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Coronary Artery Disease

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definition-chest discomfort (pain) due to decreased blood flow resulting in atheroma or spasm ... usually transient chest pain (3-5'), subsides when ... – PowerPoint PPT presentation

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Title: Coronary Artery Disease


1
Coronary Artery Disease
2
Coronary Atherosclerosis
  • definition- abnormal accumulation of lipids and
    fibrous tissue in the coronary arteries which
    results in decreased blood flow to myocardium
  • Atheroma comprises the lumen of the
    vessel---clots may form and obstruct the lumen

3
Clinical Manifestations
  • a) narrowing-angina (ischemia)
  • b) occlusion- AMI (necrosis)
  • c) other
  • -EKG changes
  • - aneurysms
  • -dysrhythmias
  • d) sudden cardiac death

4
Angina Pectoris
  • definition-chest discomfort (pain) due to
    decreased blood flow resulting in atheroma or
    spasm
  • decreased blood flow results in myocardial
    ischemia-nerve endings around cells send pain
    messages to brain
  • usually transient chest pain (3-5), subsides
    when precipitating factor removed

5
Types of Angina
  • Unstable- referred to as preinfarction,Crescendo,u
    npredictable,or
  • progressive (increase in frequency and
    duration)
  • treated with ASA and Calcium Channel
    Blocking Agents

6
Chronic, Stable Angina
  • referred to as predictable and consistent
  • occurs on exertion
  • relieved with rest
  • EKG changes-ST depression
  • classic type of angina

7
Nocturnal Angina
  • referred to as Angina Decubiti
  • occurs at night due to lying flat when the
    workload on the heart is increased (increased
    venous return or preload)
  • relieved by standing or sitting

8
Prinzmetals Angina
  • usually spontaneous and accompanied by increased
    ST elevations on the EKG due to coronary artery
    spasm
  • associated with risk of MI
  • rare form of angina

9
Factors Precipitating Angina
  • a) physical exertion-increases workload of heart
    ( sex, exercise, raking leaves ,or lifting heavy
    objects)
  • b) exposure to heat or cold resulting in
    vasoconstriction-elevated blood
    pressure-increased demands of body for oxygen

10
Factors Precipitating Angina
  • c) heavy meals-divert blood to GI tract (25of
    CO)
  • d) strong emotions-increased release of
    catecholamines
  • e) cigarette smoking
  • f) sexual activity
  • g) stimulants-coffee or cocaine
  • h) circadian rhythm patterns-early a.m. after
    arising

11
Description of Pain
  • a) substernal-varies in intensity from discomfort
    to pressure to agonizing pain
  • adjectives used to describe pain
  • heavy feeling, pressure,weight
  • oppressive or sharp
  • tightness
  • viselike

12
Description of Pain
  • crushing
  • constricting
  • squeezing
  • suffocating
  • burning
  • indigestion

13
Types of Pain
  • b) deep-retrosternal
  • c) localized but may radiate to
    neck,jaws,shoulder,inner aspects of either arm-
  • usually subsides when cause removed
  • relieved by nitrates and rest
  • duration of pain -approximately 15 or less

14
Diagnostic Tests
  • a) EKG-changes occur only while having angina
  • b) Stress tests results-look for changes in ST
    segments
  • c) Thallium stress test-inject dye 1 minute
    before peak exercise, scan immediately and in 2-4
    hours. Look for cold spots indicating lack of
    Thallium uptake or lack of perfusion

15
Diagnostic Tests
  • d) Cardiac Catheterization-Angiography Looks
    at oxygen levels and pressure readings in heart
    chambers as well as blood flow through coronary
    arteries
  • e) Chest X-Ray- Identifies enlarged heart,
    calcification,pulmonary congestion
  • f) Lipids and Enzymes

16
Diagnostic Tests
  • g) PET-Positron Emission Tomography-
  • non invasive test that identifies and
  • quantifies ischemia and infarction
  • h) Echocardiography

17
Management of Angina
  • Objective-decrease the discrepancy between the
    oxygen supply and demand
  • - Rest-decrease the amount of oxygen needed
    by all tissues of body
  • - Percutaneous Transluminal Coronary
    Angioplasty (PTCA)
  • -Intracoronary Stints
  • -Atherectomy

18
Interventions for Angina
  • Acute Attack - Pain assessment - quantify the
    pain using a 1-10 scale (1-least severe and
    10-most severe)
  • Remember that cardiac pain is diffuse, deep and
    intense

19
Acute Anginal Attack
  • Provide oxygen at 2L/minute
  • Take Vital Signs
  • perform EKG - look for changes in ST segments
  • Administer Nitrates or Analgesia
  • semi-Fowlers position

20
Nursing Interventions-Angina
  • Prevent Pain
  • -Avoid activities that cause pain
  • - Change ADL schedules if pain in a.m.
  • - Unhurried pace
  • -Avoid causes

21
Nursing Interventions- Angina
  • Reduce Anxiety
  • - Fear of Death is common
  • - Stay with anxious client
  • - Educate client for discharge

22
Nursing Interventions- Angina
  • Objectives of Client Education- Home Care
  • - reduce frequency/ severity of attacks
  • - delay disease progression
  • - protect from complications
  • - plan activities to minimize episodes
  • - modify risk factors

23
Medications To Treat Angina
  • 1) Nitroglycerin-,decreases preload and
    afterload by dilating venous and arterial
    system,decreases venous return and arterial
    pressure
  • a) works in 2-3 minutes
  • b) dose-0.3-0.6 mg sl.x3 at 5-10 minute
  • intervals
  • c) effects last only 10-15 minute maximum

24
Side Effects of Nitroglycerin
  • Increased Heart Rate
  • Orthostatic Hypotension
  • Throbbing Headache
  • Flushing of face
  • Vertigo
  • Tachycardia

25
Nursing Implications Associated With Nitroglycerin
  • Fresh supply every 6-9 months
  • Take at earliest sign of pain or discomfort
  • Keep in brown bottle and cool spot-it is volatile
    to air
  • Sit or lie down when taking
  • Remove cotton from bottle
  • Does not always sting under tongue

26
Nitrate Preparations
  • Nitroglycerin sublingual-If no relief from 3
    pills taken 5 minutes apart-seek medical
    attention
  • Long Acting Nitrates
  • a) Topical Ointments-duration of effect
  • is 4 hours so client needs 4-6
    applications a day
  • Apply to arms, legs ,any unhairy body
    area

27
Long Acting Nitrate Preparations
  • DM preparation-long acting
  • examples-Peritrate, Isordil -last 6-8 hours
  • Nitrodiscs-apply in a.m., remove at h.s.to
    provide a nitrate free period
  • Examples-Transderm NitroDur discs where
    drugs are continually
  • released to skin absorption site

28
Intravenous Nitroglycerin
  • rationale-increase collateral blood flow to
    ischemic area, decrease myocardial oxygen demand
    by decreasing preload and decreasing afterload
  • examples- Nitrol IV, Nitrostat IV, Nitrobid or
    Tridil IV

29
Beta Blockers
  • action-decrease myocardial oxygen consumption by
    blocking sympathetic impulses to heart, smooth
    muscle of bronchi and blood vessels. It lowers
    heart rate and blood pressure and decreases
    myocardial contractility

30
Beta Blockers
  • Common Drugs in Use
  • - Inderal-80-320mg BID or QID
  • - Atenolol (Tenormin)-50-100mg/day
  • may take up to 200 mg/day
  • -Metoprolol (Lopressor) -50-100mg/day
  • may take up to 450mg/day

31
Beta Blockers
  • Timolol (Blocadren10 mg. BID or up to 100
  • mg./day

32
Side Effects of Beta Blockers
  • Musculoskeletal Weakness
  • Hypertension
  • Bradycardia
  • Depression
  • Fatigue
  • Sexual dysfunction
  • Bronchospasm-watch clients with history of Asthma
    .COPD
  • Hyperglycemia-watch for DM
  • Weight gain

33
Calcium Channel Blocking Agents
  • Calcium influences cardiac contraction and
    electrical stimulation
  • Action--dilates smooth muscle of coronary
    arteries thus, increasing oxygen supply,decreases
    systemic arterial pressure and decreases workload
    of LV (decreasing peripheral resistance)

34
Calcium Channel Blocking Agents
  • Effects-
  • - Systemic vasodilatation with decreased
    systemic vascular resistance
  • - Decreased myocardial contractility
  • - Coronary vasodilatation

35
Common Calcium Channel Blocking Agents
  • Nifedipine (Procardia) -10-30 mg.q4-8 hours
  • Verapamil (Isoptin, Calan)-60-80 mg. q8 hrs. po
    or IV
  • Diltiazem (Cardizem) -60-90- mg. q8 hrs.po
  • Nicarpine (Cardene) -

36
Side Effects of Calcium Channel Blocking Agents
  • Orthostatic Hypotension
  • Bradycardia
  • Flushing
  • Headache
  • Pedal Edema-Nifedipine
  • Constipation- (Verapamil)

37
Common Nursing Diagnoses-Angina
  • a) Pain rel.to ischemia of myocardium
  • b) Activity Intolerance rel. to fatigue or
    weakness
  • c) Altered Health Maintenance rel to knowledge
    deficit
  • d) Anxiety rel. to fear of cardiac disease,
    future sudden death

38
Percutaneous Transluminal Coronary Angioplasty
  • (PTCA)
  • rationale- attempts to improve blood flow within
    the coronary artery by cracking the plaque or
    atheroma that is interfering with the circulation
    of blood to the heart
  • Procedure is done in Cath Lab-cardiac
    catheterization documents stenosis

39
PTCA
  • Catheter equipped with an inflatable ballon tip
    is inserted into coronary artery and passed
    beyond lesion
  • Ballon is inflated (3-4 seconds) and
    atherosclerotic plaque is compressed resulting in
    vasodilation
  • Ballon is deflated
  • Procedure may be repeated several times

40
Advantages of PTCA
  • Alternative to surgery
  • Local anesthesia used
  • Eliminates Thoracotomy Incision
  • Client is ambulatory within 24 hours
  • Hospital stay is 1-3 days not 5-7 days as with
    CABG procedure
  • Rapid return to work-1week instead of 8weeks with
    CABG procedure

41
Advancements with PTCA
  • Use of more flexible guidewire/catheters
  • Dilates stenosed CABG grafts
  • Provide blood flow to distal myocardium during
    inflation

42
Complications of PTCA
  • Dissection of dilated artery
  • Rupture of artery causing tamponade, ischemia,
    infarct, decreased CO,death
  • Occlusion of vessel distal to catheter
  • Coronary spasm from mechanical or chemical
    irritation from dye
  • abrupt closure-24 hours
  • Restenosis rates of 30 within 3-6 months

43
Newer Treatments
  • Radiation with Intravascular Stent
    Placements-expandable, meshlike structures to
    maintain vessel patency
  • requires anticoagulants for 3 months
  • Atherectomy-shave plaque using rotating blade
    when proximal or middle part of artery involved

44
Newer Treatments for Angina
  • Laser Angioplasty-A small laser on tip of
    catheter welds the area open or melts the
    plaque areas facilitating blood flow
  • Is still a new technique and needs refinement
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