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FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 NUR 317 CH 27Management of Patients With Coronary Vascular Disorders OBJECTIVES At the end this lecture the learner will be able to: Describe the pathophysiology, clinical manifestations, and treatment of coronary atherosclerosis. Describe the pathophysiology, clinical manifestations, and treatment of angina pectoris. Use the nursing process as a framework for care of patients with angina pectoris. Describe the pathophysiology, clinical manifestations, and treatment of myocardial infarction. Use the nursing process as a framework for care of a patient with acute coronary syndrome. Describe percutaneous coronary interventional and coronary artery revascularization procedures. Identify the nursing care of a patient who has had a percutaneous coronary interventional procedure for treatment of coronary artery disease. Apply the nursing process as a framework for care of a patient who has undergone cardiac surgery. Coronary Artery Disease Epidemiology 16.5 million people over age 20 Coronary artery disease (CAD) affects an estimated 16.5 million people over the age of 20 and occurs when the blood vessels that deliver oxygen-rich blood to the heart muscle become obstructed or dysfunctional. It is also known as coronary heart disease or ischemic heart disease. The incidence increases with age for all people; however, there are racial and gender differences. According to the American Heart Association (AHA), the prevalence of CAD was higher in Caucasian males than in African and Hispanic American males (7.7%, 7.1%, and 5.9%, respectively). Among females, Hispanic women had the highest prevalence rate of 6.1%, followed by African American females at 5.7% and Caucasian females at 5.3%. The prevalence in American Indians and Native Alaskans is estimated to be highest of all groups at 9.3%. Studies have shown that postmenopausal women are three times more likely to have clinical symptoms of CAD than women of the same age who are premenopausal. This evidence suggests estrogen may be cardioprotective. Risk Factors Modifiable Increased total cholesterol, hypertension, diabetes, obesity,smoking, physical activity Nonmodifiable Gender, race, heredity, age
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Risk factors are classified as modifiable or nonmodifiable. Modifiable risk factors are amenable to intervention. Nonmodifiable factors are inherent risk factors that are not amenable to intervention. Nonmodifiable risk factors include gender, race, heredity, and age. Men of all ages have a higher risk of heart disease than women. Risk increases with a family history of CAD and aging. Modifiable risk factors include increased total cholesterol, hypertension, diabetes, obesity, smoking, and physical inactivity. Stress and excessive alcohol consumption can also contribute to CAD risk. Pathophysiology Atherosclerosis forms and occludes coronary arteries Unstable angina Myocardial infarction Sudden cardiac death Reduced blood flow through coronary microvasculature Ischemic symptoms Layers of the Arterial Wall 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
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Total cholesterol, triglycerides, LDL, HDL , CK, CK-MB, troponin Electrocardiogram Exercise stress test Coronary angiography Medical Management – Medications Stop aggregation of blood components to endothelium Control factors leading to endothelial damage Relief of symptoms Cholesterol Medications Six types of lipid-lowering agents: affect the lipid components somewhat differently (Table 27-2) 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 Surgical Management Percutaneous transluminal coronary angioplasty Coronary artery bypass graft Stent Placement Within the Artery
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Medical Management – Lifestyle management Maintain healthy body weight Diet Physical activity Smoking cessation Screening and treatment for depression Refraining from excessive alcohol use Cardiac rehabilitation Complications Myocardial infarction Nursing Management – Assessment and analysis Careful assessment of chest pain Be mindful of nonspecific symptoms Nursing Management – Nursing diagnoses Decreased tissue perfusion Nursing Interventions – Assessments Vital signs Pain Electrocardiogram Physical assessment Patient history Recreational drug use Depression screening Laboratory values Nursing Interventions – Actions Administer oxygen Obtain ECG Administer medications as ordered Administer oxygen to keep oxygen saturation greater than 93% – Supplemental oxygen optimizes oxygen delivery to the myocardium. Cardiac dysrhythmias, especially tachycardia, and anxiety increase myocardial oxygen consumption. Obtain ECG with the occurrence of chest pain – Evaluates new anginal episode for evidence of ischemia or injury. In cases of acute chest pain, an ECG within 10 minutes is recommended.
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Bleeding precautions if on anticoagulants – Avoiding activities that have high injury or fall risk, using a soft toothbrush and electric razor, and using caution with sharp objects reduces bleeding risk. Risk factor reduction strategies: physical activity, blood pressure management, healthy diet/weight loss, smoking cessation, decreased alcohol consumption, control of glucose – Risk factor reduction can prevent primary disease and limits the progression of CAD. When to call providers or emergency services – Unrelieved chest pain—chest pain at rest requires early intervention. For PCI patients: uncontrolled bleeding, swelling, redness, purulent discharge, and pain at insertion site or fever need prompt treatment. Encourage participation in cardiac rehabilitation for ACS patients after PCI or CABG. Reduces morbidity and mortality Nursing Management – Evaluating care outcomes Comply with medication therapy Maintain healthy diet Limit alcohol Engage in regular exercise Patients with CAD can achieve optimal functional status by complying with prescribed medical therapy, maintaining a healthy diet, limiting alcohol, and engaging in regular exercise. Achieving desired activity levels and meeting self-care needs with minimal or no pain indicate achievement of care goals in this patient population. It is important that the patient understands the disease process, the medications used to treat it, and when to call 911. Clinical Manifestations 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) Four modifiable risk factors cited as major (cholesterol abnormalities, tobacco use, HTN, and diabetes)
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 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 Cholesterol Medications Six types of lipid-lowering agents: affect the lipid components somewhat differently 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 estersholesterol Medications 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 Stable angina Unstable angina Variant angina Assessment and Findings May be described as tightness, choking, or a heavy sensation Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left)
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Anxiety related to cardiac symptoms and possible death Deficient knowledge about the underlying disease and methods for avoiding complications Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes Collaborative Problems # ACS, MI, or both Dysrhythmias and cardiac arrest Heart failure Cardiogenic shock Nursing Process: The Care of the Patient With Angina Pectoris—Planning 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 Process: The Care of the Patient With Angina Pectoris—Interventions Treat angina Reduce anxiety Prevent pain Educate patients about self-care Continuing care Nursing Intervention—Treat Angina Priority Patient is to stop all activity 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: Reduce Anxiety Use a calm manner Stress-reduction techniques
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Patient teaching Addressing patient’s spiritual needs may assist in allaying anxieties Address both patient and family needs Nursing Intervention: Preventing Pain Identify level of activity that causes patients prodromal S&S Plan activities accordingly Alternate activities with rest periods Teach patient and family Nursing Intervention: Patient Teaching # 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 # 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 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 Effects of Ischemia, Injury, and Infarction on ECG
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Provide continuing care Nursing Management: ACS/MI 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! Invasive Coronary Artery Procedures Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery stent Coronary artery bypass graft (CABG) Cardiac surgery Percutaneous Coronary Intervention Coronary Artery Bypass Grafts
FALL 2022- R. BLAIR NUR 317 Nursing Care of the Adult with Altered Cardiac Needs Learning Activities Content Mastery Series Review Module RN Adult Medical Surgical Nursing Edition 11.0 Purple book Chapters 27-38 Unit 4 Suddarth's Textbook of Medical-Surgical Nursing, 14th ed Chapters 14, 25-31 Unit 6 Greater and Lesser Saphenous Veins Are Commonly Used for Bypass Graft Procedures Cardiopulmonary Bypass System Nursing Management: Patient Requiring Invasive Cardiac Intervention #
