Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen.

1.

In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium.

2.

Cardiovascular disease is the leading cause of death in the United States for men and women of all racial and ethnic groups.

3.

CAD (coronary artery disease) is the most prevalent cardiovascular disease in adults.

4.

Coronary Artery Disease (Most common in US)

Pathophysiology of Atherosclerosis

Coronary Arteries

Family history of CADa.Increasing age (as age increase, more prone to atherosclerosis)b.Genderc.Race (most common in African-American)d.

Non-modifiable (can't change)1.

LDL < 100 mg i.High risk for cardiovascular = LDL < 70ii.Total cholesterol < 200iii.High density lipoprotein > 60 Considered good cholesteroliv.Triglycerides < 150v.

Hyperlipidemia a.

Increases carbon monoxide level: makes oxygen less available for the hemoglobin

i.

Nicotine acid: trigger catecholamine which increase heart rate, B/P, platelet adhesion which could lead to a thrombus

ii.

Cigarette smoking, tobacco useb.

Hypertension c.Diabetes Mellitus d.

Insulin resistancei.Central obesityii.Dyslipidemiaiii.Elevated blood pressureiv.High C- reactive protein - test used to measure protein that is produce by liver when there is systemic inflammation

v.

Metabolic syndrome: Conditions includee.

Obesityf.Physical inactivity g.

Modifiable (can change)2.

Risk Factors

Symptoms are due to myocardial ischemia.1.Symptoms and complications are related to the location and degree of vessel obstruction.

2.

Angina pectoris 3.Myocardial infarction4.Heart failure5.Sudden cardiac death 6.

Clinical Manifestations

The most common symptom of myocardial ischemia is chest pain; however, some individuals may be asymptomatic or have atypical symptoms such as weakness, dyspnea, and nausea.

1.

Atypical symptoms are more common in women and in persons who are older or who have a history of heart failure or diabetes.

2.

Clinical Manifestations

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Ask about their pain: where, when, how long, etc...a.Symptoms and activities, especially those that precede and precipitate attacks1.

Risk factors, lifestyle, and health promotion activities 2.Patient and family knowledge3.

Meds are too expensivei.Signs and symptomsii.Hard to follow diet regimeniii.

Reason why some people won't adhere to POC:a.Adherence to the plan of care4.

Nursing Process: The Care of the Patient with Angina Pectoris: Assessment - See Chart 28-4

Ineffective cardiac tissue perfusion1.Death anxiety (patient thinks they are going to die)2.Deficient knowledge 3.Noncompliance, ineffective management of therapeutic regimen4.

Nursing Process: The Care of the Patient with Angina Pectoris: Diagnosis

Prevention of anginaa.Reduction of anxietyb.Awareness of the disease processc.Understanding of prescribed cared.Adherence to the self-care programe.Absence of complicationsf.

Goals include the immediate and appropriate treatment of angina:1.Nursing Process: The Care of the Patient with Angina Pectoris: Planning

Treatment of angina pain is a priority nursing concern.1.Patient is to stop all activity and sit or rest in bed.2.

Assessment includes VS, observation for respiratory distress, and assessment of pain. In the hospital setting, the ECG is assessed or obtained.

a.Assess the patient while performing other necessary interventions3.

Administer oxygen.4.Administer medications as ordered or by protocol, usually NTG. 5.

Treatment of Anginal Pain

Use a calm manner1.Stress-reduction techniques2.Patient teaching3.Addressing patient spiritual needs may assist in allaying anxieties4.Address both patient and family needs5.

Reducing Anxiety (Treatment of Angina Pain)

Lifestyle changes and reduction of risk factors 1.Explore, recognize, and adapt behaviors to avoid or reduce the incidence of episodes of ischemia.

2.

Teaching regarding disease process3.Medications4.Stress reduction5.When to seek emergency care6.

Patient Teaching - See Chart 28-5

A syndrome characterized by episodes of paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow

1.

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.

2.

Stable angina: predictable and consistent pain that occurs on exertion that is relieved by rest or NGT

a.

Unstable angina (preinfarction): symptoms increase in frequency and severity, not relieved by rest or NTG

b.

Intractable/refractory angina: fear incapacitating chest painc.Varied angina : pain at rest with reversible ST segment elevation cause by vasospasm

d.

Silent ischemia: person doesn’t know what's going on, changes in EKG, usually through a stress test

e.

Types of angina -See Chart 28-23.

Angina Pectoris

May be described as tightness, choking, or a heavy sensation in chest1.It is frequently retrosternal and may radiate to neck, jaw, shoulders, back, or arms (usually left).

2.

Anxiety frequently accompanies the pain.3.Other symptoms may occur: dyspnea/shortness of breath, dizziness, nausea, and vomiting.

4.

The pain of typical angina subsides with rest or NTG. 5.Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention!

6.

Anginal pain varies from mild to severe

Onset of murmur, feels heart beating, ausculation-S3 or S4, elevated B/P, changes in EKG, irregular pulse

a.

Respiratory - tachypnea, SOB, crackles, pulmonary edemab.GI-N&Vc.Decrease urinary outputd.Changes in skin-diaphoretic, cool, clammy, or pale e.Neurological-anxiety, restlessness, lightheadednessf.Psychological-fear of impending doomg.

Chest pain, other symptoms - See Chart 28-61.

ECG: T-wave inversion2.C-reactive protein (CRP): test used to measure protein that is produce by liver when there is systemic inflammation

3.

Assessment and Diagnostic Findings

Patient needs their mouth moisten, under tongue to let it dissolve quicker, a.Storage needs to kept in container it's in, every 6 months need a new container of NTG, don’t keep in pocket because of body heat,

b.

Can take it prophylactively before doing something strenuousc.Take 3 doses 5 minutes apart, no more than 3, if pain does not subside, go to ERd.Side effects: Flushing, throbbing headache, tachycardia, hypotension: needs to be sitting down when taking NTG

e.

Nitroglycerin: See Chart 28-31.

Beta-adrenergic blocking agents2.Calcium channel blocking agents3.Antiplatelet and anticoagulant medications4.Aspirin5.Clopidogrel and ticlopidine6.Heparin7.Glycoprotein IIB/IIIa agents8.Oxygen Administration9.

Pharmacologic Therapy

Angina PectorisTuesday, January 17, 20129:46 PM

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An area of the myocardium is permanently destroyed. Usually caused by reduced blood flow in a coronary artery due to rupture of an atherosclerotic plaque and subsequent occlusion of the artery or a thrombus.

1.

In unstable angina, the plaque ruptures but the artery is not completely occluded. Unstable angina and acute myocardial infarction are considered the same process but at different point on the continuum.

2.

The term “acute coronary syndrome” includes unstable angina and myocardial infarction3.

Acute Coronary Syndrome and Myocardial Infarction

Similar to signs and symptoms exhibited for angina pectoris1.In many cases, the signs and symptoms of MI cannot be distinguished from those of unstable angina

2.

Clinical Manifestations

Get patient History1.ECG2.Echocardiogram (ECHO): 3D imaging of heart-size, heart in motion, ejection fraction, percentage of diastolic blood volume, shape of heart

3.

CK-MB: test specific to the heart, elevate few hours and peak within 24 hoursa.Myoglobin: looks at heart and skeletal muscle, increases to 1-3 hours and peaks within 12 hours

b.

Troponin T or I: specific to cardiac muscle, can elevate within a few hours and remain elevated for 3 weeks

c.

Laboratory tests--biomarkers - See Figure 28-74.

Assessment and Diagnostic Findings -

Inverted T-wave1.Elevated ST segment2.Abnormal QRS3.

Effects of Ischemia, Injury, and Infarction on ECG (changes in EKG)

Obtain diagnostic tests including ECG within 10 minutes of admission to the ED.1.Give Oxygen2.Give Aspirin, nitroglycerin, morphine, beta-blockers3.ACE inhibitors within 24 hours4.

Give anti-platelet meds: IV heparin or LMWH, clopidogrel (Plavix) or ticlopidine (Ticlid), glycoprotein IIb/IIIa inhibitor

a.Evaluate for percutaneous coronary intervention or thrombolytic therapy.5.

Bed rest6.

Medical Management (See Chart 28-7)

Active program is initiated once symptom free1.Program that targets risk reduction by means of education, individual and group support, and physical activity

2.

Most insurance programs, including Medicare, cover the cost of cardiac rehab3.

Cardiac Rehabilitation

Percutaneous Transluminal Coronary Angioplasty (PTCA): goes into blood vessel-catheter with balloon: smashes plaque so the heart muscle can profuse, problem is vessel can collapse

a.

Intracoronary stent implantation (keeps vessels open)b.Atherectomy: goes in and remove plaque by scraping, cut away, or grindingc.Brachytherapy: used when patient has recurrent clotting-delivers gamma or beta radiation to the lesion

d.

Percutaneous Coronary Interventions (PCIs)1.

Coronary Artery Bypass Graft (CABG): take another vessel and they bring it to the heart and graft it in and it bypass the clot.

a.Surgical Procedures: Coronary Artery Revascularization2.

Invasive Coronary Artery Procedures

Percutaneous Coronary Intervention

Coronary Artery Bypass Grafts

Greater and lesser saphenous veins are commonly used for bypass graft procedures

Cardiopulmonary Bypass System

Postoperative Care of the Cardiac Surgical Patient

A vital component of nursing care!1.Assess all symptoms carefully and compare to previous and baseline data to detect any changes or complications.

2.

Assess IVs.3.Monitor ECG.4.

Nursing Process: The Care of the Patient with ACS: Assessment - See Chart 28-6

Ineffective cardiac tissue perfusion1.Risk for fluid imbalance2.Risk for ineffective peripheral tissue perfusion3.Death anxiety4.Deficient knowledge5.

Nursing Process: The Care of the Patient with ACS: Diagnosis

Goals include the relief of pain or ischemic signs and symptoms, prevention of further myocardial damage, absence of respiratory dysfunction, maintenance of or attainment of adequate tissue perfusion, reduced anxiety, adherence to the self-care program, absence or early recognition of complications.

1.Nursing Process: The Care of the Patient with ACS: Planning

Acute Coronary Syndrome and Myocardial InfarctionTuesday, January 17, 20122:42 PM

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Differentiate between the modifiable and nonmodifiable risk factors for CAD.a.Discuss low-density lipoprotein (LDL) and high-density lipoprotein (HDL) as they relate to CAD.

b.

A patient recently diagnosed with coronary artery disease (CAD) states he has had a high cholesterol level for several years.

1.

Modifiable: high blood cholesterol levels, cigarette smoking, hypertension, diabetes mellitus, and obesity

a.

Nonmodifiable: family history of coronary artery disease (CAD), increasing age, gender, race.

○

Low-density lipoprotein (LDL) parameters b.○ High-density lipoprotein (HDL) parameters○ The desired level of LDL depends on the pt: Less than 160 mg/dL for pts with one or no risk

factors; less than 130mg/dL for pts with two or more risk factors; less than 100 for pt with CAD or at high risk for CAD, less than 70mg/dl is desirable for pts at very high risk for acute coronary event.HDL should exceed 40mg/dL & should ideally be more than 60mg/dL ○

Discussion Topic #1 Answers

Discussion Topic #1

Discuss nursing measures to be completed during the postoperative period.a.Identify potential complications after a PTCA. b.

A 60-year-old patient with CAD is undergoing a percutaneous transluminal coronary angioplasty (PTCA).

1.

a. Nursing care in the postoperative period is aimed at hemostasis, patient positioning after the procedure with sandbag, and maintenance of bedrest.

b. Complications of percutaneous transluminal coronary angioplasty (PTCA) include bleeding or hematoma, lost or weakened pulse distal to the sheath insertion site, pseudoaneurym and arteriovenous fistula, and retroperitoneal bleeding.

Discussion Topic #2 Answers

Discussion Topic #2

a. Discuss the diagnosis and prevention of rheumatic endocarditis.List four signs and symptoms of streptococcal pharyngitis. b.

A 50-year-old patient has been admitted to the cardiac unit with rheumatic endocarditis.1.

a. Penicillin therapy inpatients with streptococcal infections b. Throat culture for accurate diagnosis of rheumatic fever c. Signs ands symptoms of streptococcal pharyngitis include fever, chills, sore throat, redness

of throat, and enlarged and tender lymph nodes.

Discussion Topic #3 Answers

Discussion Topic #3

What are the rationales for the ordered medications?a.Mr. Simpson continues to smoke despite his disease process. How does smoking increase Mr. Simpson’s chances of angina episodes?

b.

The nurse reviews the correct procedure for taking nitroglycerin for chest pain, and includes what information?

c.

The nurse uses the PQRST acronym to assess for symptoms of angina. What is the nurse assessing?

d.

The home health care nurse is visiting Mr. Simpson, a 62-year-old male with a significant history of angina pectoris. During the visit, the nurse assesses Mr. Simpson’s current status, including his vital signs, activity level, and dietary intake. Mr. Simpson’s medications include: Nitroglycerin sublingual as needed for chest pain, Metoprolol, Cardiazem, and Ticlopidine.

•

Nitroglycerin is a vasoactive agent that reduces myocardial oxygen consumption, which decreases ischemia and relieves pain. Beta-adrenergic blocking agents (metoprolol) reduce oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. These medications reduce heart rate, slow conduction of impulses, decrease blood pressure, and reduce myocardial contractility. Cardiazem is a calcium channel blocker which was ordered to decrease sinoatrial automaticity and atrioventricular node conduction. This results in a slowing of heart rate, and a decrease in heart muscle contraction. Calcium channel blockers also relax blood vessels causing a decrease in blood pressure, and an increase in coronary artery perfusion. The net effect is an increase in myocardial oxygen supply. Ticlopidine is given to Mr. Simpson to inhibit platelet aggregation.

a.

Smoking increases heart rate, blood pressure, and blood carbon monoxide levels. Increased heart rate, in particular, leads to increased oxygen demand and can result in chest pain.

b.

c. Mr. Simpson is instructed to place one Nitroglycerin tablet under his tongue when experiencing chest pain/angina. He should have the medication with him at all times. The patient may take tablets, five minutes apart. If the pain persists, emergency transfer to the nearest level t trauma facility is encouraged. P Position/Location or Provocationd.Q Quality – Describe the painR Radiation or Relief of painS Severity or SymptomsT Tingling

Case Study Answers

Case Study

NCLEX Question of the DayThe nurse is caring for a patient with rheumatic heart disease. To prevent bacterial endocarditis, the nurse would expect which of the following medications to be prescribed prior to any type of dental work.A. Gentamicin (Garamycin)B. Amoxicillin (Amoxil)C. Enoxaparin (Lovenox)D. Azathioprine (Imuran)

Any of the layers of the heart may be affected by an infectious process.1.Diseases are named by the layer of the heart that is affected.2.Diagnosis is made by patient symptoms and echocardiogram.3.Blood cultures may be used to identify the infectious agent and to monitor therapy.4.Treatment is with appropriate antimicrobial therapy. Patients need to be instructed to complete the course of appropriate antimicrobial therapy, and require teaching about infection prevention and health promotion.

5.

Infectious Diseases of the Heart

Occurs most often in school-age children, after group A beta-hemolytic streptococcal pharyngitis1.Injury to heart tissue is caused by inflammatory or sensitivity reaction to the streptococci.2.Myocardial and pericardial tissue is also affected, but endocarditis results in permanent changes in the valves.

3.

Need to promptly recognize and treat “strep” throat to prevent rheumatic fever. See Chart 29-2.4.

Rheumatic Endocarditis

A microbial infection of the endothelial surface of the heart. Vegetative growths occur and may embolize to tissues throughout the body.

1.

Usually develops in people with prosthetic heart valves or structural cardiac device. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy. See Chart 29-3.

2.

3. Patients on immunosuppressant can also be susceptible to fungal endocarditis and bacteremia endocarditis

Occurs within days to weeki.Acute bacterial: onset of infection and results from valvular destruction and is rapid a.

Develops in people with prosthetic cardiac valvesi.Hx of congenital heart disease and history of bacterio-endocarditisii.

Sub acute: onset of infection of valvular destruction takes 2 weeks to a monthb.

2 Types:4.

Infective Endocarditis

1. May have fever, heart murmur, petechiae, fingers, and toes, may also have cardiomegaly, heart failure, tachycardia, and enlarged spleen

a. Janeway Lesion: irregular red or purple painless flat nodulesb. Splinter hemorrhages: reddish, black line and streak under nails

2. Small painful nodules on pads of hands

Clinical Manifestations of Infective Endocarditis

Inflammation of the myocardium1.Can cause heart dilation, thrombi on the heart wall, infiltration of circulating blood cells around the coronary vessels and between the muscle fibers, and degeneration of the muscle fibers themselves.

2.

Some develop cardiomyopathy and heart failure3.

Myocarditis

Multiple abscesses1.

Fatigue a.Dyspneab.Palpitation c.Chest and abdominal paind.Flu-like symptome.

Symptoms include:2.

Myocarditis (Microabscesses)

Inflammation of the pericardium1.Subacute, acute, or chronic process2.

Seruma.Purulent fluidb.Calciumc.Bloodd.

e. Fibrous substance

Classified as either adhesive (constrictive) or by what accumulates in the pericardial sac:3.

Many causes of pericarditis - See Chart 29-44.Nursing diagnoses – pain5.

Accumulation of fluid in pericardial sac, increases pressure on heart which can lead to cardiac tamponade

i.

Heart sounds may be distanceii.

Pericardial effusion:a.

Thickening, decrease elasticity of pericardium, scarring may occur, heart can't fill up with blood, decrease cardiac output

i.

Symptoms: sob, chest tightness, and restlessness, decrease in B/Pii.

Cardiac tamponade: b.

Potential Complications6.

•○ More likely to occur with metastatic tumor or with tuberculosis

Hemorrhagic Pericarditis

•○ Surface appears rough and glistering with strands of pinkish tan fibers

Fibrous Pericarditis

•○ yellowish

Purulent Pericarditis

Pericarditis

Valvular defects including mitral click and murmur or mitral regurgitation, mitral stenosis, aortic stenosis, and aortic regurgitation.

1.

A history of rheumatic heart disease, endocarditis, or myocarditis2.Antibiotic Prophylaxis is required for dental procedures and surgical interventions, including GU and GI procedures, to prevent endocarditis

3.

Antibiotic Prophylaxis (Treatment of Endocarditis)

Endocarditis and Discussion TopicsTuesday, January 17, 20122:00 PM

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