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Coronary Artery Disease

Coronary Artery Disease. By: Julie Tamoney. Objectives. Understand the signs and symptoms of CAD Recognize who is at risk Discussion of case scenario Understand the purpose of a CABG Identify interventions to reduce sternal wound infections. Pathophysiology.

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Coronary Artery Disease

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  1. Coronary Artery Disease By: Julie Tamoney

  2. Objectives • Understand the signs and symptoms of CAD • Recognize who is at risk • Discussion of case scenario • Understand the purpose of a CABG • Identify interventions to reduce sternal wound infections

  3. Pathophysiology • CAD is the narrowing of the coronary arteries, usually resulting from atherosclerosis • Signs and symptoms: • Some individuals report pain, burning, or pressure in their chest that starts from exertion, exposure to cold air, or consuming a huge meal • Substernal pain can radiate to the arm, neck, or between the shoulder blades

  4. Pathophysiology • Signs and Symptoms: • Patients can also be asymptomatic • Atypical pain may start in the jaw, shoulder or elbow • Some patients won’t have pain, but may complain about shortness of breath, nausea, vomiting, light headedness, or sweating (Unbound Medicine 2012)

  5. Deaths • CAD is the leading cause of death and illness in Western societies • Accounts for 20% of all deaths (Unbound Medicine 2012)

  6. Who’s At Risk? • First degree relatives of CAD patients are at higher risk for developing the disease and to develop it at an earlier age (Unbound Medicine 2012) • Elevated serum cholesterol levels • Elevated blood pressure • Cigarette smoking

  7. Who’s At Risk? • Obesity • Lack of physical exercise • Stress • Diabetics

  8. Who’s At Risk? • CAD is a major cause of death for women in their late 50s • At the age of 80, the risk for CAD is equal for both men and women • Of all the deaths related to cardiovascular problems in the elderly, 85% are from CAD (Unbound Medicine 2012)

  9. Case Scenario • Mrs. Smith, who is 57 years old, complains of jaw and shoulder pain as well as shortness of breath. She smokes 15 cigarettes a day, does not exercise, and is a diabetic. Mrs. Smith is currently under a lot of pressure at work. Her family history indicates her mother had “bad cholesterol”, and died at the age of 48 of CAD.

  10. Objective Findings • Patient’s blood pressure is 156/90 • Heart rate is 87, irregular • LDL is 188 • HDL is 42 • Triglycerides is 474 • Total Cholesterol 248

  11. CABG • Surgeons will perform a CABG to treat patients with severe coronary heart disease • This surgery will improve the blood flow to the heart

  12. CABG • A healthy artery or vein from the body is connected to the blocked coronary artery • The grafted vein or artery bypasses the blocked portion of the artery

  13. How to Reduce Sternal Wound Infections in CABG Patients • Identification of modifiable risk factors is vital for the implementation of practices that decrease the frequencies of infections • Preoperative risk factors include: Obesity, diabetes, and smoking

  14. Modifiable Risk Factors • Intra operative risk factors include: bilateral use of internal mammary arteries and transfusion of 4 or more units of blood • Post operative risk factors include prolonged ventilator support

  15. Medical and Nursing Interventions • Identify and treat all infections remote to the surgical site before surgery • Only use clippers to remove hair from the site • Encourage patient to stop using tobacco (Dunaway & Goldrick 2007)

  16. Medical and Nursing Interventions • Administer the initial dose of prophylactic antibiotic IV • The first dose of IV prophylactic should be timed so that the bactericidal concentration of the drug in the serum and tissues is reached before the incision is made • Utilize continuous insulin infusion to maintain normal blood glucose levels • In the postoperative phase, elevated blood glucose levels have been associated with an increased rate of sternal wound infections (Dunaway & Goldrick 2007)

  17. Medical and Nursing Interventions • Protect closed incisions with sterile dressing for 24-48 hours • Hibiclensantimicrobial scrubs for patient cleansing • Wash hands before and after coming in contact with the surgical site • Educate the patient and family regarding care and S/S of infection (Dunaway & Goldrick 2007)

  18. Interventions Used for Mrs. Smith • Mrs. Smith was given prophylactic antibiotic before and after surgery • Continuous insulin was infused to maintain normal blood glucose levels • Incisions are protected with sterile dressings • Hibiclensantimicrobial was used to clean the site • Nurses and Doctors washed hands before and after coming into contact with Mrs. Smith

  19. Prognosis • After applying these interventions, only 2.2% for superficial and 1.5% for deep wound infection have been reported (Hettenbaugh 2006)

  20. Prognosis • Mrs. Smith’s (post-op day two) sternum is healing without any signs of infection

  21. Nursing Diagnosis • Altered tissue perfusion related to narrowing of the coronary artery associated with atherosclerosis

  22. NCLEX Questions • The nurse is giving health teachings to several clients. Which among these clients is at risk for coronary artery diseases? • The client who works in the department store • The client who had her menarche at age 12 years old • The client whose serum cholesterol level is 180 mg/dL • The client who smokes cigarette

  23. NCLEX Questions • The client has coronary artery disease (CAD). Which of the following statements when made by the client indicates that he understands the health instructions? A) I need to avoid carbohydrates B) I need to avoid working in cold weather C) I need to avoid exercise D) I need to avoid fruits

  24. Answers • 1. D. The client who smokes cigarette • 2. B. Working in cold weather precipitates coronary artery spasm. This reduces myocardial tissue perfusion and oxygenation. Therefore the client with CAD should avoid working in cold weather.

  25. Sternal Wound Infection • http://www.youtube.com/watch?v=Dtgvc_sXyoU

  26. Reference • Austin, K., Boyle, D., & Coulen, C. (2005, Oct). Implementing evidence-based practice findings to decrease postoperative sternal wound infections following open heart surgery. Retrieved from http://www.nursingcenter.com/lnc/journalarticle?Article_ID=599757 • Dunaway, E., & Goldrick, B. (2007, July). Sternal wound infections: What every nurse should know. Retrieved from http://www.nursingcenter.com/prodev/ce_article.asp?tid=736522 • Hettenbaugh, V. (2006, July 22). Best Practice Interventions for the Reduction of Sternal Wound Infections in Coronary Artery Bypass Graft Patients. Retrieved from https:// stti.confex.com/stti/congrs06/techprogram/paper_28871.htm • National Institutes of Health. (2012, Feb 23). What is coronary artery bypass grafting. Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/cabg/ • Rosenberger, L., Politano, A., & Sawyer, R. (2011, August 03). Surgical infections . Retrieved from http://online.liebertpub.com/doi/abs/10.1089/sur.2010.083 • Unbound Medicine. (2000-2012). Nursing Central. http://nursing.unboundmedicine.com/ nursingcentral/ub

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