Cad 3

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Chapter 40

Care of Patients

with Acute Coronary Syndromes

2Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Learning Outcomes

Compare and contrast the clinical manifestations of stable angina and unstable angina.

Prioritize nursing care for patients with chest pain. Describe the etiology, pathophysiology, clinical

manifestations, diagnostic findings, complications,

collaborative care, and nursing management for patients with coronary artery disease (CAD) and chronic stable angina.

Develop a plan of care for the patient who has a

percutaneous coronary angioplasty (PTCA). Develop a teaching plan for patients at risk for CAD

regarding cardiovascular risk modification programs and lifestyle changes.


Coronary Artery Disease

Includes stable angina, acute coronary syndromes

Ischemia—insufficient oxygen supply to meet requirements of myocardium

Infarction—necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue


Chronic Stable Angina (CSA) Pectoris

“Strangling of the chest” Temporary imbalance between coronary

artery’s ability to supply oxygen and cardiac muscle’s demand for oxygen


Chronic Stable Angina (CSA) Pectoris (cont’d)

Ischemia limited in duration and does not cause permanent damage to myocardial tissue

Chronic stable angina Unstable angina


Acute Coronary Syndrome (ACS)

Patients who present with either unstable angina or acute myocardial infarction

Believed that atherosclerotic plaque in coronary artery ruptures, resulting in platelet aggregation, thrombus formation or vasoconstriction


Unstable Angina Pectoris

New-onset angina Variant (Prinzmetal’s) angina Pre-infarction angina Patients present with ST changes on 12-lead

ECG, but will not have changes in troponin or CK levels


Nonmodifiable Risk Factors

Age Gender Family history Ethnic background


Modifiable Risk Factors

Elevated serum cholesterol Cigarette smoking Hypertension Impaired glucose tolerance/DM Obesity Excessive alcohol Limited physical activity Stress


Laboratory Assessment

Troponin T and troponin I Creatine kinase-MB (CK-MB) Myoglobin Imaging assessment 12-lead electrocardiograms Cardiac catheterization


Pathophysiology of Atherosclerosis


Progression of Atherosclerosis

Fig. 34-2Fig. 34-2


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.


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.


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.


Location of Chest Pain (Angina)

Fig. 34-7


Nursing Process: The Care of the Patient with Angina Pectoris—Assessment

Symptoms and activities, especially those that precede and precipitate attacks

Risk factors, lifestyle, and health promotion activities

Patient and family knowledge Adherence to the plan of care


Nursing Process: The Care of the Patient with Angina Pectoris—Diagnoses

Ineffective cardiac tissue perfusion Death anxiety Deficient knowledge Noncompliance, ineffective management of

therapeutic regimen


Collaborative Problems Acute pulmonary edema Heart failure Cardiogenic shock Dysrhythmias and cardiac arrest Myocardial infarction


Nursing Process: The Care of the Patient with Angina Pectoris—Planning

Goals include immediate and appropriate treatment of angina prevention of angina reduction of anxiety awareness of the disease process understanding of prescribed care adherence to the self-care program absence of complications.


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


Treatment of Angina Pain Treatment of angina pain is a priority nursing concern. Patient is to stop all activity and sit or rest in bed. Assess the patient while performing other necessary

interventions. Assessment includes VS, and observation for respiratory distress, and assessment of pain. In the hospital setting, the ECG is assessed or obtained.

Administer oxygen. Administer medications as ordered or by protocol,

usually NTG. MONA


Pain Management

Nitroglycerin Morphine sulfate Oxygen Position of comfort; semi-Fowler’s position Quiet and calm environment


Medications

• Nitroglycerin• Beta-adrenergic blocking agents• Calcium channel blocking agents• Antiplatelet and anticoagulant medications

• Aspirin• Clopidogrel and ticlopidine• HeparinKNOW THE PHYSIOLOGIC ACTION OF THESE

MEDICATIONS, THE MOST COMMON SIDE EFFECTS, AND THE NURSING IMPLICATIONS


Ineffective Tissue Perfusion (Cardiopulmonary)

Interventions: Drug therapy (aspirin, thrombolytic agents) Restoration of perfusion to injured area limits

amount of extension, improves left ventricular function

Complete sustained reperfusion of coronary arteries in first few hours after MI has decreased mortality


Thrombolytic Therapy

Fibrinolytics dissolve thrombi in coronary arteries, restore myocardial blood flow Tissue plasminogen activator Reteplase Tenecteplase


Other Drug Therapies

Glycoprotein (GP) IIB/IIIa inhibitors Once-a-day beta blockers ACE inhibitors or angiotensin receptor

blockers Calcium channel blockers Ranolazine (Ranexa)


Reperfusion Therapy

Myocardial tissue can become increasingly ischemic and necrotic

Thrombolytic therapy using fibrinolytics dissolves thrombi in the coronary arteries and restores myocardial blood flow


Percutaneous Transluminal Coronary Angioplasty

Clopidogrel before procedure IV heparin after procedure IV or intracoronary nitroglycerin or diltiazem Possible IV GP IIb/IIIa inhibitors Long-term therapy, antiplatelet therapy, beta

blocker, ACE inhibitor, or ARB


Percutaneous Transluminal Coronary Angioplasty (cont’d)


Other Procedures

Arthrectomy Stents Rheolytic thrombectomy


Coronary Stent

http://www.youtube.com/watch?v=N7nghr9TpSU


Coronary Artery Bypass Graft Surgery


Community-Based Care

Home care management Teaching for self-management Health care resources


Patient Teaching

• Lifestyle changes and reduction of risk factors • Explore, recognize, and adapt behaviors to

avoid to reduce the incidence of episodes of ischemia

• Teaching regarding disease process• Medications• Stress reduction• When to seek emergency care


Paramedics arrive at the ED with a 78-year-old man who presents with severe chest pains. In triage, he reports that he experienced chest pains for several hours before calling 911. He reports that he takes “heart medications” but he does not know their names. He describes his chest pain as a 9 on a 0-to-10 scale. Patient history includes an MI 6 years ago that resulted in stent placement for severe CAD. One stent was placed in the LAD and another in his circumflex artery. He states that his health care provider told him he also has heart failure.

What laboratory tests do you anticipate the provider will order for this patient?


(cont’d)

Two hours later, the patient is admitted to the cardiac stepdown unit with orders for a saline lock, cardiac diet, and oxygen at 2 L per nasal cannula with follow-up cardiac enzymes, and 12-lead ECG in 6 hours. One hour later, the patient reports severe shortness of breath. His oxygen saturation has dropped to 88%, BP is 96/54, and his monitor shows sinus tachycardia with a rate of 114. He reports mild chest pain.

1.What do you suspect is happening to the patient at this time?

2.The patient’s laboratory values include troponin T 0.6 mg/mL. What is your best interpretation of this finding?


You immediately notify the provider and within 45 minutes, the patient is transferred to the CCU for close monitoring. He is in serious condition and has developed crackles bilaterally, and his chest pain level has increased.

What medications do you anticipate will be ordered for this patient? (Select all that apply.)

A.Furosemide (Lasix)

B.Atenolol (Tenormin)

C.Acetaminophen (Tylenol)

D.Morphine

E.Prednisone (Deltasone)

(cont’d)


The next morning, the patient is taken to the cardiac catheterization laboratory. The cardiologist finds that there is an 80% blockage in the proximal LAD coronary artery.

Which procedure is most likely to be performed to correct this condition?

A.Coronary artery bypass graft surgery

B.Coronary atherectomy

C.Percutaneous transluminal coronary angioplasty (PTCA)

D.PTCA with coronary artery stent placement

(cont’d)


The patient’s condition improves and he is returned to the cardiac stepdown unit. He is to be discharged after 6 days in the hospital.

What should you teach him before he is discharged from the hospital?

(cont’d)


PREGUNTAS???


If there are no questions . . . .

Let’s have . . . .

Cad 3

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