Bakersfield College Nursing Program Nursing B28: Medical Surgical Nursing 4

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1 Bakersfield College Nursing Program Nursing B28: Medical Surgical Nursing 4 1 Unit 5: Problems of Cardiac Output and Tissue Perfusion Coronary Artery Disease, Acute Coronary Syndrome, and Disorders of the Aorta I. Coronary artery disease (CAD) or coronary heart disease (CHD). A. CHD is the leading cause of death in the U. S. 1. Final mortality data for 2006: 34.3% or 1 in 2.9 deaths was due to cardiovascular disease. 2. Death rate decreased 36.4% between 1996 and B. Etiology / pathogenesis. 1. Chronic conditions cause an inflammatory process injury to the endothelial lining of the artery (atherosclerosis). a. Cigarette smoking, hyperlipidemia, hypertension (HTN), etc. b. Atherogenesis = build up of plaque within the artery. 2. Injury due to platelet (PLT) activation and aggregation at endothelium. 3. Fatty streaks earliest lesions (plaque), reversible. 4. Smooth muscle proliferation and migration into the intima. 5. Fibrous plaque or atheroma. 6. Plaque rupture. Coronary artery occlusion, injury, infarction, coagulation cascade. C. Collateral circulation. Angiogenesis = growth of new blood vessels. D. Risk factors. 1. Modifiable. a. Cigarette smoking. b. Hypertension or on antihypertensive agent (s). c. Hyperlipidemia high and low density lipoproteins. d. Diabetes mellitus (DM). e. Overweight / obesity. f. Physical inactivity. 2. Not modifiable. a. Age ( 45, 55). b. Gender (males > females). c. Ethnicity (Caucasian > African American). d. Genetic predisposition (family history of heart disease).

2 3. Markers. a. C reactive protein (CRP) with inflammatory process. b. Homocysteine amino acid used as indicator of CAD. 2 E. Nursing considerations / treatment. 1. Past medical history (PMH). a. Cardiac issues age, problem. b. Treatment medications, surgeries outcomes. c. Lifestyle diet, activity, stress. 2. Patient education modify what you can. a. Lifestyle modifications. 1. Diet. 2. Weight loss / control. 3. Physical activity. b. Smoking cessation. c. Control blood pressure. d. Control cholesterol / lipid levels. Sole (2009) page 315, Box e. Control serum glucose level. 3. Pharmacological treatment. a. Weight loss. Phentermine, Meridia. b. Smoking cessation. 1. Nicotine replacement. 2. Zyban (wellbutrin). c. Antihypertensive therapy. d. Cholesterol / lipid management. 1. Sole (2009) page 320, Laboratory Alert. 2. Sole (2009) page 321, Table 12 4, Medications F. CAD progresses blood flow and oxygen to myocardium ischemia. II. Ischemia / chest pain. A. Silent ischemia. Up to 80% with myocardial ischemia are asymptomatic (HTN, DM). B. Signs / symptoms. 1. Pain. a. Location. 1. Sternal, epigastric, left arm. 2. Jaw, infrascapular. b. Description. 1. Crushing, heavy, pressure. 2. Constricting, tightness.

3 2. Other possible signs / symptoms: a. Fatigue, dyspnea, diaphoresis. b. Nausea / vomiting. c. Possible changes in heart rate / sounds, blood pressure, lung sounds. 3 C. Stable angina. 1. Literally, pain in the chest, which is temporary and reversible, and usually has the same pattern. 2. Result of ischemia often brought on by a trigger. a. Exercise, tobacco, sex, stimulants (cocaine), anemia. b. Pain generally subsides once the precipitating factor is eliminated. 3. Treated medically. Control / anticipate triggers, medication. D. Prinzmetal s or Variant angina. 1. Pain caused by coronary vasospasm, with or without CAD, usually at rest. May occur with other vascular histories migraines, Raynaud s. 2. First line treatment calcium channel blockers, nitrates. E. Nursing considerations. 1. Patient and family education. Disease process and treatment. 2. Possible compliance issues with intermittent discomfort. III. Acute coronary syndrome (ACS). A. Unstable angina (USA). 1. Usually due to coronary artery atherosclerosis (lesion), or plaque rupture. 2. Requires immediate treatment. a. MONA. 1. Morphine. 2. Oxygen. 3. Nitroglycerin. 4. Aspirin. b. Ongoing treatment: Drugs for ACS Sole (2009), page 325, Table Nitrates. 2. Beta blockers. 3. Calcium channel blockers. 4. Platelet aggregation inhibitors. 5. Anticoagulation. 6. Pain management. c. Cardiac catheterization examine vessels, guide treatment.

4 B. Myocardial infarction (MI). 1. Sustained ischemia leading to irreversible myocardial cell death. Extension of untreated CAD Signs and symptoms. a. Intractable chest pain. 1. Unrelieved by rest, oxygen, nitrates, etc. 3. Signs / symptoms continued / increased as with angina. a. Pain. 1. Location. a. Sternal, epigastric, left arm. b. Jaw, infrascapular. 2. Description. a. Crushing, heavy, pressure. b. Constricting, tightness. b. Other possible signs / symptoms: 1. Fatigue, dyspnea, diaphoresis. 2. Nausea / vomiting. 3. Possible changes in heart rate / sounds, blood pressure, lung sounds. 4. Degree of damage is variable. a. Subendocardial or non Q wave. Damage goes through only part of the myocardial wall. b. Transmural or Q wave. Damage goes through entire wall of myocardium. 5. Complications. a. Dysrhythmias. b. Heart failure, cardiogenic shock. c. Pericarditis. d. Dressler s syndrome. Antigen antibody reaction causing pericarditis with fever. e. Papillary muscle dysfunction. f. Ventricular aneurysm. g. Pulmonary embolism. 6. Nursing considerations. a. Assessment / monitoring. 1. Pain / management. 2. Physical assessment cardiac, vital signs, cardiac rhythm. b. Prep / education for diagnostic studies and treatment. 1. Fibrinolytics. 2. Cath lab. 3. Surgery. d. Monitor for complications. Extension, lethal cardiac rhythm, failure, shock. e. Emotional and psych support.

5 IV. Diagnostic studies. A. Lab studies. 1. Serum cardiac markers. a. Creatine kinase (CK) hours, usually peak within 24 hours. 2. Look at total and CK MB. 3. Wash out. b. Troponin. 1 6 hours, remains elevated 5 14 days. c. Lactic dehydrogenase (LDH) hours, peak hours. d. Cholesterol / lipid profile Markers. 1. C reactive protein (CRP) with inflammatory process. 2. Homocysteine amino acid used as indicator of CAD. 3. Myoglobin. B. Diagnostic studies. 1. Electrocardiograms (EKGs). a. Serial: Q 6 8 H, X 3 4; baseline, pre / post intervention. b. Looking for changes primarily in ST and t waves. c. Identify area of the heart affected. 1. Ischemia / injury / infarction changes on EKG? 2. EKG changes correlated to vessel / heart wall. a. Sole (2009), page 332, Table b. Left anterior descending (LAD) = anterior / septal. c. Circumflex (CX) = lateral, posterior. d. Right coronary artery (RCA) = inferior. e. May be combination of areas. f. Collateral circulation may limit the amount of damage. 2. Echocardiography. Surface, transesophageal, stress. 3. Nuclear testing. 4. Stress testing. Treadmill, bike, dobutamine, Persantine. 5. Coronary angiography. 6. Nursing considerations with testing primarily patient and family education.

6 V. Treatment. A. Lifestyle changes. 1. Control blood pressure, lipids, glucose, etc. 2. Physical activity, weight, smoking. 3. Psych support fear, depression. 4. Patient education. 6 B. Testing. 1. Labs. a. Cardiac enzymes. b. Hematology, electrolytes. 2. Diagnostic studies. C. Pharmacological intervention. 1. Morphine. Why? 2. Oxygen. 3. Nitrates. a. Peripheral and coronary artery dilatation. b. Example(s): 4. Antiplatelet aggregation. a. Oral. Example(s): b. IV glycoprotein IIb / IIIa receptor blockers. 1. Integrilin (eptifibatide). 2. Aggrastat (tirofiban). 5. Beta blockade. a. HR / BP / contractility myocardial oxygen demand. b. morbidity and mortality with CAD, especially MI. c. Side effects = bradycardia, hypotension, bronchoconstriction. d. Example(s): 6. Calcium channel blockade. a. Coronary artery and peripheral vasodilatation ( SVR). b. myocardial contractility. c. Controls HR, BP, and dysrhythmias. Each drug manifests action in different areas. d. Example(s):

7 7. Fibrinolytics. a. Breaks up the fibrin mesh within the clot. b. Use indicated in the presence of MI with ST segment elevation. 7 c. Example(s): D. Interventions. 1. Hemodynamic support. a. IV fluid / medication to support HR, BP, CO. b. Control dysrhythmias electrolytes, medication. 2. Cardiac catheterization. 3. Intracoronary agents. a. Medications are given during catheterization. b. Examples: fibrinolytics, nitroglycerin, heparin. 4. Percutaneous coronary intervention (PCI). Percutaneous transluminal coronary angioplasty (PTCA). 1. Balloon catheter passed through clot inflated compresses plaque. 2. Risk of plaque rupture, arterial dissection. 5. Stent. a. Used in conjunction with PTCA. PTCA done stent deployed, opens against the plaque, stays in place. b. Several months anticoagulation therapy, then ASA. 6. Atherectomy. Drills through the plaque; vacuum action of catheter to remove plaque. 7. Myocardial revascularization. a. Coronary artery bypass grafting (CABG, CAB, MCAB). 1. Vessel connected from aorta past occluded area of coronary artery. 2. Vessels harvested from patient s legs and arms. b. Minimally invasive direct coronary artery bypass grafting (MIDCAB). 1. Used for bypassing a single vessel, LAD. 2. Laparoscopic technique without cardiopulmonary bypass. c. Transmyocardial revascularization (TMR). 1. Used in those who are not surgical candidates. 2. Multiple holes poked with laser through the left ventricle. E. Nursing considerations. 1. Patient and family education. 2. Pre and post procedure / operative care. Pain and hemodynamic management, prep for procedure, psych support, prep / begin rehab.

8 VI. Rehabilitation. A. Post procedure / operative recovery. 8 B. Lifestyle changes. 1. Smoking cessation. 2. Control blood pressure, glucose, stress. 3. Diet / nutrition. 4. Weight loss / control. C. Physical activity. D. Medication compliance. E. Psychological factors. VII. Aortic aneurysms. A. Definition. 1. Outpouching or widening of arterial wall. 2. Underlying cause atherosclerosis and degradation of connective tissue. 3. Common to have clots in / around the aneurysm. B. Location. 1. Thoracic. a. Most common symptom is deep, diffuse chest pain. b. Ascending and arch. Symptoms: hoarseness, dysphagia. c. Descending. Symptoms: chest and / or back pain. 2. Abdominal. a. Most often found between renal arteries and bifurcation. b. Signs / symptoms. 1. Abdominal / back pain, pulsatile abdominal mass. 2. Neurovascular changes to lower extremities. C. Types. 1. False. a. All layers of vessel walls disrupted causing bleeding, forming a clot. b. Can result from trauma, infection, procedure, surgery. 2. Fusiform. Outpouching is circumferential; shape is relatively uniform. 3. Saccular. Pouch or sack, often with a narrow neck.

9 4. Dissecting. a. Tear in the intimal lining of the aorta, causes blood flow diversion. b. Pain is sudden, sharp, and shifting; distal ischemic symptoms. c. Can lead to rupture Grey Turner s sign. d. Surgical emergency. 9 D. Treatment. 1. Goal is to prevent dissection / rupture. 2. Intervention decision. a. Medical. 1. Aneurysm < 5 cm. 2. Risk factor modification. 3. Serial ultrasound / MRI / CT to assess size / growth Q 6 months. b. Endovascular graft. 1. Cath lab procedure. 2. Criteria: single vessel involvement, smaller aneurysm, no bifurcation. c. Surgical. 1. Aneurysm > 5 6 cm. 2. Other structures involved such as renal or iliac artery (ies). 3. Comorbidities: HTN, DM, known vascular disease. 4. Rapid expansion: 0.5 cm or more in 6 months, dissect or rupture. E. Nursing considerations. 1. Medical treatment. a. Patient education compliance and follow up. b. Monitor for signs / symptoms of extension of aneurysm. 2. Surgical treatment. a. Continual monitoring prior to surgery. 1. Hemodynamics / blood pressure. 2. Pain. 3. Physical signs / symptoms organ perfusion. b. Patient education. 1. Procedures, post operative course. 2. Psych support. c. Post operative care. 1. Surgical site itself. 2. Hemodynamics / blood pressure, organ perfusion. 3. Routine post operative care pulmonary, activity.

10 References 10 Cardiovascular Disease Statistics. Retrieved October 23, 2010 from Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Journal of the American medical association, 2001; 285: Retrieved October 12, 2009 from Grundy, S M., Cleeman, J. I., Merz, C. N. B., Brewer, Jr., H. B., Clark. L. T., Hunninghake, D. B., et al. (2004). Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation, 110, Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2007). Medical surgical nursing (7 th ed.). St. Louis: Mosby. Sole, M. L., Klein, D. G., & Moseley, M. J. (2009). Introduction to critical care nursing (5 th ed.). St. Louis: Saunders. Urdan, L. D., Stacy, K. M., & Lough, M. E. (2005). Thelan s critical care nursing (5 th ed.). St. Louis: Mosby.