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Cardiovascular Stressors • Assessment – Nursing History • Acutely ill cardiac patient – Focus on problem at hand – Get complete assessment when stable • Chronically ill &/or stable cardiac patient CAD Risk Factors • Risk Factors that CANNOT be changed – – – – – + family history Increasing age Gender Race geography • Risk Factors that CAN be changed – – – – – – – – Hyperlipidemia** Hypertension** Cigarette smoking** Inactive lifestyle** Hyperglycemia Obesity Stress Use of estrogen contraceptives Physical Assessment • • • • • • • • General Appearance Vital Signs (including postural) Hands Head & Neck Heart (including heart sounds) Lungs Abdomen Feet & Legs Serum Assessment for Risk • Homocysteine (5-15 umol/L) – Amino acid linked to development of atherosclerosis • Cholesterol (<200 mg/dL) – LDL (60 - 160 mg/dL) – HDL (35-70 mg/dL men; 35-85 women) • Triglycerides (<150 mg/dL) General Cardiac Diagnostic Tests • Chest x-ray – determines size, contour, and position of heart. • Exercise Stress Test – (inaccurate for women) determines heart’s response to increased demand for oxygen • EKG/ECG – visual representation of electrical activity of heart (not all MI’s have initial EKG changes) 1994 Classification of Functional Capacity and Objective Assessment of Pts w/ Heart Disease Functional Capacity Based on subjective symptoms Objective Assessment Based on measurements such as EKGs, stress tests, w-rays, echocardiograms, and radiological images Class I – Pts w/ cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. No objective evidence of cardiovascular disease Class II – Pts w/ cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain Objective evidence of minimal cardiovascular disease Class III – Pts w/ cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Objective evidence of moderately severe cardiovascular disease Class IV – Pts w/ cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is Objective evidence of severe cardiovascular disease CAD Progression CAD MI Cardiac Arrest Angina Coronary Artery Disease • Most common heart disorder in US is coronary atherosclerosis • It is completely REVERSIBLE CAD • SYMPTOMS –Chest pain –SOB –EKG changes –Dysrhythmias –Sudden death • TREATMENT –Decrease risk factors –PTCA • Percutaneous transluminal coronary angioplasty –CABG • Coronary artery bypass graft Medications for CAD • Antilipidemics –Used after diet and exercise have proven ineffective –Lowers cholesterol, triglycerides, and/or LDL’s HMG-CoA Reductase Inhibitors (statins) – Blocks the production of cholesterol, increases HDL levels – Contraindicated with liver disease – 4-6 weeks before therapeutic level achieved – Take at HS – Photosensitivity – Liver function studies – lovastatin (Mevacor); simvastatin (Zocor); atorvastatin (Lipitor) Bile Acid Sequestrants aka bile acid-binding resins - Binds bile in the intestine, leading to a decrease in LDL and serum cholesterol - Not 1st antihyperlipidemic of choice - Decreases effect of anticoagulants - Potential malabsorption of fat soluble vitamins - CONSTIPATION - Take at mealtimes - cholestyramine (Questran) Antiplatelets • ASA • Plavix • Persantine Angina Pectoris • Insufficient coronary blood flow which results in inadequate oxygen supply for the myocardium • Types: – Stable – causes are known – Unstable – unpredictable – Prinzmetal’s – no cause, occurs same time qd Angina Pectoris • Precipitating Factors – Anything that increases pulse or BP • Physical exertion • Exposure to cold • Eating a heavy meal • Stress • Emotional strain • Symptoms – PAIN • From feeling of pressure to agonizing pain • Tightness, choking or strangling sensation • Weakness, numbness in arms, wrists, hands • Sense of impending death/doom Pain subsides when precipitating factor is eliminated Angina Pectoris • Diagnosis –Assess clinical manifestations of pain –Assess patient history –EKG –Cardiac cath • Treatment/Pt Teaching –CABG –PTCA –Reduce risk factors (life style changes) –REST –Medications Nitrates • NTG – fast acting; • isosorbide dinitrate– long acting – NTG dilates veins and arteries, less blood is returned to heart by veins, decreased BP in arteries, decreased myocardial oxygen requirements • Beta-Adrenergic Blockers – Inderal – Blocks sympathetic impulses to heart, decreased pulse & BP, and myocardial contractility – Monitor vs**** – DO NOT abruptly stop taking medication Calcium Channel Blockers • (Procardia, Cardizem, Isoptin) • myocardial oxygen supply by dilating coronary arterioles and decreasing oxygen demand by decreasing systemic BP Myocardial Infarction Death of part of the myocardial tissue • Leading cause of death in the US • ½ of all MI patients die within an hour after MI onset • Men tend to wait about an hour after onset of symptoms; women wait 4-8 hours • 10-15% of survivors will die within the year MI • Precipitating Factors – Coronary atherosclerosis** – Shock, hemorrhage – Vasospasm – Cocaine • Clinical Picture – Pain • Location, quality, duration, intensity, time, alleviation – Vital Signs • BP, P, To – N/V – Feeling of doom – Diaphoresis – Indigestion Potential Complications of MI • • • • • • Cardiac arrest Heart failure Cardiogenic shock Pulmonary embolism Heart block Cardiac rupture Arterial Insufficiency • Contributing Factors – > age of 50 – Male – Influenced by # of CAD risk factors • Subjective Symptoms – Intermittent claudication – Rest pain – Coldness/numbness in extremity • Physical Assessment – Extremity cool – Pale when elevated, dependent rubor – Skin/nail changes – Toe ulcerations – Gangrene – 5 P’s • Tests – Dopplar – Treadmill testing Buerger’s Disease • Key Factors: – Improve circulation to extremities – Prevent the progression of the disease – Protect the extremities from trauma/infection • Symptoms – – – – – Pain Intense dependent rubor Absent pedal pulses Parasthesia Ulceration w/ gangrene • Treatment – essentially the same as for arterial insufficiency Symptoms – Thoracic • Asymptomatic • Pain • Dyspnea • Cough • Hoarseness • dysphagia – Abdominal • 2/5 asymptomatic • c/o feeling heart beating in their abdomen when lying down • Some can feel a mass • Systolic bruit • Treatment – Surgical repair – Control of predisposing factors • HTN • atherosclerosis • Ruptured aortic aneurism – Mortality rate 5075% – Constant, intense back pain – decreased BP – decreased Hct – Hematomas in scrotum, perineum, flank, or penis Arterial Embolism • Symptoms – Depends on size of embolus and organ involved – Immediate cessation of distal blood flow – Acute severe pain and gradual loss of sensory and motor function – 5 P’s – Cold distally • Treatment – Depends on cause – Surgery as time is critical – embolectomy – Heparin initiated stat to prevent further development – Thrombolytics if enough time Anticoagulants • Heparin – indirectly interferes w/ conversion of prothrombin to thrombin • Given sq or IV ONLY • Overdose – tx with protamine sulfate • PTT control 25-37 seconds; therapeutic level 1.5-2.5 X’s control • Lovenox – low molecular weight heparin **May be on Heparin and Coumadin at same time • Coumadin – inhibits blood clotting by interfering w/ synthesis of Vitamin Kdependent clotting factors • Given po ONLY • Overdose –tx with Vitamin K • PT control 12-15 seconds; therapeutic level 1.5-2.5X’s control, takes 24-48 hours to reach therapeutic level INR 2-3.5 Heparin Coumadin Indications for use Acute thromboembolic problems Prophylaxis for @ risk clients Long-term treatment or prevention Onset Rapid, within minutes Delayed 2-5 days Duration Short 2-5 days after discontinued Route IV, sq PO Blood Tests APTT (activated partial thromboplastin time) PT (prothrombin time) INR (International Normalized Ratio) Antidote Protamine sulfate Vitamin K Raynaud’s Disease • Symptoms – White/Blue/Red • Vasoconstriction • Cyanosis • Rebound vasodilation – Numbness, tingling, and burning pain – Tends to be bilateral and symmetrical • Treatment – Avoid stimuli – Calcium channel blockers – sympathectomy • Which of the following manifestations would alert the nurse that a patient in prolonged bradycardia was experiencing decreased cardiac output? • A. increase in BP • B. decrease in respiratory rate • C. increase in pupillary dilation • D. decrease in urinary output • Which of the following clinical manifestations would a nurse expect to note in a patient whose hemoglobin value is below normal? • A. reddened, flushed facial appearance • B. slow, shallow respirations • C. fatigue and weakness • D. slow and bounding pulse • A 72 yo Black male, is being discharged following cardiac rehab after an MI. He has a hx of high cholesterol, sedentary and stressful profession, and is 50# overweight. It would be most important for the nurse to assess which of the following prior to planning pt ed? The patient’s • • • • A. readiness to learn B. educational level C. home layout D. social support system • After completing the assessment, the nurse is going to provide pt ed for Mr. Abbott. Which of the following should receive highest priority? • A. low fat diet • B. exercise • C. stress reduction methods • D. restricting activity until he is completely recovered • A 59 yo female presents to the ED c/o SOB, nausea, and “just not feeling right”. When taking her history, it is most important for the nurse to ask: • A. “how many children do you have?” • B. “how long has this feeling lasted?” • C. “has this ever happened before?” • D. “do you have a family hx of cardiac problems?” • Ms. About T. Blow, 42, has just been dx with HTN. Which of the following statements made by the patient indicates she needs further teaching? • A. “I’ll make sure I take my medication when I wake up with a H/A” • B. “I’m going to join a yoga class” • C. “I’m going to start making homemade soup instead of buying Campbell’s” • D. “I’m going to see about a nicotine patch so I can quit smoking” • A patient is scheduled for a thallium stress test. Which of the following is most important for the nurse to ask? • A. “have you eaten since midnight?” • B. “do you have any questions about the diary you are to keep?” • C. “do you take anticoagulants?” • D. “have you ever had this test before?” • Which of the following • A. complaints of chest clinical manifestations is pain and tightness most indicative of • B. edema of lower decreased coronary extremities oxygenation secondary • C. complaints of to atherosclerotic dizziness with position plaque deposits? changes • D. exertional dyspnea • Which of the following classes of drugs is indicated most for the management of symptoms associated with coronary artery atherosclerosis? • • • • A. Nitrate B. Vasopressor C. Salicylate D. Thrombolytic