Ishemic Heart Disease (IHD)

Image result for IHD
Image result for IHD
Image result for IHD
Image result for IHD
Image result for IHD
Image result for IHD
View all
Ischemic heart disease is a condition of recurring chest pain or discomfort that occurs when a part of the heart does not receive enough blood. This condition occurs most often during exertion or excitement, when the heart requires greater blood flow.

1. ISCHEMIC HEART DISEASE

2. EPIDEMIOLOGY OF IHD The magnitude of the health problem presented by IHD can be illustrated by mortality statistics. Of the 716,215 or 89.7% due to IHD. About 90% of the person who develop IHD are between the age of 40 & 70 years. The incidence is much higher in men than women

3. CAUSES OF IHD:- Family history of coronary artery disease. Hypertension. High level of blood serum cholesterol. Diabetes mellitus. Over nutrition or obesity. Excessive smoking. Muscular build. Sedentary existence .

4. SIGNS AND SYMPTOMS OF IHD:- Angina pectoris (chest pain on exertion) Acute myocardial infarction (“heart attack”, severe chest pain.) Heart failure (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle.) CLINICAL MANIFESTION OF ISCHEMIC HEART DISEASE

5. ANGINA PECTORIS CAUSE:- Insufficient coronary blood flow. Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest.

6. CLINICAL MANIFESTATION:- Pain: felt deep in the chest behind the upper or middle third of sternum. Feeling of indigestion. Feel tightness or heaviness. Feeling of weakness or numbness in the arms, wrists & hands. Shortness of breath. Pallor, diaphoresis. Dizziness & light headache. Nausea & vomiting.

7. MEDICAL MANAGEMENT:- The objectives of the medical management of angina are to decrease the o 2 demand of the myocardium & to increase the o 2 supply. The objective are met through pharmacologic therapy & control of risk factors. Revascularization procedures to restore the blood supply to the myocardium include Percutaneous Coronary Interventional (PCI) procedures ( Eg : Percutaneous transluminal coronary angioplasty [PTCA], Intracoronary stents & atherectomy ), CABG & percutaneous transluminal mycordial revascularization (PTMR).

8. PHARMACOLOGICAL THERAPY:- Nitroglycerin (Nitrates): A vasoactive agent, it is administered to reduce myocardial o 2 consumption, which decreases ischemia & relieves pain. It may be given by several routes: sublingual tablets or spray, topical agent & intravenous. The amount of NTG administered is based on the patient’s symptoms while avoiding side effect such as hypotension.

9. Beta-Adrenergic Blocking Agents: Beta-blockers such as propranolol, mentoprolol & antenolol appear to reduce myocardial o 2 consumption by blocking the beta-adrenergic sympathetic stimulation to the heart. Calcium channel blocking agents: It relax the blood vessels, causing decrease in B.P. & an increase in coronary artery perfusion. It increase myocardial o 2 supply by dilating the smooth muscle wall of the coronary arterioles. Most commonly used are amlodipine , verapamil & diltiazem .

10. Antiplatelet and Anticoagulant Medication:- Aspirin: It prevents platelets activation & reduces the incidence of MI & death in patient with CAD. A 160 to 325 mg dose of aspirin should be given to the patient with angina & continued with 81 to 325 mg daily. Heparin: Unfractionated heparin prevents the formation of new blood clots. Use of heparin alone in treating patient with unstable angina reduces the occurrence of MI.

11. NURSING MANAGEMENT:- O 2 administration 2 L/min. NTG administration sublingually Assess the vital signs. Advise the patient to stop all activities & sit or rest in bed in semi-fowler position to reduce the o 2 requirement of ischemic myocardium. Reduce the patient anxiety. Prevent the pain by minimize the activity.

12. MYOCARDIAL INFARCTION MI refers to the process by which areas of myocardial cells in the heart are permanently destroyed. CAUSES :- Reduced blood flow in coronary artery artery due to atherosclerosis & occlusion of an artery by an embolus or thrombus. Vasospasm of coronary artery. Decreased o 2 supply ( eg : from acute blood loss, anemia or low BP.) Increased demand for o 2 (From a rapid heart rate, ingestion of cocaine etc.)

13. PATHOPHYSIOLOGY Due to any cause Necrosis develop in affected Part of the muscle Completely occlusive artery thrombus & Full muscle thickness Complete absence of flow Infarction (> 20 min) (Reduction in coronary blood flow >2 hrs.)

14. CLINICAL MANIFESTATION:- Chest pain or discomfort, palpitation Tachycardia, bradycardia & dysrhythmias ST-segment & T-wave change in ECG Shortness of breath Dyspnea & tachypnea Pulmonary edema may be present Nausea & vomiting Decrease urine output Cool, clammy & pale skin Anxiety , restlessness & light headache Visual disturbance & altered speech

15. ASSESSMENT & DIAGNOSTIC FINDING:- Patient history ECG Echocardiogram Laboratory test - creatine kinase (ck), lactic dehydrogenize etc.

16. MEDICAL MANAGEMENT:- Goal: i . To minimize myocardial damage ii. ToPreserve myocardial function iii. To prevent complication This goals are achieve by - use of thrombolytic agents - PTCA - O 2 administration - Bed rest

17. PHARMACOLOGICAL THERAPY:- 1. Thrombolytic :- The purpose of trombolytics is to dissolve & lyse the thrombus in a coronary artery (Thrombolysis), allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction & preserving ventricular functions. The thrombolytic agents used most often are streptokinase, alteplase & reteplase 2. Analgesics:- The analgesic of choice for acute MI is morphine sulphate administered in intravenous boluses. Morphine reduces pain & anxiety. It reduces preload, which decreased the work load of the heart.

18. Angiotensin -Converting Enzyme Inhibitor:- Angiotensin -I is formed when the kidneys release renin in response to decreased blood flow. ACE inhibitors prevent the conversion of angiotensin from I to II. In the absence of angiotensin II,the BP decreases & the kidney excrete sodium, fluid , decreasing the O 2 demand of the heart. Emergent Percutaneous Coronary Intervention(PCI) PCI may be used to open the occluded coronary artery in an acute MI & promote reperfusion to the area that has been deprived of O 2 . PCI is performed should be less than 60 minutes.

19. NURSING MANAGEMENT:- Reliving pain & other singn & symptoms of ischemia: Balancing the cardiac O 2 supply with it’s O 2 demand. Administration of thrombolytic therapy & emergent PCI Administer the morphine for relief of pain. Assess the vital signs frequently. Improving respiratory function: Regular & carefull assessment of respiratory function can help the nurse detect early sign of pulmonary complication. Encouraging the client to breath deeply & change position frequently, help keep fluid from pooling in the bases of the lungs.

20. Promoting adequate tissue perfusion: Limiting the client to bed or chair rest during the initial phase of treatment is particularly helpful in reducing in myocardial O2 consumption. Checking vital signs frequently for ensuring adequate tissue perfusion. Reducing Anxiety: Developing a trusting & coping relationship. Providing adequate information. Provide a quiet environment.

21. 5. Monitoring & Managing potential complications: The nurse monitors the client closely for changes in cardiac rate & rhythm, heart sound, BP, chest pain, respiratory status, urinary out put, skin colour , & temperature, ECG changes. Any changes in the client’s condition are reported to the physicians & emergency measures are provide when necessary.

22. INVESTIGATION & DIAGNOSIS FOR IHD Clinical diagnosis based on characteristc & complaint of chest pain or discomfort. ECG- During the episodes of pain there may be depression of ST-segment & a T-way inversion in several leads. Echocardiogram- help in showing any functional abnormality in various cardiac chambers & in assessing the pumping efficiency of the heart. Treadmill test (TMT exercise testing)- indicated in patient who have symptoms but normal ECG patterns.

23. 4. Coronary Angiogram- provides accurate information about actual site & extent of the stenosis . 5. Blood study- to measure total fat, cholesterol & lipoproteins 6. Chest X-ray

24. PREVENTION OF IHD Risk factors like a fatty diet, smoking, sedentary life style & stress should be avoided. Avoiding food rich in saturated fat is vital to reduce lipid level in the blood & to prevent arteriosclerosis . Adequate regular exercise is also essential. Diabetes mellitus & hypertension should be kept under good control with proper treatment.

25. GENERAL MEASURES Stop smoking Treat elevated cholesterol level with low fat, low cholesterol diet, exercise & cholesterol lowering medication. Treat elevated BP Reduce stress Maintain ideal body weight

26. PHARMACOLOGICAL THERAPY Beta-blocker:- Reduce the resting heart rate & so reduce the demand for 0 2 . beta-blockers & nitrates have been proven to reduce the incidence of heart attacks & sudden deaths in people with coronary artery disease. eg : propranol , metoprolol & antenolol etc.

27. 2. Nitrates :- Such as Nitroglycerin, cause dilatation of the blood vessels. There are short-acting & long-acting nitrates. NTG is available as a Tablet(sublingual) or an oral spray. A tablets of NTG placed under the tongue or inhalation of the oral spray usually relieves an episode of angina in 1 to 3 minute-the effect of these short-acting nitrate lasts 30 minutes. Anyone with chronic stable angina must keep NTG tablets or spray with them at all times. Long-acting nitrate are available as tablets, skin patches or paste. Tablets are taken 1 to 4 time daily. Nitro paste & skin patches,in which the drug is absorbed through skin over many hour, are also effective.

28. 3. Calcium channel antagonist:- Prevent the blood vessels from constricting & thus prevent coronary artery spasms. Certain calcium antagonists, such as varapamil & diltiazem , also show the heart rate & in some patients this drugs are used in conjunction with beta-blockers to prevent episodes of tachycardia. Anti-platelet drugs:- Such as aspirin is recommended for patient with coronary artery disease. Aspirin binds irreversibly to platelets & prevents them from clumping on blood vessels-walls-thus preventing platelets from forming a clot on the fatty plaoues which could block an artery & result in heart attack.

29. General Surgical Measures:- Balloon angioplasty- treatment for obstructed arteries, specially those supplying blood to heart & brain. A small uninflated balloon is passed up the artery to the obstruction & than expanded to release the obstruction. Surgery to Bypass Arteries (In severe cases) Heart transplant (In rare cases)- end stage coronary artery disease, event when no simple procedure will help.

30. NURSING MANAGEMENT Assessment:- It is establishes the baseline for the patient so that any deviation may be identified, systematically identifies the patient’s need & helps determine the priority of those needs. Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing, palpitation, unusual fatigue, faintness or sweating. Each symptoms must be evaluated with regard to time, duration, the factors that precipitate the symptoms & relieve it. IV sites are examined frequently.

31. Nursing Diagnosis:- Ineffective cardiopulmonary tissue perfusion R/t reduced coronary blood flow from coronary thrombus & atherosclerotic plaque. Potential impaired gas exchange R/t fluid overload from left ventricular dysfunction. Potential altered peripheral tissue perfusion R/t decreased cardiac output from left ventricular dysfunction. Anxiety R/t fear of death. Deficient knowledge about post MI-self care.

32. ASSIGNMENT A 40 years old male patient came in your ward with complain of chest pain, he diagnose the IHD. Answer the following Question: Q. What are the nursing care you will provide for this patient?

33. BIBLIOGRAPHY Richard Hatchett & David thompson.cardiac nursing.first edition(2002); publish by churchil Livingstone sydney P.N 152-160. Shaffer’s.Medical-Surgical.seven editions. BI publications New Delhi (2002). P.N. 439-444. Brunner & Suddarth’s.Medical -Surgical nursing.10 th edition.Lippincott williams & wilkins publication (2004). P.N. 649-656. www.google.com. www.pubmed.com.

34. THANK YOU