nursing management: coronary artery disease

1. Nursing Management: Coronary Artery Disease NURS 1228 Class 17

3. Medications: Familiarize Yourself! Antiplatelet Aggregation Nitrates Beta-adrenergic blockers (b adrenergic blocker) Calcium Channel Blockers

4. 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

5. Coronary Artery DiseaseWhat is it? How does it Happen? Atherosclerosis: Stages of development: Fatty Streak Raised Fibrous Plaque (Smooth muscle cell proliferation) Complicated Lesion

6. Plaque Build Up

7. Collateral Circulaton What is it? How is it formed?

8. Coronary Circulation

9. Risk Factors Modifiable Diet: Serum lipid levels Smoking (You would guess this one, wouldn�t you??!) Hypertension (stress does it, too!!) Physical Inactivity (sorry, student nurses�) Obesity Unmodifiable Age and gender Family history and heredity

10. Modifiable Contributing Risk Factors Diabetes Mellitus Stress and behavior patterns This guy�s 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).

11. 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

12. 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)

13. 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

14. 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.

15. Types of Angina Continued Prinzmetal�s 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)

16. 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

17. What does it look like? Pain: Substernal Referred GI Feeling of anxiety Shortness of breath, weakness, cold sweat, etc. Prinzmetal�s: longer in duration; may wake patient from sleep Can cause dysrhythmias, decreased myocardial contractility

18. 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

20. Myocardial Infarction

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

22. Drug Therapy Antiplatelet aggregation therepy (aspirin!) Nitrates � vasodiltors Nitroglycerine b-adrenergic blockers Calcium Channel blockers

23. 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

24. 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

25. End of ClassDrive Carefully!