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7/25/2019 Cad Nursing Stikes

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Coronary Artery

Disease


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Coronary

Atherosclerosisdefnition- abnormalaccumulation of lipids and brous

tissue in the coronary arterieswhich results in decreased bloodow to myocardium

Atheroma comprises the lumen ofthe vessel---clots may form andobstruct the lumen


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Clinical Maniestationsa) narrowing-angina (ischemia)

b) occlusion- AMI (necrosis)

c) other

-E! changes

- aneurysms -dysrhythmias

d) sudden cardiac death


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Angina Pectorisdenition-chest discomfort (pain) due todecreased blood ow resulting in

atheroma or spasmdecreased blood ow results inmyocardial ischemia-nerve endingsaround cells send pain messages to brain

usually transient chest pain ("-#$)%subsides when precipitating factorremoved


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Types o AnginaUnstable- referred to aspreinfarction%&rescendo%unpredicta

ble%or progressive (increase in fre'uency

and duration)

treated with AA and &alcium&hannel loc*ing Agents


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Chronic, Stable Anginareferred to as predictable andconsistent

occurs on e+ertion

relieved with rest

E! changes-, depression

classic type of angina


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Nocturnal Anginareferred to as Angina ecubiti

occurs at night due to lying at

when the wor*load on the heart isincreased (increased venous returnor preload)

relieved by standing or sitting


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Prinzetal!s Anginausually spontaneous andaccompanied by increased ,

elevations on the E! due tocoronary artery spasm

associated with ris* of MI

rare form of angina


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"actors

Precipitating Anginaa) physical e+ertion-increases

wor*load of heart ( se+% e+ercise%

ra*ing leaves %or lifting heavyob.ects)

b) e+posure to heat or cold resulting

in vasoconstriction-elevated bloodpressure-increased demands ofbody for o+ygen


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"actors Precipitating

Anginac) heavy meals-divert blood to !I tract

(/#0of &1)

d) strong emotions-increased release ofcatecholamines

e) cigarette smo*ing

f) se+ual activity

g) stimulants-co2ee or cocaineh) circadian rhythm patterns-early a3m3

after arising


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Description o Paina) substernal-varies in intensity fromdiscomfort to pressure to agoni4ing

painadjectives used to describe pain

heavy feeling% pressure%weight

oppressive or sharp tightness

viseli*e


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Description o Pain crushing

constricting

s'uee4ing

su2ocating

burning

indigestion


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Types o Painb) deep-retrosternal

c) locali4ed but may radiate to

nec*%.aws%shoulder%inner aspects ofeither arm-

usually subsides when causeremoved

relieved by nitrates and rest

duration of pain -appro+imately 5#$or less


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Diagnostic Testsa) E!-changes occur only while having

angina

b) tress tests results-loo* for changes in, segments

c) ,hallium stress test-in.ect dye 5 minutebefore pea* e+ercise% scan immediately

and in /-6 hours3 7oo* for 8cold spots9indicating lac* of ,hallium upta*e orlac* of perfusion


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Diagnostic Testsd) &ardiac &atheteri4ation-

Angiography 7oo*s at o+ygen

levels and pressure readings inheart chambers as well as blood owthrough coronary arteries

e) &hest :-;ay- Identies enlarged

heart% calcication%pulmonarycongestion

f) 7ipids and En4ymes


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Diagnostic Testsg)


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Manageent o Angina#b$ecti%e-decrease the discrepancybetween the o+ygen supply and demand

- ;est-decrease the amount of o+ygenneeded by all tissues of body

-


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&nter%entions or

AnginaAcute AttackAcute Attack-


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Acute Anginal Attac'minute

,a*e ?ital igns

perform E! - loo* for changes in, segments

Administer @itrates or Analgesia

semi-owlers position


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Nursing &nter%entions(

AnginaPre%ent Pain

-Avoid activities that cause pain

- &hange A7 schedules if pain ina3m3

- Bnhurried pace

-Avoid causes


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Angina)educe An*iety

- 8ear of eath9 is common

- tay with an+ious client

- Educate client for discharge


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Angina#b$ecti%es o Client +ducation(oe Care

- reduce fre'uency> severity ofattac*s

- delay disease progression

- protect from complications

- plan activities to minimi4e episodes

- modify ris* factors


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Medications To Treat

Angina5) @itroglycerin-%decreases preload and

afterload by dilating venous and arterialsystem%decreases venous return andarterial pressure

a) wor*s in /-" minutes

b) dose-=3"-=3C mg sl3+" at #-5= minute

intervals c) e2ects last only 5=-5# minute

ma+imum


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Side +-ects o

NitroglycerinIncreased Deart ;ate

1rthostatic Dypotension

,hrobbing Deadache

lushing of face

?ertigo,achycardia


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Nursing &plicationsAssociated .ith

Nitroglycerinresh supply every C- months

,a*e at earliest sign of pain ordiscomfort

eep in brown bottle and cool spot-it is volatile to air

it or lie down when ta*ing;emove cotton from bottle

oes not always sting under tongue


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Nitrate Preparations@itroglycerin sublingual-If no relief from "pills ta*en # minutes apart-see* medicalattention

Long Acting Nitrates

a) ,opical 1intments-duration of e2ect

is 6 hours so client needs 6-Capplications a day

Apply to arms% legs %any unhairy bodyarea


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/ong Acting Nitrate

PreparationsM preparation-long acting

e+amples-


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&ntra%enous

Nitroglycerinrationale-increase collateral bloodow to ischemic area% decrease

myocardial o+ygen demand bydecreasing preload and decreasingafterload

examples- @itrol I?% @itrostat I?%@itrobid or ,ridil I?


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0eta 0loc'ersaction-decrease myocardial o+ygenconsumption by bloc*ing

sympathetic impulses to heart%smooth muscle of bronchi andblood vessels3 It lowers heart rate

and blood pressure and decreasesmyocardial contractility


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0eta 0loc'ersCoon Drugs in Use

- Inderal-F=-"/=mg I or GI

- Atenolol (,enormin)-#=-5==mg>day may ta*e up to /== mg>day

-Metoprolol (7opressor) -#=-

5==mg>day may ta*e up to 6#=mg>day


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0eta 0loc'ers,imolol (locadren5= mg3 I orup to 5==

mg3>day


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Side +-ects o 0eta

0loc'ersMusculos*eletalHea*ness

Dypertensionradycardia

epression

atiguee+ualdysfunction

ronchospasm-watch clients with

history ofAsthma 3&1


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Calciu Channel

0loc'ing Agents&alcium inuences cardiaccontraction and electrical stimulation

Action--dilates smooth muscle ofcoronary arteries thus% increasingo+ygen supply%decreases systemic

arterial pressure and decreaseswor*load of 7? (decreasing peripheralresistance)


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Calciu Channel

0loc'ingAgentsEfects-

- ystemic vasodilatation with

decreased systemic vascularresistance

- ecreased myocardial

contractility

- &oronary vasodilatation


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CoonCalciu

Channel 0loc'ingAgents@ifedipine (


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Side +-ects o Calciu

Channel0loc'ingAgents1rthostatic Dypotension

radycardia

lushing

Deadache


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Coon Nursing

Diagnoses(Anginaa1 Pain rel3to ischemia of

myocardium

b) Acti%ity &ntolerance rel3 tofatigue or wea*ness

c) Altered ealth Maintenance rel

to *nowledge decitd1 An*ietyrel3 to fear of cardiac

disease% future sudden death

P t


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PercutaneousTransluinalCoronary

Angioplasty2PTCA1

rationale- attempts to improve

blood ow within the coronary arteryby crac*ing the pla'ue or atheromathat is interfering with the circulationof blood to the heart


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Ad%antages o PTCAAlternative to surgery

7ocal anesthesia used

Eliminates ,horacotomy Incision&lient is ambulatory within /6 hours

Dospital stay is 5-" days not #-

days as with &A! procedure;apid return to wor*-5wee* insteadof Fwee*s with &A! procedure


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Ad%anceents 3ith

PTCABse of more e+ibleguidewire>catheters

ilates stenosed &A! grafts


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Coplications o PTCA

issection of dilated artery

;upture of artery causing tamponade%

ischemia% infarct% decreased &1%death1cclusion of vessel distal to catheter

&oronary spasm from mechanical orchemical irritation from dye

abrupt closure-/6 hours

;estenosis rates of "=0 within "-C months


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Ne3er Treatents

)adiation 3ith &ntra%ascular StentPlaceents(e+pandable% meshli*estructures to maintain vessel patency

re'uires anticoagulants for " months

Atherectoy(shave pla'ue using

rotating blade when pro+imal ormiddle part of artery involved


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Ne3er Treatents or

Angina/aser Angioplasty(A small laseron tip of catheter welds the area

open or melts the pla'ue areasfacilitating blood ow

Is still a new techni'ue and needs

renement

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