Cmanagement patient with coronary blood desorder

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 28
Management of Patients With
Coronary Vascular Disorders

Question
Is the following statement True or False?
Individuals at highest risk for a cardiac event within 10
years are those with existing coronary artery disease.

Answer
True
Individuals at highest risk for a cardiac event within 10
years are those with existing coronary artery disease and
those with diabetes, peripheral arterial disease,
abdominal aortic aneurysm, and carotid artery disease.

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.
• CAD, coronary artery disease, is the most prevalent
cardiovascular disease in adults.

Pathophysiology of Atherosclerosis

Coronary Arteries

Clinical Manifestations
• Symptoms are due to myocardial ischemia
• Symptoms and complications are related to the location
and degree of vessel obstruction
• Angina pectoris
• Myocardial infarction
• Heart failure
• Sudden cardiac death

Question
Which is considered a modifiable risk factor for coronary
artery disease?
A.Race
B.Gender
C.Family history
D.Cigarette smoking

Answer
D
A modifiable risk factor for coronary artery disease is
cigarette smoking. Race, gender, and family history are
nonmodifiable risk factors.

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

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.

Angina pain varies from mild to severe
• 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/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!

Treatment
• Treatment seeks to decrease myocardial oxygen demand
and increase oxygen supply
• Medications
• Oxygen
• Reduce and control risk factors
• Reperfusion therapy may also be done

Medications
• Nitroglycerin
• Beta-adrenergic blocking agents
• Calcium channel blocking agents
• Antiplatelet and anticoagulant medications
• Aspirin
• Clopidogrel and ticlopidine
• Heparin
• Glycoprotein IIB/IIIa agents

Question
Is the following statement True or False?
Nitroglycerin tablets should never be removed and stored
in metal or plastic pillboxes.

Answer
True
Nitroglycerin tablets should never be removed and stored
in metal or plastic pillboxes.

Nursing Process: The Care of the Patient
with Angina Pectoris—Assessment
• Symptoms and activities, especially those that precede
and precipitate attacks
• Risk factors, lifestyle, and health promotion activities
• Patient and family knowledge
• Adherence to the plan of care

with Angina Pectoris—Diagnoses
• Ineffective cardiac tissue perfusion
• Death anxiety
• Deficient knowledge
• Noncompliance, ineffective management of therapeutic
regimen

Collaborative Problems
• Acute pulmonary edema
• Heart failure
• Cardiogenic shock
• Dysrhythmias and cardiac arrest
• Myocardial infarction

with Angina Pectoris—Planning
• Goals include the immediate and appropriate treatment
of angina, prevention of angina, reduction of anxiety,
awareness of the disease process, understanding of
prescribed care, adherence to the self-care program, and
absence of complications.

Treatment of Angina Pain
• Treatment of angina pain is a priority nursing concern.
• Patient is to stop all activity and sit or rest in bed.
• Assess the patient while performing other necessary
interventions. Assessment includes VS, and observation
for respiratory distress, and assessment of pain. In the
hospital setting, the ECG is assessed or obtained.
• Administer oxygen.
• Administer medications as ordered or by protocol, usually
NTG.

Anxiety
• Use a calm manner
• Stress-reduction techniques
• Patient teaching
• Addressing patient spiritual needs may assist in allaying
anxieties
• Address both patient and family needs

Patient Teaching
• Lifestyle changes and reduction of risk factors
• Explore, recognize, and adapt behaviors to avoid to
reduce the incidence of episodes of ischemia
• Teaching regarding disease process
• Medications
• Stress reduction
• When to seek emergency care

Myocardial Infarction
• 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 by a thrombus.
• 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.
• The term acute coronary syndrome includes unstable
angina and myocardial infarction.

Effects of Ischemia, Injury, and Infarction
on ECG

Clinical Manifestations and Diagnosis
• Chest pain, other symptoms
• ECG
• Laboratory tests—biomarkers
– CK-MB
– Myoglobin
– Troponin T or I

Question
What is the purpose of an echocardiogram?
A.Evaluate arterial function of the heart
B.Evaluate ventricular function of the heart
C.Detect hyperkinetic wall motion
D.Identify ischemia changes

Answer
B
The echocardiogram is used to evaluate ventricular
function. It can detect hypokinetic and akinetic wall
motion and can determine the ejection fraction.

Treatment of Acute MI
• Obtain diagnostic tests including ECG within 10 minutes
of admission to the ED
• Oxygen
• Aspirin, nitroglycerin, morphine, beta-blockers
• Angiotensin-converting enzyme inhibitor within 24 hours
• Evaluate for percutaneous coronary intervention or
thrombolytic therapy
• As indicated; IV heparin or LMWH, clopidogrel or
ticlopidine, glycoprotein IIb/IIIa inhibitor
• Bed rest

with ACS—Assessment
• A vital component of nursing care!
• Assess all symptoms carefully and compare to previous
and baseline data to detect any changes or
complications.
• Monitor ECG.

with ACS—Diagnoses
• Ineffective cardiac tissue perfusion
• Risk for fluid imbalance
• Risk for ineffective peripheral tissue perfusion
• Death anxiety
• Deficient knowledge

Collaborative Problems
• Acute pulmonary edema
• Heart failure
• Cardiogenic shock
• Dysrhythmias and cardiac arrest
• Pericardial effusion and cardiac tamponade

with ACS—Planning
• 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 tissues perfusion, reduced
anxiety, adherence to the self-care program, and
absence or early recognition of complications.

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

Cmanagement patient with coronary blood desorder

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