Cardiac Disorders

CORONARY ARTERIAL DISEASE/ ISCHEMIC HEART

DISEASE
 STAGES OF DEVELOPMENT OF CORONARY
ARTERY DISEASE
1. Myocardial Injury - Atherosclerosis

2. Myocardial Ischemia – Angina Pectoris

3. Myocardial Necrosis – Myocardial Infarction

 
ATHEROSCLEROSIS ARTERIOSCLEROSIS
- narrowing of artery - hardening of artery
- lipid or fat deposits - calcium and protein
- tunica intima deposits
- tunica media
 Predisposing Factors
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet – increased saturated fats
10. Type A personality
 Signs and Symptoms
• Chest pain
• Dyspnea
• Tachycardia
• Palpitations
• Diaphoresis
 Treatment
Percutaneous Transluminal Coronary Angioplasty
Objectives:
• Revascularize myocardium
• To prevent angina
• Increase survival rate – done in single occluded vessels.
Coronary Arterial Bypass and Graft Surgery
3 Complication of CABG
• Pneumonia
• Shock
• Thrombophlebitis
 Angina Pectoris (Syndrome)
• Clinical syndrome characterized by paroxysmal
chest pain that is usually relieved by rest or
nitroglycerine due to temporary Myocardial
Ischemia.
 Predisposing Factors
• Sex – male
• Race – Black
• Smoking
• Obesity
• Hyperlipidemia
• Sedentary Lifestyle
• DM
• Hypothyroidism
• Diet – increased saturated fats
• Type A personality
 Precipitating Factors
4 E’s of Angina Pectoris
• Excessive physical exertion
• Exposure to cold environment
• Extreme emotional response
• Excessive intake of foods rich in saturated fats
 Signs and Symptoms
• Levine Sign – initial sign that shows the hand clutching
the chest.
• Chest pain characterized by sharp stabbing pain located
at sub sterna usually radiates from back, shoulder, arms,
axilla, and jaw muscles . Usually relieved by rest or
taking NTG.
• Dyspnea
• Tachycardia
• Palpitations
• Diaphoresis
 Diagnostic Proceudure
• History taking and Physical exam
• ECG tracing reveals ST segment depression
• Stress test – treadmill test
• Serum cholesterol and uric acid is increased
 Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
a. Nitroglycerine (NTG) – when given in small doses will act as venodilator, but in large doses
will act as vasodilator
- Give first dose of NTG (sublingual) 3 – 5 minutes
- Give second dose of NTG if pain persist after giving first dose with interval of 3 - 5 minutes
- Give third and last dose of NTG if pain still persist at 3 – 5 minutes interval
Nursing Management when giving NTG
Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug
Monitor side effects
– Orthostatic hypotension
– Transient headache and dizziness
Instruct the client to rise slowly from sitting position
Assist or supervise in ambulation
When giving nitrol or transdermal patch
– Avoid placing near hairy areas as it may decrease drug absorption
– Avoid rotating transdermal patches as it may decrease drug absorption
– Avoid placing near microwave ovens or duting defibrillation as it may lead to burns
(most important thing to remember)
 Nursing Management
b. Beta-blockers
- Propanolol - side effects PNS
- Not given to COPD cases because it causes bronchospasm
 
c. ACE Inhibitors
- Enalapril
 
d. Calcium Antagonist
- NIfedipine
 
3. Administer oxygen inhalation
4. Place client on semi fowlers position
5. Monitor strictly vital signs, intake and output and ECG tracing
6. Provide decrease saturated fats sodium and caffeine
7. Provide client health teachings and discharge planning
a. Avoidance of 4 E’s
b. Prevent complication (myocardial infarction)
c. Instruct client to take medication before indulging into physical exertion to achieve the maximum
therapeutic effect of drug
d. The importance of follow up care
 Myocardial Infarction or Heart Attack

• Terminal stage of coronary artery disease

characterized by malocclusion, necrosis and
scarring.
 Types
Transmural Myocardial Infarction
– most dangerous type characterized by
occlusion of both right and left coronary
artery.

Subendocardial Myocardial Infarction

– chracterized by occlusion of either right or left
coronary artery.
 Predisposing Factors
• Sex – male
• Race – Black
• Smoking
• Obesity
• Hyperlipidemia
• Sedentary Lifestyle
• DM
• Hypothyroidism
• Diet – increased saturated fats
• Type A personality
 Signs and Symptoms
• Chest pain
• Dyspnea
• Increase blood pressure
• Hyperthermia
• Pallor
• Mild restlessness and apprehension
Occasional findings
-pericardial friction rub
-split S1 and S2
-rales and crackles upon auscultation
 Diagnostic Procedure
1. Cardiac Enzymes
a. CPK – MB
- Creatinine phosphokinase is increased
- Heart only, 12 – 24 hours
b. LDH – Lactic acid dehydroginase is increased
c. SGPT – Serum glutamic pyruvate transaminase is increased
d. SGOT – Serum glutamic oxal-acetic transaminase is increased
2. Troponin Test – is increased
3. ECG tracing reveals
a. ST segment elevation
b. T wave inversion
c. Widening of QRS complexes indicates that there is arrhythmia in MI
4. Serum Cholesterol and uric acid are both increased
5. CBC – increased WBC
 Nursing Management
Goal: Decrease myocardial oxygen demand
 
1. Decrease myocardial workload (rest heart)
- Administer narcotic analgesic/morphine sulfate
- Side Effects: respiratory depression
- Antidote: Narcan/Naloxone
- Side Effects of Naloxone Toxicity is tremors
2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min
3. Enforce CBR without bathroom privileges
a. Using bedside commode
4. Instruct client to avoid forms of valsalva maneuver
5. Place client on semi fowlers position
6. Monitor strictly vital signs, intake and output and ECG tracing
7. Provide a general liquid to soft diet that is low in saturated fats, sodium and
caffeine
8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce
vasodilation
9. Administer medication as ordered
a. Vasodilators
- Nitroglycerine
- ISD (Isosorbide Dinitrate, Isodil) sublingual

b. Anti Arrythmic Agents

- Lidocaine (Xylocane
- Side Effects: confusion and dizziness
- Brutylium
c. Beta-blockers

d. ACE Inhibitors

e. Calcium Antagonist

f. Thrombolytics/ Fibrinolytic Agents

- Streptokinase
- Side Effects: allergic reaction, pruritus
- Urokinase
- TIPAF (tissue plasminogen activating factor)
- Side Effects: chest pain
- Monitor for bleeding time

g. Anti Coagulant
- Heparin (check for partial thrombin time)
- Antidote: protamine sulfate
- Coumadin/ Warfarin Sodium (check for prothrombin time)
- Antidote: Vitamin K

h. Anti Platelet
- PASA (Aspirin)
- Anti thrombotic effect
- Side Effects of Aspirin
Tinnitus
Heartburn
Indigestion/Dyspepsia
- Contraindication
Dengue
Peptic Ulcer Disease
Unknown cause of headache
10. Provide client health teaching and discharge planning concerning
a. Avoidance of modifiable risk factors
- arrhythmia (caused by premature ventricular contraction)
b. Cardiogenic shock
- late sign is oliguria
c. Left Congestive Heart Failure
d. Thrombophlebitis
- homan’s sign
e. Stroke/CVA
f. Post MI Syndrome/Dressler’s Syndrome
- client is resistant to pharmacological agents, administer 150,000 – 450,000 units
of streptokinase as ordered
g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac
rehab, post CABG and instruct to
- make sex as an appetizer rather than dessert
- instruct client to assume a non weight bearing position
- client can resume sexual intercourse if can climb staircase
- dietary modification
h. Strict compliance to mediation and importance of follow up care