Cardiovascular disorders

Philippine statistics (PSA, 2011)

DEATH
• # 1 - Diseases of the heart - 107,294
• 1 in every 1000 Filipino will die of Diseases of the heart per year
MORBIDITY
• # 9 - Diseases of the heart - 37,589
• 4 in every 10,000 Filipino will be diagnosed of Diseases of the heart per year

1
Management of Patients With Coronary Vascular Disorders

Pathophysiology of Atherosclerosis CORONARY ATHEROSCLEROSIS

• Atherosclerosis is the abnormal
accumulation of lipid deposits and fibrous
tissue within arterial walls and lumen.
• In coronary atherosclerosis, blockages and
narrowing of the coronary vessels reduce
blood flow to the myocardium.
• Cardiovascular disease is the leading cause
of death in the United States for men and
women of all racial and ethnic groups.
• CAD, coronary artery disease, is the most
prevalent cardiovascular disease in adults.

Clinical Manifestations
• Symptoms are due to myocardial ischemia
• Symptoms and complications are related to
the location and degree of vessel obstruction
• Angina pectoris
• Myocardial infarction
• Heart failure
• Sudden cardiac death

• The most common symptom of myocardial

ischemia is chest pain; however, some
individuals may be asymptomatic or have
atypical symptoms such as weakness,
dyspnea, and nausea.
• Atypical symptoms are more common
in women and in persons who are
older, or who have a history of heart
failure or diabetes.

2
Angina Pectoris

• A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by
insufficient coronary blood flow.
• Physical exertion or emotional stress increases myocardial oxygen demand and the coronary vessels are
unable to supply sufficient blood flow to meet the oxygen demand.

Types of angina
• Stable angina:
• predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin
• Unstable angina (also called preinfarction angina or crescendo angina):
• symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin
• Intractable or refractory angina:
• severe incapacitating chest pain
• Variant angina (also called Prinzmetal’s angina):
• pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery
vasospasm
• Silent ischemia:
• objective evidence of ischemia (such as electrocardiographic changes with a stress test), but patient
reports no pain

Angina pain varies from mild to severe

• May be described as tightness, choking, or a heavy sensation.
• Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left).
• Anxiety frequently accompanies the pain.
• Other symptoms may occur: dyspnea/shortness of breath, dizziness, nausea, and vomiting.
• The pain of typical angina subsides with rest or NTG.

3
• Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG.
Requires medical intervention!

Treatment
• Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply
• Medications
• Oxygen
• Reduce and control risk factors
• Reperfusion therapy may also be done

Medications
• Nitroglycerin
• Beta-adrenergic blocking agents
• Calcium channel blocking agents
• Antiplatelet and anticoagulant medications
• Aspirin
• Clopidogrel and ticlopidine
• Heparin
• Glycoprotein IIB/IIIa agents
MEDICATIONS USED TO TREAT ANGINA PECTORIS

4
NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION

5
Acute Pain Related to Reduced Coronary Artery Blood Flow and Increased Myocardial Oxygen Needs
Causing an Imbalance Between Oxygen Supply and Demand
EXPECTED OUTCOME: The patient will report an absence of pain.
• Ensure vascular access is established. Intravenous access may be necessary to use to administer drugs
for pain relief.
• Administer oxygen as ordered via nasal cannula to increase oxygen availability to myocardium.
• Obtain a 12-lead ECG as ordered to determine ischemia or injury of the myocardium with evaluation of
the ST segment.
• Administer aspirin as prescribed to decrease platelet aggregation.
• Administer morphine as prescribed to provide pain relief.
• Administer sublingual nitroglycerin as ordered. Notify physician if pain is unrelieved after three doses of
NTG or as prescribed, or if vital signs change. Chest pain unrelieved by nitrates may represent unstable
angina or myocardial infarction.
• Remain with patient and reassess pain in 5 minutes after administration of medication. A patient who has
chest pain should never be left alone.
• Notify physician of ECG changes. ST-segment elevation may indicate a myocardial infarction.
• Offer the patient assurance and emotional support to decrease anxiety. Emotional support is important
because patients and their families are often afraid that the patient may die.
• Promote rest and decrease anxiety for the patient with chest pain to help relieve stress and chest pain.
• Document patient data in the medical record to communicate patient’s problem and outcome.

Deficient Knowledge Related to Ineffective Management of Regimen for Atherosclerosis or Coronary

Artery Disease
EXPECTED OUTCOME: The patient will report understanding and management of atherosclerosis and CAD.
 Identify cognitive or physical impairments that would interfere with the patient’s ability to learn desired
information.
 Include significant other as appropriate to support patient during learning.
 Collect data on patient’s present understanding of atherosclerosis and CAD to determine baseline
knowledge.
 Collect data on patient’s readiness to learn and desired learning needs and feelings about incorporating
lifestyle changes into daily routine to prioritize teaching topics.
 Determine cultural beliefs because they may infl uence learning.
 Provide for patient’s physical comfort during teaching to increase learning.
 Use appropriate teaching tools to meet individual learning needs, such as pamphlets, diagrams, or other
written materials in simple language.
 Use an interpreter as needed, and provide written materials in patient’s native language to facilitate
understanding.
 Explain pathophysiology of atherosclerosis and CAD, control of risk factors, and management of CAD
symptoms to promote understanding.
 Explain action, side effects, and importance of taking medications as prescribed to relieve pain and
prevent complications.
 Provide information about community resources that can assist in making lifestyle changes, such as
weight loss, smoking cessation, stress management, and exercise.
 Teach patient to monitor blood pressure and heart rate as appropriate and to report chest pain or
dyspnea, which may point to the presence of complications from CAD.
 Help patient plan how to incorporate information into daily life to increase likelihood that change will
occur.
 Encourage questions and allow patient opportunity to verbalize new information and skills to enhance
learning.
 Document teaching and evaluation of patient knowledge to validate understanding.
Myocardial Infarction

6
• An area of the myocardium is permanently destroyed.
• Usually caused by reduced blood flow in a coronary artery due to rupture of an atherosclerotic plaque and
subsequent occlusion of the artery by a thrombus.

• In unstable angina, the plaque ruptures but the artery is not completely occluded.
• Unstable angina and acute myocardial infarction are considered the same process but at different
point on the continuum.
• The term acute coronary syndrome includes unstable angina and myocardial infarction.
Effects of Ischemia, Injury, and Infarction on ECG

Clinical Manifestations and Diagnosis

• Chest pain, other symptoms
• ECG
• Laboratory tests—biomarkers
• CK-MB
• Myoglobin
• Troponin T or I
The echocardiogram is used to evaluate ventricular function. It can detect hypokinetic and akinetic wall motion
and can determine the ejection fraction.
Treatment of Acute MI
• Obtain diagnostic tests including ECG within 10 minutes of admission to the ED
• Oxygen
• Aspirin, nitroglycerin, morphine, beta-blockers
• Angiotensin-converting enzyme inhibitor within 24 hours
• Evaluate for percutaneous coronary intervention or thrombolytic therapy
• As indicated; IV heparin or LMWH, clopidogrel or ticlopidine, glycoprotein IIb/IIIa inhibitor
• Bed rest
Nursing Process: The Care of the Patient with ACS—Assessment
• A vital component of nursing care!
• Assess all symptoms carefully and compare to previous and baseline data to detect any changes or
complications.
• Monitor ECG.
7
Nursing Process: The Care of the Patient with ACS—Diagnoses
• Ineffective cardiac tissue perfusion
• Risk for fluid imbalance
• Risk for ineffective peripheral tissue perfusion
• Death anxiety
• Deficient knowledge
Collaborative Problems
• Acute pulmonary edema
• Heart failure
• Cardiogenic shock
• Dysrhythmias and cardiac arrest
• Pericardial effusion and cardiac tamponade
Nursing Process: The Care of the Patient with ACS—Planning
• Goals include the
• relief of pain or ischemic signs and symptoms,
• prevention of further myocardial damage,
• absence of respiratory dysfunction,
• maintenance of or attainment of adequate tissues perfusion,
• reduced anxiety,
• adherence to the self-care program, and
• absence or early recognition of complications.
COMPLICATIONS OF MYOCARDIAL INFARCTION

MYOCARDIAL INFARCTION SUMMARY

8
9
Percutaneous Coronary Intervention

Coronary Artery Bypass Grafts

10
Greater and lesser saphenous veins are commonly used for bypass graft procedures.

11
Cardiopulmonary Bypass System

Postoperative Care of the Cardiac Surgical Patient

12
13