Med-Surg Ch. 23

Management of Patients with Coronary Vascular Disorders

CH. 23

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

• Stable vs Unstable

• Thick fibrous cap = stable

• Thin = vulnerable plaque

• A ruptured plaque attracts platelets and causes thrombus formation

• Thrombus = ACS = MI

Pathophysiology of Atherosclerosis

​The Coronary Arteries

Labelling

Label the coronary arteries

Drag labels to their correct position on the image

Left Anterior Decending

Right Coronary Artery

Left Circumflex

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(pg. 728)

• 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

• Six types of lipid-lowering agents: affect the lipid components somewhat differently (Table 23-1)

• 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (or statins)

• Nicotinic acids

• Fibric acids (or fibrates)

• Bile acid sequestrants (or resins)

• Cholesterol absorption inhibitors

• Omega-3 acid-ethyl esters

Cholesterol Medications

Multiple Choice

The nurse is caring for a patient with hypercholesterolemia who has been prescribed atorvastatin (Lipitor). What serum levels should be monitored in this patient?

• Complete blood count (CBC)

• Blood cultures

• Na and K levels

• Liver enzymes

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

  • Refer to Chart 23-2

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

• Aspirin

• Clopidogrel and ticlopidine

• Heparin

• Glycoprotein IIb/IIIa agents

• Nitroglycerin

• Beta-adrenergic blocking agents

• Calcium channel blocking agents

• Antiplatelet and anticoagulant medications

Medications for Angina

Multiple Choice

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?

• Dry mucous membranes

• Heart rate of 88 bpm

• Blood pressure of 86/58 mm Hg

• Complaints of headache

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

​​EKG Changes

STEMI

J point

Area of Infarct

ST Depression = ischemia
ST Elevation = infarct

INFERIOR STEMI

Math Response

The MD orders your patient to start an IV Heparin drip at 12 units/kg/hr and to administer a loading bolus dose of 60 units/kg IV before initiation of the drip. You’re supplied with a Heparin bag that reads 25,000 units/250 mL. The patient weighs 189 lbs. What is the flow rate you will set the IV pump at (mL/hr)?

ROUND TO NEAREST TENTH

Type answer here

Correct Answer: 10.3

Deg^°

Rad

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

  • Immediate and appropriate treatment of angina

  • Prevention of angina

  • Reduction of anxiety

  • Awareness of the disease process

  • Understanding of prescribed care and adherence to the self-care program

  • 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: 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

  • Occurs suddenly and continues despite rest and medication

  • Other S&S: SOB; C/O indigestion; nausea; anxiety; cool, pale skin; increased HR, RR

• ECG changes

  • 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:

  • Relief of pain or ischemic signs (e.g., ST-segment changes) and symptoms

  • Prevention of myocardial damage

  • Maintenance of effective respiratory function, adequate tissue perfusion

  • Reduction of anxiety

  • Adherence to the self-care program

  • 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!

Multiple Choice

The nurse is caring for a patient after cardiac surgery. Which nursing intervention is appropriate to help prevent complications arising from venous stasis?

• Encourage crossing of legs

• Use pillows in the popliteal space to elevate the knees in the bed

• Discourage exercising

• Apply sequential pneumatic compression devices as prescribed

• Percutaneous transluminal coronary angioplasty (PTCA)

• Coronary artery stent

• Coronary artery bypass graft (CABG)

• Cardiac surgery

Invasive Coronary Artery Procedures

CABG

Vein Graft

​A. Left internal thoracic artery (formerly called the left internal mammary artery), used frequently because of its functional longevity. B. Saphenous vein, also used as bypass graft

​ The greater and lesser saphenous veins are commonly used in bypass graft procedures.

The cardiopulmonary bypass system, in which cannulas are placed through the right atrium into the superior and inferior vena cavae to divert blood from the body and into the bypass system. The pump system creates a vacuum, pulling blood into the venous reservoir. The blood is cleared of air bubbles, clots, and particulates by the filter and then is passed through the oxygenator, releasing carbon dioxide and obtaining oxygen. Next, the blood is pulled to the pump and pushed out to the heat exchanger, where its temperature is regulated. The blood is then returned to the body via the ascending aorta

​

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

Have a nice day!