestrants (or resins)
oCholesterol absorption inhibitors
oOmega-3 acid-ethyl esters

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Question #1
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

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Answer to Question #1
D. Liver enzymes
Rationale: Atorvastatin (Lipitor) is an HMG-CoA
reductase inhibitor and is hepatotoxic. Therefore, liver
enzymes should be monitored in patients taking this
medication.

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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
oRefer to Chart 23-2

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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!

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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!

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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

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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

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Question #2
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. Which 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

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Answer to Question #2
C. Blood pressure of 86/58 mm Hg
Rationale: Nitroglycerin dilates vessels in the body.
Dilation of the veins causes venous pooling of blood
throughout the body. As a result, less blood returns to
the heart, and filling pressure (preload) is reduced. If
the patient is hypovolemic, the decrease in filling
pressure can cause a significant decrease in cardiac
output and blood pressure. This patient was working
outside on a hot day, and the possibility of
dehydration and hypovolemia should be considered.
Dry mucous membranes can cause poor absorption of
sublingual nitroglycerin but is not the most
concerning. B and D are insignificant findings.

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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

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Effects of Ischemia, Injury, and Infarction
on ECG

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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

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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)

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Planning and Goals for the Patient with
Angina Pectoris
Goals
oImmediate and appropriate treatment of angina
oPrevention of angina
oReduction of anxiety
oAwareness of the disease process
oUnderstanding of prescribed care and adherence
to the self-care program
oAbsence of complications

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Nursing Interventions for the Patient with
Angina Pectoris
Treat angina
Reduce anxiety
Prevent pain
Educate patients about self-care
Continuing care

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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

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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

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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

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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

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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

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Assessment of the Patient with ACS
Chest pain
oOccurs suddenly and continues despite rest and
medication
oOther S&S: SOB; C/O indigestion; nausea;
anxiety; cool, pale skin; increased HR, RR
ECG changes
oElevation in the ST segment in two contiguous
leads is a key diagnostic indicator for MI
Lab studies: cardiac enzymes, troponin, creatine
kinase, myoglobin

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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)

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Planning and Goals for the Patient with
ACS
Goals:
oRelief of pain or ischemic signs (e.g., ST-
segment changes) and symptoms
oPrevention of myocardial damage
oMaintenance of effective respiratory function,
adequate tissue perfusion
oReduction of anxiety
oAdherence to the self-care program
oEarly recognition of complications

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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

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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!

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Question #3
The nurse is caring for a patient after 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

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Answer to Question #3
D. Apply sequential pneumatic compression devices as
prescribed
Rationale: Sequential pneumatic compression devices
should be used when prescribed to help prevent
venous stasis and clotting complications such as deep
vein thrombosis and pulmonary embolism. Patients
should be discouraged to cross their legs. Pillows
should not be used in the popliteal space to elevate
the knees; rather, this should be avoided. Exercises,
passive and active, should be encouraged.

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Invasive Coronary Artery Procedures
Percutaneous transluminal coronary angioplasty
(PTCA)
Coronary artery stent
Coronary artery bypass graft (CABG)
Cardiac surgery

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Percutaneous Coronary Intervention

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Coronary Artery Bypass Grafts

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Veins Commonly Used for Bypass Graft
Procedures

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Cardiopulmonary Bypass System

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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

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Nursing Management: Patient Requiring
Invasive Cardiac Intervention #2
Relieve pain
Maintain adequate tissue perfusion
Maintain body temperature
Promote health and community-based care