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Chapter 14
Nursing Management: Patients
With Coronary Vascular
Disorders
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Coronary Atherosclerosis
• The most common cause of cardiovascular disease
• Atheromas or plaques protrude into the lumen of the
vessel
• Thrombi may form and obstruct blood flow, leading to
sudden cardiac death or an acute MI
• The anatomic structure of the coronary arteries makes
them particularly susceptible to the mechanisms of
atherosclerosis
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Coronary Atherosclerosis
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Risk Factors
• Nonmodifiable:
– Age
– Gender
– Race
– Family history
• Modifiable:
– Diabetes, hypertension, smoking, obesity, physical
inactivity, and high cholesterol
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Risk Factor: Metabolic Syndrome
• Consists of three or more of the following:
– Insulin resistance
– Abdominal obesity
– Dyslipidemia
– Hypertension
– Proinflammatory state
– Prothrombotic state
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Question
• The nurse is caring for a patient who had a recent MI.
The nurse is aware that the plaque that likely contributed
to this event is mostly made up of:
A. Lipids
B. Dead leukocytes
C. Interferons
D. Adipose tissue
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Answer
• A. Lipids
• Rationale: Atherosclerosis begins as monocytes and lipids
enter the intima of an injured vessel. A fibrous tissue
develops, and this causes plaques to form on the inner
lumen of vessel walls.
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Clinical Manifestations of Atherosclerosis
• Ischemia: An inadequate blood supply that deprives the
cardiac muscle cells of oxygen needed for their survival
• Angina pectoris: Chest pain that is brought about by
myocardial ischemia
• Classic signs and symptoms of myocardial ischemia
include acute onset of chest pain, shortness of breath,
extreme fatigue, diaphoresis, and nausea and vomiting
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Prevention and Medical and Nursing
Management
• Control cholesterol levels:
– Diet, exercise, medication, smoking cessation
• Manage hypertension
• Manage diabetes
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Angina Pectoris
• Almost always associated with a significant obstruction of
a major coronary artery
• Anginal pain can have widely varying characteristics
• Diagnosis is usually by history, ECG, and cardiac
biomarker analysis
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Question
• When discussing angina pectoris secondary to
atherosclerotic disease with a patient, the patient asks
why she experiences chest pain with exertion. The nurse
informs the patient that exertion:
A. Increases the heart's oxygen demands
B. Causes vasoconstriction of the heart
C. Increases blood flow to the mesenteric area
D. Reduces the effectiveness of medications
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Answer
• A. Increases the heart's oxygen demands
• Rationale: Physical exertion increases the myocardial
oxygen demand. If the patient has arteriosclerosis of the
coronary arteries, then blood supply is diminished to the
myocardium, resulting in pain. Exercise does not cause
vasoconstriction, reduced effectiveness of medications,
or increased blood flow to the mesenteric area.
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Management of CAD and Angina
• Nitrates
• Beta blockers
• Calcium channel blockers
• Antiplatelet medications and anticoagulants
• Oxygen administration
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Percutaneous Coronary Interventions
(PCIs)
• Percutaneous transluminal coronary angioplasty
• Intracoronary stent implantation
• Nursing care
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Question
• Is the following statement true or false?
• A patient who has undergone a PCI has had one or more
coronary vessels replaced with new, patent vessels.
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Answer
• False
• Rationale: During a PCI, an occluded coronary artery is
opened and reperfusion to the area that has been
deprived of oxygen is reestablished. The vessel itself is
not replaced.
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Surgical Procedures: Coronary Artery
Revascularization
• Coronary artery bypass graft (CABG):
–
Indications
– Qualification criteria
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CABG
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Nursing Process: The Postoperative
Cardiac Surgery Patient
• Initial postoperative care focuses on hemodynamic
stability and recovery from general anesthesia
• Later care focuses on the monitoring of cardiopulmonary
status, pain management, wound care, progressive
activity, and nutrition
• Frequent, multisystemic assessment is imperative
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Nursing Interventions: The Postoperative
Cardiac Surgery Patient
• Restoring cardiac output
• Maintaining adequate tissue perfusion
• Maintaining body temperature
• Preventing infection
• Preventing fluid and electrolyte imbalances
• Preventing impaired gas exchange
• Promoting cerebral circulation
• Pain control
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Myocardial Infarction (MI)
• Pathophysiology, risk factors, and manifestations are
similar to those of angina.
• Diagnosis and categorization of MI is based on ECG
changes and analysis of cardiac biomarkers (CK-MB,
myoglobin, troponin).
• ECG analysis results in diagnosis of:
1. Unstable angina
2. ST-segment elevation MI (STEMI):
3. Non–ST-segment elevation MI (Non-STEMI)
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Management of MI
• Medications include aspirin, nitroglycerin, morphine, beta
blockers, ACE inhibitors, and statins
• Thrombolytics
• Analgesics
• Reperfusion therapy
• Cardiac rehabilitation
• Nursing care focuses on relieving pain, promoting
respiratory function, promoting tissue perfusion, reducing
anxiety, and monitoring for complications
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Question
• The nurse caring for a patient with an MI knows that the
top priority in the care of this patient is what?
A. Balancing intake and output
B. Decreasing energy expenditure of the myocardium
C. Balancing myocardial oxygen supply with demand
D. Decreasing nutritional need of myocardial muscle
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Answer
• C. Balancing myocardial oxygen supply with demand
• Rationale: Balancing myocardial oxygen supply with
demand (eg, as evidenced by the relief of chest pain) is
the top priority in the care of the patient with an MI. This
supersedes interventions related to nutrition, fluid
balance, or energy expenditure.
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