Nursing Management: Coronary Artery Disease

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Nursing Management Coronary Artery Disease

• NURS 1228
• Class 17

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Terms to Know

• Angina Pectoris
• Laser Angioplasty
• Atherectomy
• Plaque
• Atherosclerosis
• Prinzmetals Angina
• Collateral Circulation

• PTCA
• Coronary Artery Disease
• Stent Placement
• Low fat diet

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Medications Familiarize Yourself!

• Antiplatelet Aggregation
• Nitrates
• Beta-adrenergic blockers
• (b adrenergic blocker)

• Calcium Channel Blockers

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Diagnostic Tests Familiarize Yourself!

• Chest X-ray
• Lipid Level
• ECG
• Echocardiography
• Exercise Stress Test
• CK
• Nuclear Imaging Studies

• LDH
• Position Emission Tomography
• Cardiac Troponin
• Coronary Angioplasty Studies

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Coronary Artery DiseaseWhat is it? How does it
Happen?

• Atherosclerosis
• Stages of development
• Fatty Streak
• Raised Fibrous Plaque
• (Smooth muscle cell proliferation)
• Complicated Lesion

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Plaque Build Up
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Collateral Circulaton

• What is it?
• How is it formed?

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Coronary Circulation
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Risk Factors

• Modifiable
• Diet Serum lipid levels
• Smoking (You would guess this one, wouldnt
  you??!)
  
• Hypertension (stress does it, too!!)
• Physical Inactivity (sorry, student nurses)
• Obesity

• Unmodifiable
• Age and gender
• Family history and heredity

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Modifiable Contributing Risk Factors

• Diabetes Mellitus
• Stress and behavior patterns
• This guys an MI and a cardiac arrest waiting for
  a chance to happen!! (To say nothing of a CVA
  which is not discussed in this class).

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Health Promotion

• Identify and Manage High Risk Persons
• Exercise Begin young
• Drug Therapy
• Questran and Colestid
• B vitamins
• Lopid, Zocor, Lipitor, etc.
• See table 32-7 on p.852

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CAD What does it look like?

• Insufficient blood supply to the heart itself
• The heart muscle does not receive the oxygenated
  blood it requires
  
• Atherosclerotic stenosis
• Coronary artery spasm
• Coronary thrombosis
• All result in Myocardial Ischemia
• Either silent or symptomatic (angina)

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Angina

• When an occlusion occurs
• The myocardial cells do not get the glucose
  needed for aerobic metabolism
  
• Anaerobic metabolism takes over lactic acid
  produced (hence the pain)
  
• Myocardial cells can live about 20 minutes
  without oxygen. When oxygen is restored, aerobic
  metabolism returns and things return to normal.
  
• See p. 852 for precipitating factors that may be
  connected with myocardial ischemia

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Types of Angina

• Stable Angina
• Infrequent and controlled with medication
  predictable
  
• Unstable Angina
• Unpredictable with less pattern discernable
• Associated with seterioration of once stable
  atherosclotic plaque.
  
• Thrombus formation occurs can progress to an MI
  (Myocardial Infarction)
  
• Treated with ASA and anticoagulants along with
  nitrates and Beta Blockers.

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Types of Angina Continued

• Prinzmetals Angina
• Occurs at rest major coronary artery goes into
  spasm.
  
• Patient may not have known CAD
• May occur at night especially during REM sleep
• May be cyclical
• Confirmed with Coronary Angiography (detects
  obstruction of coronary arteries)
  

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Types of Angina Continued

• Nocturnal Angina
• Occurs only at night
• Awake or asleep
• Sitting up or laying down
• Angina Decubitus
• While the patient is lying down
• Relieved by standing or sitting

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What does it look like?

• Pain
• Substernal
• Referred
• GI
• Feeling of anxiety
• Shortness of breath, weakness, cold sweat, etc.
• Prinzmetals longer in duration may wake
  patient from sleep
  
• Can cause dysrhythmias, decreased myocardial
  contractility

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Other Diagnostic Studies

• Chest x-ray
• Detects_________________
• ________________________
• ________________________
• Lab tests Serum Lipids, Cardiac enzyme values
• ECG, ECG stress test
• Ambulatory ECG Monitoring (Holter Monitor)
• Angiography (Cardiac Catheterization)
• Nuclear imaging (Thallium scan, Sestimbi)
• Positron Emission Tomography (PET scan)
  identifies ischemia and infarcted areas.
  
• Stress echocardiogram

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Myocardial Infarction
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Treatment Options

• Percutaneous Transluminal Coronary Angioplasty
• Stent placement
• Atherectomy
• Laser Angioplasty
• Coronary Artery Bypass Graft

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Drug Therapy

• Antiplatelet aggregation therepy (aspirin!)
• Nitrates vasodiltors
• Nitroglycerine
• b-adrenergic blockers
• Calcium Channel blockers

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NURSING IMPLEMENTATION

• Health Promotion and Education
• As discussed earlier
• Acute Needs
• Assessment of pain, history, activity
• Pain deep or superficial? Diffuse or well
  located?
  
• Care during anginal attack
• O2 therapy
• Vitals, ECG
• Pain relief with Nitrate ( narcotic analgesic if
  ordered)
  
• Assessment of heart and breath sounds
• Patient comfort
• Assessment of patient response to therapy

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Instructions regarding Nitrate Therapy

• Storage of medicaton
• Sub lingual administraton
• Immediate side effects and experience of
  medication working should be discussed with the
  patient.
  
• Sitting and standing postural hypotension
• of tablets to take to obtain relief of pain

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End of ClassDrive Carefully!