Chapter 14 Nursing Management: Patients With Coronary Vascular Disorders

1. Chapter 14Nursing Management: Patients With Coronary Vascular Disorders

2. Coronary Atherosclerosis • The most common cause of cardiovascular disease • Atheromas or plaques protrude into the lumen of the vessel • Thrombi may form and obstruct blood flow, leading to sudden cardiac death or an acute MI • The anatomic structure of the coronary arteries makes them particularly susceptible to the mechanisms of atherosclerosis

3. Coronary Atherosclerosis

4. Risk Factors • Nonmodifiable: • Age • Gender • Race • Family history • Modifiable: • Diabetes, hypertension, smoking, obesity, physical inactivity, and high cholesterol

5. Risk Factor: Metabolic Syndrome • Consists of three or more of the following: • Insulin resistance • Abdominal obesity • Dyslipidemia • Hypertension • Proinflammatory state • Prothrombotic state

6. Question • The nurse is caring for a patient who had a recent MI. The nurse is aware that the plaque that likely contributed to this event is mostly made up of: • Lipids • Dead leukocytes • Interferons • Adipose tissue

7. Answer • A. Lipids • Rationale: Atherosclerosis begins as monocytes and lipids enter the intima of an injured vessel. A fibrous tissue develops, and this causes plaques to form on the inner lumen of vessel walls.

8. Clinical Manifestations of Atherosclerosis • Ischemia: An inadequate blood supply that deprives the cardiac muscle cells of oxygen needed for their survival • Angina pectoris: Chest pain that is brought about by myocardial ischemia • Classic signs and symptoms of myocardial ischemia include acute onset of chest pain, shortness of breath, extreme fatigue, diaphoresis, and nausea and vomiting

9. Prevention and Medical and Nursing Management • Control cholesterol levels: • Diet, exercise, medication, smoking cessation • Manage hypertension • Manage diabetes

10. Angina Pectoris • Almost always associated with a significant obstruction of a major coronary artery • Anginal pain can have widely varying characteristics • Diagnosis is usually by history, ECG, and cardiac biomarker analysis

11. Question • When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why she experiences chest pain with exertion. The nurse informs the patient that exertion: • Increases the heart's oxygen demands • Causes vasoconstriction of the heart • Increases blood flow to the mesenteric area • Reduces the effectiveness of medications

12. Answer • A. Increases the heart's oxygen demands • Rationale: Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium, resulting in pain. Exercise does not cause vasoconstriction, reduced effectiveness of medications, or increased blood flow to the mesenteric area.

13. Management of CAD and Angina • Nitrates • Beta blockers • Calcium channel blockers • Antiplatelet medications and anticoagulants • Oxygen administration

14. Percutaneous Coronary Interventions (PCIs) • Percutaneous transluminal coronary angioplasty • Intracoronary stent implantation • Nursing care

15. Question • Is the following statement true or false? • A patient who has undergone a PCI has had one or more coronary vessels replaced with new, patent vessels.

16. Answer • False • Rationale: During a PCI, an occluded coronary artery is opened and reperfusion to the area that has been deprived of oxygen is reestablished. The vessel itself is not replaced.

17. Surgical Procedures: Coronary Artery Revascularization • Coronary artery bypass graft (CABG): • Indications • Qualification criteria

18. CABG

19. Nursing Process: The Postoperative Cardiac Surgery Patient • Initial postoperative care focuses on hemodynamic stability and recovery from general anesthesia • Later care focuses on the monitoring of cardiopulmonary status, pain management, wound care, progressive activity, and nutrition • Frequent, multisystemic assessment is imperative

20. Nursing Interventions: The Postoperative Cardiac Surgery Patient • Restoring cardiac output • Maintaining adequate tissue perfusion • Maintaining body temperature • Preventing infection • Preventing fluid and electrolyte imbalances • Preventing impaired gas exchange • Promoting cerebral circulation • Pain control

21. Myocardial Infarction (MI) • Pathophysiology, risk factors, and manifestations are similar to those of angina. • Diagnosis and categorization of MI is based on ECG changes and analysis of cardiac biomarkers (CK-MB, myoglobin, troponin). • ECG analysis results in diagnosis of: • Unstable angina • ST-segment elevation MI (STEMI): • Non–ST-segment elevation MI (Non-STEMI)

22. Management of MI • Medications include aspirin, nitroglycerin, morphine, beta blockers, ACE inhibitors, and statins • Thrombolytics • Analgesics • Reperfusion therapy • Cardiac rehabilitation • Nursing care focuses on relieving pain, promoting respiratory function, promoting tissue perfusion, reducing anxiety, and monitoring for complications

23. Question • The nurse caring for a patient with an MI knows that the top priority in the care of this patient is what? • Balancing intake and output • Decreasing energy expenditure of the myocardium • Balancing myocardial oxygen supply with demand • Decreasing nutritional need of myocardial muscle

24. Answer • C. Balancing myocardial oxygen supply with demand • Rationale: Balancing myocardial oxygen supply with demand (eg, as evidenced by the relief of chest pain) is the top priority in the care of the patient with an MI. This supersedes interventions related to nutrition, fluid balance, or energy expenditure.