Chapter 30

Nursing Care of
Clients with
Coronary Heart
Disease
 Objectives
• Discuss the pathophysiology of heart disease
• Describe nursing care for patients with Coronary
Heart Disease (CHD)
• Relate the outcomes of diagnostic testing and
procedures to the pathophysiology of cardiac
disorders and implications for patient responses
to the disorder
• Discuss nursing implications for medications and
treatments used to prevent and treat CHD and
dysrhythmias
Coronary Heart Disease (CHD)

 Affects 16.8 million people in the United States

 Caused by impaired blood flow to myocardium due to
atherosclerosis (fibrous fatty plaque)

 May be asymptomatic, or may lead to:

 Angina pectoris
 Acute coronary syndrome
 Myocardial infarction
 Dysrhythmias
 Heart failure
 Sudden death
• Five properties of cardiac cells

• Automaticity
• Excitability
• Conductivity
• Refractoriness
• Contractility
• Controlled by the cardiac conduction system
Coronary Circulation
• Left main coronary artery
• Anterior descending
• Circumflex branch
• Right coronary artery
• Supplies the right ventricle
• Posterior descending artery supplies posterior portion
of heart
• Collateral channels
• Develop between small arteries
• Providing alternative routes for blood flow
PATHOPHYSIOLOGY ILLUSTRATED Coronary Heart
Disease
PATHOPHYSIOLOGY ILLUSTRATED (continued) Coronary Heart Disease
 ATHEROSCLEROSIS
• Lipids accumulate in intimal layer of arteries
• Fibroblast respond – produce collagen
• Smooth muscles proliferate
• Leads to plaque formation (lesion)
• Effects:
•  lumen size
• May ulcerate &  thrombus which can occlude
vessel
Atherosclerosis
• Causes
• Abnormal lipid metabolism
• Injury or inflammation of the endothelial cells
• Results in blood flow obstruction, weakened arterial
walls
• Major cause of aneurysms
Myocardial Ischemia
• Myocardial ischemia results from inadequate oxygen
supply to the heart muscle.
• Two categories:
• Chronic:
• Stable and vasospastic angina,
• Silent myocardial ischemia
• Acute angina:
• From unstable angina to myocardial infarction
Contributing Factors pg 912
Risk Factors pg 913
 General Diagnostic Testing

 Lipid profiles
 C-reactive protein
 Ankle-brachial blood pressure index
 Exercise ECG testing
 Electron beam computed tomography
 Myocardial perfusion imaging

s
Treatments to Prevent /Treat Atherosclerosis
 Drug therapy
 To lower total serum cholesterol and LDL levels and to
raise HDL levels
 Goal to reduce LDL levels to <130mg/dl

 Memory jogger –
 LDL (less desirable lipoproteins)
 HDL (Highly desirable lipoprotein)

 4 classes of cholesterol-lowering drugs

 Statins
 Bile acid dequestrants
 Nicotinic acid
 Fibrates or fibric acid derivatives
Health Promotion
• Assessment
• Health Hx
• BP,
• peripheral pulses
• BMI
• Nursing Dx
• Imbalanced Nutrition: More than……
• Ineffective Health Maintenance
Angina Pectoris
• Chest pain resulting from reduced coronary blood flow or
ischemia

• Pain might feel:

• Tight
• Squeezing
• Heavy
• Constricting substernal pain, radiates to jaw,
epigastric area, back
Angina Pectoris
• Additional manifestations:
• Dyspnea
• Pallor
• Tachycardia
• Great anxiety or fear
• Silent myocardial ischemia has no symptoms.
Women can present with atypical symptoms

• Indigestion
• Nausea
• Vomiting
• Upper back pain
Angina
 Diagnosis
Past medical history and family history
Comprehensive description of the chest
pain
Physical assessment findings
Electrical Changes for Angina on ECG
Figure 30-1 pg 921
 Electrocardiography
Nonspecific ST and T wave changes
ST segment is depressed or down sloping
T wave may flatten or invert
 Angina

 Other diagnostic testing

ECG stress testing

Radionuclide testing
Echocardiography
Coronary angiography – gold standard
Aka Heart cath
ANGINA Treatments

 Management focuses on maintaining coronary

blood flow and cardiac function
 Goal is to reduce oxygen demand and
increase oxygen supply

 Three major classes of medications

 Nitrates
 Beta blockers
 Calcium channel blockers &
 Low dose aspirin (salicylate)
A client with angina pectoris tells the nurse that chest pain usually occurs after going up
two flights of stairs. Recently the client has had three more severe episodes of chest pain
while watching TV, while going downstairs, and after falling asleep. The nurse interprets
that the client is now experiencing which of the following types of angina?

• A. nocturnal angina
• B. unstable angina
• C. variant angina
• D. intractable angina
A client with angina pectoris tells the nurse that chest pain usually occurs after going up
two flights of stairs. Recently the client has had three more severe episodes of chest pain
while watching TV, while going downstairs, and after falling asleep. The nurse interprets
that the client is now experiencing which of the following types of angina?

• A. nocturnal angina
• B. unstable angina
• C. variant angina
• D. intractable angina
Rationale
• Unstable angina is triggered by an unpredictable amount
of exertion or emotion and may occur at night. The
attacks increase in number, duration, and severity over
time. Nocturnal angina (Prinzmetals) may be associated
with dreaming that occurs with rapid eye movement
sleep. Variant angina is triggered by coronary artery
spasm, and the attacks are of longer duration than those
of classic angina and tend to occur early in the day and
at rest. Intractable angina is chronic and incapacitating
and may not respond to medical therapy.
Lets take a break!!

Stand Up
• Snap, Flap, Clap
ACUTE CORONARY SYNDROME

 Condition of cardiac ischemia

With or without significant injury
See Fast Facts pg 925
1.5 million admitted annually
 Clients generally admitted to acute care unit
 Nursing care is similar to that for clients with
angina and AMI
Acute Coronary Syndrome
• ACS usually causes angina to occur, precipitated by:
• Rupture or erosion of atherosclerotic plaque
• Coronary artery spasm
• Progressive vessel obstruction by plaque or by
restenosis after treatment
• Inflammation of a coronary artery
• Increased myocardial oxygen demand and/or
decreased supply
Acute Coronary Syndrome

 Diagnostic testing
 ECG
 Serum cardiac markers ( CK, CKI, Troponin, BNP)

 Procedures
 Transluminal coronary angioplasty
 Laser angioplasty
 Coronary atherectomy
 Intracoronary stents
 Coronary artery bypass grafting (CABG)
A nurse is caring for a client admitted to the hospital with acute myocardial
infarction (MI). The nurse should monitor the client for which common
complication of MI?

• A. cardiogenic shock
• B. cardiac dysrhythmias
• C. congestive heart failure
• D. recurrent myocardial infarction
A nurse is caring for a client admitted to the hospital with acute myocardial
infarction (MI). The nurse should monitor the client for which common
complication of MI?

• A. cardiogenic shock
• B. cardiac dysrhythmias
• C. congestive heart failure
• D. recurrent myocardial infarction
Rationale
• Dysrhythmias are the most common complication and
cause of death after an MI. Cardiogenic shock,
congestive heart failure and recurrent MI are also
complications but occur less often.
Acute Coronary Syndrome Treatment

Medications include drugs to

Reduce myocardial ischemia
(nitrates and beta blockers)
Reduce the risk for blood clotting
(aspirin, other antiplatelet drugs, and
heparin)
Coronary Revascularization Procedures
• Percutaneous coronary revascularization
• Percutaneous transluminal coronary angioplasty
• Intracoronary stents placement
• Coronary artery bypass grafting
• Minimally invasive coronary artery surgery
• Transmyocardial laser revascularization
 Percutaneous
Coronary
Revascularization
Figure 30-2 page 928
Coronary Artery Bypass Graft
Figure 31-3 pg 928
Cardiopulmonary Bypass
Figure 30-4 pg 930
Acute Myocardial Infarction (AMI)
• Death/irreversible damage of myocardial cells
• Extent of the AMI can be limited by swift return of blood
flow
• AMIs are described:
• As non-Q wave infarction or Q-wave infarction
• By the damaged area of the heart
Figure 30-5 pg 938
ECG Changes due to MI
Myocardial Myocardial
Injury Infarct
Cardiac Dysrhythmia
• Disturbance or irregularity in the electrical system of the
heart
• Caused by disruption automaticity, excitability,
conductivity, refractoriness
• Classifications include:
• Tachydysrhythmias
• Bradydysrhythmias
• Ectopic rhythms
Acute Myocardial Infarction
 Immediate treatment goals
Relieve chest pain
Reduce the extent of myocardial
damage
Maintain cardiovascular stability
Decrease cardiac workload
Prevent complications.
Laboratory testing
CBC, ESR
ABGs
CRP
Cardiac Markers
TNI, CRP, Myoglobin
Diagnostic Testing for Acute MI

Electrocardiography
Echocardiography
Myocardial nuclear scans
Hemodynamic monitoring
Acute MI Treatment
Medications
 Aspirin is now considered an essential part of
treating AMI
 Fibrinolytic agents - streptokinase
 Analgesics
 Antidysrhythmic agents
Treatments for Acute MI
• ICU monitoring for first 24-48 hours
• BEDREST
• O2
• Possibly liquid diet to decrease O2 demand for first
4-12 hours
Acute MI
 Other invasive procedures
 Intra-aortic balloon pump placement
 Ventricular assist device placement
 Cardiac rehabilitation
A client is admitted to the hospital with a myocardial infarction and is
not experiencing pain at this time. The nurse reviews the EKG strip and
notes that the PR intervals are 0.16 seconds. The nurse understands
that a PR interval of 0.16 seconds found on the electrocardiogram
rhythm strip indicates which of the following?

• A. a normal finding
• B. an abnormal finding
• C. first degree atrioventricular block
• D. an impending reinfarction
A client is admitted to the hospital with a myocardial infarction and is
not experiencing pain at this time. The nurse reviews the EKG strip and
notes that the PR intervals are 0.16 seconds. The nurse understands
that a PR interval of 0.16 seconds found on the electrocardiogram
rhythm strip indicates which of the following?

• A. a normal finding
• B. an abnormal finding
• C. first degree atrioventricular block
• D. an impending reinfarction
Rationale
• The PR interval represents the time it takes for the
cardiac impulse to spread from the atria to the ventricles.
The PR interval range is 0.12 to 0.20 seconds. Therefor
the finding is normal.
Nursing Diagnoses (NANDA stems and r/t) for
Cardiac Surgery Client

 Decreased cardiac output related to potential

fluid loss during surgical procedure
 Risk for impaired gas exchange
 Potential alteration in fluid & electrolyte balance
 Knowledge deficit related to self-care activities

 Risk for sensory-perceptual alterations

 Risk for altered tissue perfusion
 Risk for altered renal perfusion
Pre-operative or Pre-procedure

 Nursing Responsibilities include:

Comprehensive physical assessment

Education regarding the procedure or

surgery being performed
Nursing Diagnoses Pre-Op

 Knowledge deficit related to Post-op

expectations
 Disturbance in self-concept related to
impending heart surgery
 Anxiety and fear related to forthcoming
surgery & its outcome
Nursing Care
Post-operative or post-procedure

 Nursing responsibilities include:

Close monitoring of VS, cardiac rhythm,
output, respiratory status, and general
physical assessment
Monitor and manage IV medication
administration
Monitor and treat pain
Nursing Care
Post-Op Nursing Diagnoses

 Hypothermia
 Acute pain
 Ineffective airway clearance
 Impaired gas exchange
 Risk for infection
 Disturbed thought processes
 Activity intolerance
• Questions???
Resources on Pearson Website
• Next slides are for reference to videos on the Pearson
web site for viewing
Resources
• Cardiac Cycle
Interactive website animation/movie detailing blood
flow, aortic/ventricular volumes and pressures
present in a normal cardiac cycle, as well as an
electrocardiogram and heart sounds graph. Tutorials
are provided for each phase of the cycle and
interactive functions such as frame-by frame
viewing, high/low quality toggle for faster playback,
and a pop-up-menu to select the phase tutorials can
all be utilized within the animation itself.
Resources
• Heart Failure and Left Ventricular Hypertrophy in
Hypertension
Website featuring narrated video animationxa of the
normal heart conduction, left ventricular hypertrophy and
heart failure in hypertension.
• Atherosclerosis and Lipid Disorder Management
Website with education information on atherosclerosis.
Resources
• Cardiac Surgical Intervention
Website of the Cardiothoracic Surgery Network with
numerous narrated videos of various cardiac and
cardiothoracic surgeries.
• Pacemaker
Website featuring normal cardiac conduction, indications
and complications of a pacemaker.
Resources
• ECG Learning Center
Website with all ECG dysrhythmias with quizzes.
• Cholesterol
Website of American Heart Association with risk
assessment and pharmaceutical information on
cholesterol.
• Medication
Website developed for cardiac clients to create a
medication schedule. Applicable to all clients.
Resources
• Heart Failure
Website dedicated to create and communicate
knowledge to improve cardiovascular health for the
layman including symptoms, treatments and
pharmacology.
• Angina
National Library of Medicine/National Institutes of
Health website with numerous links to information
including an interactive tutorial program for the
public. Extensive professional medical data linkage.
Resources
• Cardiac Conditions, Interventions, Nutrition
Website featuring multi-media presentations on a variety
of cardiac topics and conditions including weight loss,
dysrhythmias, interventions, medications, myocardial
infarction, valve disease, etc.
Questions????