Nur 342

Unit II
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.

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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.
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Coronary Atherosclerosis

Atherosclerosis is the abnormal accumulation of

lipid deposits and fibrous tissue within arterial
walls and lumen;Role of inflammation is a key
factor
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.

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Principle of Supply & Demand

At rest: heart extracts 75% of oxygen from

blood flow

Increased demand for oxygen: need increased

coronary artery blood flow

If lumen of coronary artery is obstructed by

>70% blood flow not adequate to meet
increased demand

Increased demand: exercise, aortic stenosis

Decreased supply: hypotension,

coronary
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Coronary Arteries

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Pathophysiology of CAD

CAD affects the arteries that provide blood,

oxygen, and nutrients to the myocardium

Ischemia: insufficient oxygen is supplied to

meet the requirements of the myocardium

Infarction: severe ischemia is prolonged and

irreversible tissue damage occurs

Major cause: atherosclerosis of coronary

artery

Atherosclerosis begins with injury to artery

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Pathophysiology of Atherosclerosis
Atherosclerosis
begins
Monocyte
emigration
Smooth
Muscle
Proliferation
Fatty Streak
Plaque Enlarges

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Fibrofatty
atheroma
Collagen

Thrombosis of Atherosclerotic
Plaque

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Collateral Circulation that Develops

with Gradual Occlusion of Artery

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Atherosclerotic Plaque with Acute Coronary

Syndromes

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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
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Risk Factors For CAD

Modifiable risk factors

Hyperlipidemia
Cigarette smoking;
tobacco use
Hypertension
Diabetes mellitus
Metabolic syndrome
Obesity
Physical inactivity
Metabolic Syndrome
Cluster of Metabolic

Abnormalities
Figure 27-3, p. 732

Nonmodifiable risk factors

Increasing age

Gender (Males sooner than

females)

Family history: first degree relative

with cvd at 55 or younger for men

and 65 or younger for women

Race: African-Americans

>Caucasians

CAD risk equivalents:

DM
PAD
AAA
Carotid artery disease
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Types of Blood Lipids

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Types of Blood Lipids

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

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

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Angina Pectoris

A syndrome characterized by episodes of

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
See Chart 27-2, p. 736
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Anginal pain varies from mild to

severe

May be described as tightness, choking, or a

heavy sensation
It is 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!

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Atypical Angina Pain

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.
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Assessment & Diagnostic Findings

Clinical manifestations/History
12 lead EKG
Exercise or pharmacologic stress test
Echocardiogram
Nuclear scan
Cardiac catheterization & coronary
angiography

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EKG Changes That May Occur with

Angina

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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
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Medications

Nitroglycerin
Beta-adrenergic blocking agents
Calcium channel blocking agents
Antiplatelet and anticoagulant
medications
Aspirin
Clopidogrel; Prasugrel
Heparin
Glycoprotein IIB/IIIa agents
Table 27-3. p. 737
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Nitroglycerin Patient Educaton

Chart 27-3, p. 738

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

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

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Nursing Process: The Care of the Patient with Angina

Pectoris: Assessment

Symptoms and activities, especially

those that precede and precipitate
attacks
See Chart 27-4, p. 740
Risk factors, lifestyle, and health
promotion activities
Patient and family knowledge
Adherence to the plan of care

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Nursing Process: The Care of the

Patient with Angina Pectoris: Diagnosis

Risk for decreased cardiac tissue

perfusion
Anxiety r/t cardiac symptoms and
possible death
Deficient knowledge about underlying
disease and methods for avoiding
complications
Noncompliance, ineffective
management of therapeutic regimen
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Nursing Process: The Care of the Patient 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.
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Treatment of Anginal Pain

Treatment of anginal 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, observation for respiratory distress, and
assessment of pain. In the hospital setting, the
ECG is assessed or obtained.
Administer oxygen, usually 2 L/ Min, nasal
cannula
Administer medications as ordered or by
protocol, usually NTG.

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Chest Pain Protocol

Stop activity; place in Semi-Fowlers position to reduce

myocardial oxygen demand

Oxygen/(Chew 325 mg ASA as ordered)

Baseline vitals/IV access/EKG

Give 1 NTG sl q 5 minutes X3;

check BP before each NTG

EKG when pain-free

May need IV morphine titrated to pain relief and vital signs

IV NTG to CCU

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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

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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
See Chart 27-5, p. 741 Home Care
Checklist
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Acute Coronary Syndrome (ACS) &

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, non-ST-segment elevation MI
(NSTEMI) and ST-segment elevation MI (STEMI)
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Myocardial Infarction

80-90% reduction in blood flow through

coronary arteries ischemia necrosis if
blood flow not restored

Causes: atherosclerosis +
thrombosisocclusion of blood flow; coronary
artery spasm, platelet aggregation, mural
thrombi (cardiac wall)

Subendocardial layer: zone of necrosis

(greatest oxygen demand + poorest oxygen
supply)

Around zone of necrosis: zone of injury

Zone of ischemia: oxygen-deprived

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ACS & Myocardial Infarction

MI: Myocardial cells are permanently

destroyed
Caused by reduced blood flow in
coronary artery due to embolus or
thrombus
Clinical Manifestations
Assessment
Diagnostic findings
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Effects of Ischemia, Injury, and

Infarction on ECG

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Classification of MI by Location

LAD: anterior and most of septal wall of LV;

anterior and/or septal MI; 25% of MIs; highest
mortality rate; LV heart failure; ventricular
dysrhythmias

Circumflex: lateral wall of LV, SA & AV nodes;

posterior MI; lateral wall MI; sinus dysrhythmias

RCA: SA & AV nodes in most

people+diaphragmatic part of LV; inferior wall MI;
bradydysrhythmias; 2nd degree heart block

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Clinical Manifestations and

Diagnosis
Chest pain, other
symptoms
Chart 27-6, p. 742
ECG
Laboratory tests-biomarkers
See Figure 27-7, p. 744
CK-MB
Myoglobin
Troponin T or I
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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
(PCI) or thrombolytic therapy.
As indicated; IV heparin or LMWH, clopidogrel or
ticlopidine, glycoprotein IIb/IIIa inhibitor
Bed rest
(See Chart 27-7), p. 744

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Acute Myocardial Infarction

Core Measure Set

Aspirin administered upon arrival to to hospital

Aspirin prescribed at discharge from the hospital
ACE Inhibitor or ARB prescribed for patients with
concomitant LV systolic dysfunction
Beta-blocker prescribed at discharge
Thrombolytic therapy received within 30 minutes of
hospital arrival
PDI received within 90 minutes of hospital arrival
Statin prescribed at discharge

Chart 27-8, p. 744, Important information for best

practices of care for MI patient.
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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
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Answer
B
The echocardiogram is used to
evaluate ventricular function. It can
detect hypokinetic and akinetic wall
motion and can determine the
ejection fraction.

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Cardiac Rehabilitation

Goals
Components
Phases

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Nursing Process: The Care of the

Patient with ACS: Assessment

A vital component of nursing

care!
See Chart 27-6, p. 742
Assess all symptoms carefully and
compare to previous and baseline
data to detect any changes or
complications.
Assess IVs.
Monitor ECG.
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Nursing Process: The Care of the Patient with ACS:

Diagnoses

Acute pain related to increased myocardial

oxygen
Risk for decreased cardiac tissue perfusion
r/t reduced coronary blood flow
Risk for imbalanced fluid volume
Risk for ineffective peripheral tissue
perfusion r/t decreased cardiac output from
LV dysfunction
Anxiety r/t cardiac event and possible death
Deficient knowledge r/t post ACS self-care
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Nursing Process: The Care of the

Patient 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 tissue
perfusion, reduced anxiety,
adherence to the self-care program,
absence or early recognition of
complications.
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Nursing Process: The Care of the

Patient with ACS: Interventions

Relieving pain
Improving respiratory function
Promoting adequate tissue perfusion
Reducing anxiety
Monitoring/managing potential
complications
Promoting home/community-based care;
promoting health after MI, Chart 27-12, p.
750
See NCP: Chart 27-11, pp. 748-749
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Invasive Coronary Artery Procedures or Percutaneous

Coronary Interventions (PCIs)

PTCA compresses atheroma and stretches

coronary artery
Coronary artery stent is inserted after
PTCA to keep vessel open; drug-eluting
stents
Atherectomy is removal of atheroma
Brachytherapy inhibits smooth muscle cell
proliferation by placing radioisotope close
to lesion

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Percutaneous Coronary Intervention

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Percutaneous Coronary Intervention (PCI)

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Intracoronary Stent

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Post Procedure Care after

PCI

Similar to Post Cardiac Cath care

Monitor for bleeding: Achieve
hemostasis
Positioning/Mobility
Managing discomfort
Teaching
Monitoring for complications

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Surgical Procedures: Coronary

Artery Revascularization

Traditional coronary artery

revascularization or Coronary Artery
Bypass Graft (CABG) utilizes a vein or
internal mammary artery to bypass
diseased coronary artery

Alternative CABG procedures: Off-pump

CABG (OPCAB)

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Coronary Artery Bypass Grafts

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Greater and lesser saphenous veins are

commonly used for bypass graft
procedures.

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Cardiopulmonary Bypass System

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Nursing Process: Pre-op Cardiac

Surgery

Assessment of Identities
Nursing Diagnoses
Goals
Interventions
Teaching
Evaluation

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Nursing Process: The Patient who

has had Cardiac Surgery

Assessment of Identities
Complications include: Decreased CO, F/E

Imbalance, Impaired gas exchange, Impaired

cerebral circulation.
Diagnoses
Collaborative problems

Goals
Interventions & Monitoring for
Complications: pp. 758, 764-766

Teaching, self care and home care: pp. 766-767

Evaluation
See NCP, pp. 760-763

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Post-operative Care of the

Cardiac Surgical Patient

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Hemodynamic Monitoring
Hemodynamic Monitoring
Triple- or quadruple-lumen pulmonary artery catheter
Right atrial pressure
Pulmonary artery pressure (PAP)
Left ventricular end-diastolic pressure (LVEDP)
Pulmonary artery wedge pressure ( PAWP)
Cardiac output
Mixed venous oxygen saturation monitoring (SvO 2)
Central venous pressure monitoring (CVP)
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Placement of PA Line

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