Transcript Cardiovascular%20%20student%2011[1

Cardiovascular Stressors
• Assessment
– Nursing History
• Acutely ill cardiac patient
– Focus on problem at hand
– Get complete assessment when stable
• Chronically ill &/or stable cardiac patient
CAD Risk Factors
• Risk Factors that
CANNOT be changed
–
–
–
–
–
+ family history
Increasing age
Gender
Race
geography
• Risk Factors that CAN
be changed
–
–
–
–
–
–
–
–
Hyperlipidemia**
Hypertension**
Cigarette smoking**
Inactive lifestyle**
Hyperglycemia
Obesity
Stress
Use of estrogen
contraceptives
Physical Assessment
•
•
•
•
•
•
•
•
General Appearance
Vital Signs (including postural)
Hands
Head & Neck
Heart (including heart sounds)
Lungs
Abdomen
Feet & Legs
Serum Assessment for Risk
• Homocysteine (5-15 umol/L)
– Amino acid linked to development of
atherosclerosis
• Cholesterol (<200 mg/dL)
– LDL (60 - 160 mg/dL)
– HDL (35-70 mg/dL men; 35-85 women)
• Triglycerides (<150 mg/dL)
General Cardiac Diagnostic Tests
• Chest x-ray – determines size, contour, and
position of heart.
• Exercise Stress Test – (inaccurate for women)
determines heart’s response to increased
demand for oxygen
• EKG/ECG – visual representation of electrical
activity of heart (not all MI’s have initial EKG
changes)
1994 Classification of Functional Capacity and Objective
Assessment of Pts w/ Heart Disease
Functional Capacity
Based on
subjective symptoms
Objective Assessment
Based on
measurements such as EKGs, stress tests, w-rays,
echocardiograms, and radiological images
Class I – Pts w/ cardiac disease but without
resulting limitation of physical activity. Ordinary
physical activity does not cause undue fatigue,
palpitation, dyspnea, or anginal pain.
No objective evidence of cardiovascular disease
Class II – Pts w/ cardiac disease resulting in
slight limitation of physical activity. They are
comfortable at rest. Ordinary physical activity
results in fatigue, palpitation, dyspnea, or anginal
pain
Objective evidence of minimal cardiovascular
disease
Class III – Pts w/ cardiac disease resulting in
marked limitation of physical activity. They are
comfortable at rest. Less than ordinary activity
causes fatigue, palpitation, dyspnea, or anginal
pain.
Objective evidence of moderately severe
cardiovascular disease
Class IV – Pts w/ cardiac disease resulting in
inability to carry on any physical activity without
discomfort. Symptoms of heart failure or the
anginal syndrome may be present even at rest. If
any physical activity is undertaken, discomfort is
Objective evidence of severe cardiovascular
disease
CAD Progression
CAD
MI
Cardiac
Arrest
Angina
Coronary Artery Disease
• Most common
heart disorder in
US is coronary
atherosclerosis
• It is completely
REVERSIBLE
CAD
• SYMPTOMS
–Chest pain
–SOB
–EKG changes
–Dysrhythmias
–Sudden death
• TREATMENT
–Decrease risk
factors
–PTCA
• Percutaneous
transluminal
coronary
angioplasty
–CABG
• Coronary artery
bypass graft
Medications for CAD
• Antilipidemics
–Used after diet and exercise have
proven ineffective
–Lowers cholesterol, triglycerides,
and/or LDL’s
HMG-CoA Reductase Inhibitors (statins)
– Blocks the production of cholesterol, increases
HDL levels
– Contraindicated with liver disease
– 4-6 weeks before therapeutic level achieved
– Take at HS
– Photosensitivity
– Liver function studies
– lovastatin (Mevacor); simvastatin (Zocor);
atorvastatin (Lipitor)
Bile Acid Sequestrants
aka bile acid-binding resins
- Binds bile in the intestine, leading to a decrease in
LDL and serum cholesterol
- Not 1st antihyperlipidemic of choice
- Decreases effect of anticoagulants
- Potential malabsorption of fat soluble vitamins
- CONSTIPATION
- Take at mealtimes
- cholestyramine (Questran)
Antiplatelets
• ASA
• Plavix
• Persantine
Angina Pectoris
• Insufficient coronary blood flow which results
in inadequate oxygen supply for the
myocardium
• Types:
– Stable – causes are known
– Unstable – unpredictable
– Prinzmetal’s – no cause, occurs same time qd
Angina Pectoris
• Precipitating Factors
– Anything that
increases pulse or
BP
• Physical exertion
• Exposure to cold
• Eating a heavy
meal
• Stress
• Emotional strain
• Symptoms
– PAIN
• From feeling of pressure to
agonizing pain
• Tightness, choking or
strangling sensation
• Weakness, numbness in arms,
wrists, hands
• Sense of impending
death/doom
Pain subsides when
precipitating factor is
eliminated
Angina Pectoris
• Diagnosis
–Assess clinical
manifestations
of pain
–Assess patient
history
–EKG
–Cardiac cath
• Treatment/Pt
Teaching
–CABG
–PTCA
–Reduce risk
factors (life style
changes)
–REST
–Medications
Nitrates
• NTG – fast acting;
• isosorbide dinitrate– long acting
– NTG dilates veins and arteries, less blood is
returned to heart by veins, decreased BP in
arteries, decreased myocardial oxygen
requirements
•
Beta-Adrenergic Blockers
– Inderal
– Blocks sympathetic impulses to heart,
decreased pulse & BP, and myocardial
contractility
– Monitor vs****
– DO NOT abruptly stop taking medication
Calcium Channel Blockers
• (Procardia, Cardizem, Isoptin)
• myocardial oxygen supply by dilating coronary
arterioles and decreasing oxygen demand by
decreasing systemic BP
Myocardial Infarction
Death of part of the myocardial tissue
• Leading cause of death in the US
• ½ of all MI patients die within an hour after MI
onset
• Men tend to wait about an hour after onset of
symptoms; women wait 4-8 hours
• 10-15% of survivors will die within the year
MI
• Precipitating
Factors
– Coronary
atherosclerosis**
– Shock,
hemorrhage
– Vasospasm
– Cocaine
• Clinical Picture
– Pain
• Location, quality,
duration, intensity,
time, alleviation
– Vital Signs
• BP, P, To
– N/V
– Feeling of doom
– Diaphoresis
– Indigestion
Potential Complications of MI
•
•
•
•
•
•
Cardiac arrest
Heart failure
Cardiogenic shock
Pulmonary embolism
Heart block
Cardiac rupture
Arterial Insufficiency
• Contributing Factors
– > age of 50
– Male
– Influenced by # of CAD
risk factors
• Subjective Symptoms
– Intermittent claudication
– Rest pain
– Coldness/numbness in
extremity
• Physical Assessment
– Extremity cool
– Pale when elevated,
dependent rubor
– Skin/nail changes
– Toe ulcerations
– Gangrene
– 5 P’s
• Tests
– Dopplar
– Treadmill testing
Buerger’s Disease
• Key Factors:
– Improve circulation to
extremities
– Prevent the progression
of the disease
– Protect the extremities
from trauma/infection
• Symptoms
–
–
–
–
–
Pain
Intense dependent rubor
Absent pedal pulses
Parasthesia
Ulceration w/ gangrene
• Treatment – essentially
the same as for arterial
insufficiency
Symptoms
– Thoracic
• Asymptomatic
• Pain
• Dyspnea
• Cough
• Hoarseness
• dysphagia
– Abdominal
• 2/5
asymptomatic
• c/o feeling heart
beating in their
abdomen when
lying down
• Some can feel a
mass
• Systolic bruit
• Treatment
– Surgical repair
– Control of
predisposing factors
• HTN
• atherosclerosis
• Ruptured aortic
aneurism
– Mortality rate 5075%
– Constant, intense
back pain
– decreased BP
– decreased Hct
– Hematomas in
scrotum, perineum,
flank, or penis
Arterial Embolism
• Symptoms
– Depends on size of
embolus and organ
involved
– Immediate cessation of
distal blood flow
– Acute severe pain and
gradual loss of sensory
and motor function
– 5 P’s
– Cold distally
• Treatment
– Depends on cause
– Surgery as time is critical
– embolectomy
– Heparin initiated stat to
prevent further
development
– Thrombolytics if enough
time
Anticoagulants
• Heparin – indirectly
interferes w/ conversion of
prothrombin to thrombin
• Given sq or IV ONLY
• Overdose – tx with
protamine sulfate
• PTT control 25-37 seconds;
therapeutic level 1.5-2.5 X’s
control
• Lovenox – low molecular
weight heparin
**May be on Heparin and
Coumadin at same time
• Coumadin – inhibits blood
clotting by interfering w/
synthesis of Vitamin Kdependent clotting factors
• Given po ONLY
• Overdose –tx with Vitamin K
• PT control 12-15 seconds;
therapeutic level 1.5-2.5X’s
control, takes 24-48 hours
to reach therapeutic level
 INR 2-3.5
Heparin
Coumadin
Indications
for use
Acute thromboembolic problems
Prophylaxis for @ risk clients
Long-term treatment or
prevention
Onset
Rapid, within minutes
Delayed 2-5 days
Duration
Short
2-5 days after
discontinued
Route
IV, sq
PO
Blood Tests
APTT (activated partial
thromboplastin time)
PT (prothrombin time)
INR (International
Normalized Ratio)
Antidote
Protamine sulfate
Vitamin K
Raynaud’s Disease
• Symptoms
– White/Blue/Red
• Vasoconstriction
• Cyanosis
• Rebound vasodilation
– Numbness, tingling,
and burning pain
– Tends to be bilateral
and symmetrical
• Treatment
– Avoid stimuli
– Calcium channel
blockers
– sympathectomy
• Which of the
following
manifestations
would alert the
nurse that a patient
in prolonged
bradycardia was
experiencing
decreased cardiac
output?
• A. increase in BP
• B. decrease in
respiratory rate
• C. increase in
pupillary dilation
• D. decrease in
urinary output
• Which of the
following clinical
manifestations
would a nurse
expect to note in a
patient whose
hemoglobin value is
below normal?
• A. reddened, flushed
facial appearance
• B. slow, shallow
respirations
• C. fatigue and
weakness
• D. slow and
bounding pulse
• A 72 yo Black male, is
being discharged
following cardiac rehab
after an MI. He has a hx
of high cholesterol,
sedentary and stressful
profession, and is 50#
overweight. It would be
most important for the
nurse to assess which of
the following prior to
planning pt ed? The
patient’s
•
•
•
•
A. readiness to learn
B. educational level
C. home layout
D. social support system
• After completing the
assessment, the nurse
is going to provide pt ed
for Mr. Abbott. Which
of the following should
receive highest priority?
• A. low fat diet
• B. exercise
• C. stress reduction
methods
• D. restricting activity
until he is completely
recovered
• A 59 yo female presents
to the ED c/o SOB,
nausea, and “just not
feeling right”. When
taking her history, it is
most important for the
nurse to ask:
• A. “how many children
do you have?”
• B. “how long has this
feeling lasted?”
• C. “has this ever
happened before?”
• D. “do you have a family
hx of cardiac
problems?”
• Ms. About T. Blow,
42, has just been dx
with HTN. Which of
the following
statements made by
the patient indicates
she needs further
teaching?
• A. “I’ll make sure I take
my medication when I
wake up with a H/A”
• B. “I’m going to join a
yoga class”
• C. “I’m going to start
making homemade
soup instead of buying
Campbell’s”
• D. “I’m going to see
about a nicotine patch
so I can quit smoking”
• A patient is scheduled
for a thallium stress
test. Which of the
following is most
important for the nurse
to ask?
• A. “have you eaten
since midnight?”
• B. “do you have any
questions about the
diary you are to keep?”
• C. “do you take
anticoagulants?”
• D. “have you ever had
this test before?”
• Which of the following
• A. complaints of chest
clinical manifestations is
pain and tightness
most indicative of
• B. edema of lower
decreased coronary
extremities
oxygenation secondary • C. complaints of
to atherosclerotic
dizziness with position
plaque deposits?
changes
• D. exertional dyspnea
• Which of the following
classes of drugs is
indicated most for the
management of
symptoms associated
with coronary artery
atherosclerosis?
•
•
•
•
A. Nitrate
B. Vasopressor
C. Salicylate
D. Thrombolytic