1/3/2008. Karen Burke Priscilla LeMone Elaine Mohn-Brown. Medical-Surgical Nursing Care, 2e Karen Burke, Priscilla LeMone, and Elaine Mohn-Brown

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1 Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 26 Caring for Clients with Coronary Heart Disease and Dysrhythmias Coronary Heart Disease (CHD) Leading cause of death in U.S. Narrowing coronary arteries Atherosclerosis CHD Risk Factors Nonmodifiable Age Gender Ethnicity Heredity Modifiable Smoking Obesity Physical inactivity Hypertension Hyperlipidemia Metabolic syndrome 1

2 TABLE 26-2 Classification of Cholesterol and LDL Levels. CHD - Pathophysiology Atherosclerosis causing occlusions Leads to ischemia CHD - Treatment Diet Cholesterol-lowering lowering drugs 2

3 Statins CHD Nursing Care Teach common side effects: headache, gastrointestinal upset Muscle aches, skin rashes Liver function tests t and muscle enzymes are monitored Nicotinic acid CHD Nursing Care Flushing, pruritis Cholesterol binding Gastrointestinal side effects CHD Nursing Care Teach smoking cessation Healthy weight Exercise Control high blood pressure, diabetes, lipid levels Reduce stress 3

4 Angina Pectoris - Pathophysiology Obstructed coronary artery Increased myocardial oxygen demand Lactic acid release Leads to pain Three types Stable Unstable Prinzmetal s Manifestations Chest pain Radiates Onset with exercise, etc. Rli Relieved db by rest, tntg SOB, pallor, fear Angina Pectoris Angina Pectoris - Treatment NTG Beta blockers Calcium channel blockers Low-dose aspirin i 4

5 Diagnostic tests Coronary angiogram PTCA Angina Pectoris Angina Pectoris - Treatment Surgery PTCA same as coronary angiogram CABG: Preop teaching CABG: postoperative Angina Pectoris Nursing Care Assessment Risk factors Pain Focused assessment 5

6 Angina Pectoris Nursing Care Ineffective Tissue Perfusion: Cardiopulmonary NTG at bedside Oxygen Rest between activities Manage risk factors Exercise Smoking cessation Angina Pectoris Nursing Care Risk for Ineffective Therapeutic Regimen Management Angina teaching Cardiac rehabilitation program Angina Pectoris Nursing Care Management of anginal episodes Teaching NTG before activities 1 every minutes x 3 NTG storage 6

7 Acute Myocardial Infarction (AMI) Pathophysiology Occluded coronary artery stops blood flow to part of cardiac muscle Cellular death Tissue necrosis Description heart area affected Classification AMI Manifestations Chest pain Radiates to shoulder, neck, jaw, arms Lasts >15 20 minutes Not relieved with NTG Sense of impending doom SOB Diaphoresis Nausea and vomiting AMI Manifestations - women and elderly May be atypical Upper abdominal pain No chest pain but other symptoms 7

8 AMI Complications Related to size and location of infarct Dysrhythmias Pump failure Cardiogenic shock Pericarditis AMI - Treatment Pain relief Antianxiety Thrombolytics - nursing care Bleeding disorders Care during infusion Care postinfusion AMI - Treatment Aspirin Heparin Antidysrhythmic medications Bt Beta blockers ACE Inhibitors IV NTG 8

9 AMI Nursing Care Assessment Pain Evidence of adequate tissue perfusion Physical assessment findings AMI - Treatment Revascularization Angioplasty with STENT IABP VADs AMI - Treatment Early recognition Lab tests Diagnostic tests Medical management: Monitoring IVF Oxygen Bed rest with bedside commode Quiet calm environment 9

10 AMI Nursing Care Assessment Immediate and hourly ECG Labs AMI Nursing Care Pain Sign of pain Oxygen Physical and psychologic rest Morphine Ongoing chest pain AMI Nursing Care Ineffective Tissue Perfusion Change in heart rate, rhythm LOC UOP Skin appearance Heart and breath sounds ECG Antidysrhythmics as prescribed 10

11 AMI Nursing Care Ineffective Coping Trust Denial Anger Coping skills Privacy AMI Nursing Care Fear Client s perception Encourage questions Antianxiety medications Stress reduction AMI Nursing Care Cardiac Rehabiliation Improve the quality of life Teaching Reduce risk of future events Diet Activity Refer to cardiac rehabilitation Community resources Learn CPR 11

12 Cardiac Dysrhythmias Pathophysiology Due to altered formation of impulses or altered conduction of the impulse through the heart Ectopic beats Heart block Reentry phenomenon Classified to the site of impulse formation or the site and degree of conduction block Cardiac Dysrhythmias - Types Supraventricular Sinus tachycardia Sinus bradycardia PAC Atrial flutter Atrial fibrillation Junctional Ventricular dysrhythmias Cardiac Dysrhythmias Types PVCs Ventricular tachycardia Ventricular fibrillation AV conduction blocks First degree Second degree Third degree 12

13 Cardiac Dysrhythmias Diagnostic tests Cardiac monitoring Telemetry Cardiac Dysrhythmias - Treatment Antidysrhythmics Cardiac Dysrhythmias Nursing Care Assessment Assess before treating with dysrhythmia medications Chest pain SOB Palpitations ti VS Skin color LOC, mental status Heart sounds, peripheral pulses Respiratory status Anxiety 13

14 Cardiac Dysrhythmias Nursing Care Decreased Cardiac Output Assess for manifestations of decreased cardiac output ECG VS Lb Lab values IV access Emergency procedures prn Cardiac Dysrhythmias Nursing Care Risk for Ineffective Tissue Perfusion: Cerebral LOC, orientation x 3 Neurologic status Oxygen therapy HOB 15-degree angle Rest Anxiety Keep family and client informed Cardiac Dysrhythmias Nursing Care Cardiac output Cerebral perfusion Cardiac rhythm Lab data 14

15 Cardiac Dysrhythmias - Treatment Electrical therapy Cardioversion/defibrillation Electrical shock Synchronized Premedicate with anticoagulants Automatic implantable cardioverter defibrillator defibrillator Pacemakers: temporary, permanent Surgery Cardiac Dysrhythmias - Teaching Coping strategies Follow up MD visits Teach about implanted devices Activities Safety Driving CPR Sudden Cardiac Death Death within 1 hour after onset of cardiac S/S V-fibrillation and cardiac arrest CPR started within 2 to 4 minutes AED 15

16 Figure An automatic external defibrillator for emergency resuscitation. (Courtesy of Medtronic Physiocontrol.) Advanced Directives All measures used to treat cardiac arrest Advance directives treatment treatment decisions 16

Results of Ischemic Heart Disease

Results of Ischemic Heart Disease Ischemic Heart Disease: Angina and Myocardial Infarction Ischemic heart disease; syndromes causing an imbalance between myocardial oxygen demand and supply (inadequate myocardial blood flow) related to