Nursing Management: Coronary Artery Disease

NURS 1228 Class 17

Terms to Know
Angina Pectoris Laser Angioplasty Atherectomy Plaque Atherosclerosis Prinzmetals Angina Collateral Circulation PTCA Coronary Artery Disease Stent Placement Low fat diet

Medications: Familiarize Yourself!

Antiplatelet Aggregation Nitrates Beta-adrenergic blockers (b adrenergic blocker) Calcium Channel Blockers

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

Coronary Artery Disease What is it? How does it Happen?

Atherosclerosis:
Stages of development: Fatty Streak Raised Fibrous Plaque
(Smooth muscle cell proliferation)

Complicated Lesion

Plaque Build Up

Collateral Circulaton
What is it?

How is it formed?

Coronary Circulation

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

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).

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

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)

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

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.

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)

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

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

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

Myocardial Infarction

Treatment Options
Percutaneous Transluminal Coronary Angioplasty Stent placement Atherectomy Laser Angioplasty Coronary Artery Bypass Graft

Drug Therapy
Antiplatelet aggregation therepy (aspirin!) Nitrates vasodiltors
Nitroglycerine

b-adrenergic blockers Calcium Channel blockers

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

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

End of Class Drive Carefully!