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Care of Clients with Problems In Oxygenation,

Fluids and Electrolytes, Metabolism and Endocrine

(NCM103)

Cardiovascular System: Coronary Vascular Disease

Coronary Atherosclerosis

Definition: Abnormal accumulation of fatty substances Creates BLOCKAGE Repetitious inflammatory response

o Obstruction + Inflammation = Blood FlowMI or APAtherosclerosis Arteriosclerosis

1. Definition Lumen Lumen2. Cause Deposition of fatty substances Elasticity of blood vessels3. Age Toddlers Aging process4. Layer Tunica intima Tunica media

Risk Factors:

Blood lipid level Smoking lumen; vasoconstriction Hypertension Narrowing down of blood vessels Diabetes / Hyperlipidemia Obesity Metabolic Syndrome

o Hyperglycemia FBS, Glucose Tolerance Testo Hypertensiono Level of lipids in bloodo Presence of elevation CRP

Clinical Manifestations:

- Depends on1. Location and degree of

narrowing

2. Thrombus formation andobstruction of blood

CHEST PAIN~ Asymptomatic~

Prevention:

Control of cholesterol level Get lipid profile once ever 5 years (20

y/o and above)

a. Dietb. Physical Activityc. Medications Anti-lipid Drugsd. Promoting cessation of tobacco

Nicotine!! Viscosity

of blood

Vasoconstriction of Blood

Vessels

e. Managing Hypertension Religious intake of

DRUGS

Regular exercise Diet Alcohol intake

Topics Discussed Here Are:1. Coronary Atherosclerosis2. Angina Pectoris3. Myocardial Infarction

LOOKY

HERE

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NUTRIENT CONTENT OF THE THERAPEUTIC LIFESTYLE CHANGES (TLC) DIET

Nutrient Recommended IntakeTotal calories Balance intake and expenditure to maintain desirable weight

Total fat

Saturated fat Polyunsaturated fat

Monounsaturated fat

25% - 35% of total calories

Less than 7% of total caloriesUp to 10% of total calories

Up to 20% of total calories

Carbohydrate 50% - 60% of total calories

Dietary fiber 20 30 g/day

Protein Approximately 15% of total calories

Cholesterol Less than 200 mg/day

Angina PectorisFactors: Blood Flow due to Lumen

Non-modifiable Factors

1. Age2. Sex3. Race4. Family History

Modifiable Factors

5. Diet ( Na, Fat, Nicotine)6. Alcohol7. Obesity8. Sedentary activity9. Stress

Coronary

Insufficiency

Coronary occlusion

(Continuation of coronary insufficiency)

LumenCHEST

PAIN On and Off Bearable

Short Duration

Angina Pectoris

CONSTANTSEVERE

LONGER

Myocardial

Infarction

Ischemia

What is Angina Pectoris? Associated With:

Outside factors Mental / Emotional problems Relieved With: Rest Coronary vasodilators

Levines SignTypes of Angina Pectoris

1. Stable Angina Predictable and consistent pain Relieved by rest and / nitroglycerin

2. Unstable Angina / Preinfarction Angina / Crescendo Angina Symptoms increase in frequency May not be relieved by rest and nitroglycerin

3.

Variant Angina (Prinzmetals Angina) Pain at rest Reversible ST-segment elevation

4. Silent Ischemia Objective evidence of ischemia But NO PAIN :o

Management:1. Medical Management

a. Rest Minimum of 2 hours

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b. Drugs1. Coronary Vasodilators

Dilates lumen of blood vessels in the myocardium Drugs:

o Nitroglycerin 1 Tab, SL q5 min PRN for chest pain Maximum of 3 Tablets; if not resolved considered

MI

Take the medications beforeany stressful event

Loses potency whenexposed in the sun; store in

dark colored bottles

If head gets big, warm, andflushing of face it is

NORMAL, not SIDE EFFECT or ADVERSE

EFFECT

2. Anti-platelet Drugs Aspirin (Produces GIT disturbance; Coated Aspirin New) Heparin

o Side Effect = Bleeding (Petechiae, Ecchymosis, Hematoma)o WOF: Tea colored urine for HEMATURIAo

WOF: BLACK STOOLS NO PARENTERAL ADMINISTRATION OF DRUGS; if needed,apply pressure after!!

Dont use dental floss3. Beta Blockers To reduce O2 demand of myocardium4. Ca+ Channel Blocking Agent Relaxes the Blood Vessel to BP

c. Take 30 60 cc of BRANDY/WHISKY To reduce chest pain by vasodilation Amount = Vasoconstriction Amount = Vasodilation

2. Prevention of Succeeding Attacks to Angina Pectorisa. Diet

Fat Diet (THE FOLLOWING FOODS ARE NOT ALLOWED OR MODERATE) 4 Legged animals Foods with wings (Moderate) White meat Chicken (NO SKIN) Intake of food in WATER; but grows in SOIL

Na Diet (2 gm Na) AVOID THE FF FOODS 1. Na Nitrate Food colorings, cold cuts, preserved food2. Na Nitrite Tocino, Tapa3. Na HCO3 Baking Soda, bread, biscuit, pastries

8:00 1st

Tablet

8:05 2nd

Tablet

8:10 3rd Tablet

8:00 1st

Tablet

8:05 2nd

Tablet

3:30 1st

Tablet

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4. NaCl Fish sauce, soy sauce, dried fish5. Na Saccharin

b. Must be with the patient all the time!! Coronary Vasodilators

DONT EXPOSE IN THE SUN!! DONT LEAVE IN THE CAR!!

Myocardial Infarction Brought about by lack of blood supply going to the myocardium A.k.a. Coronary occlusion or Heart Attack

Pain:

- CRUSHING- TIGHTNESS- Sudden onset- Substernal- Severe- Unrelieved by Nitroglycerin- May radiate to: Back, neck, jaw, shoulders, arm-

Dyspnea- Syncope ( BP)- Nausea / Vomiting- Extreme weakness- Diaphoresis- Denial is common- HR

Treatment:

- O2 IV Medications- Dietary restrictions- Na, Cholesterol, Caffeine- Surgery? Pacemaker?

Causes:

1. Atheroma Associated with body metabolism2. O2 / Blood demand Patients with hyperthyroidism3. O2 Supply (Anemia, BP)4. Vasospasm Sudden constriction / narrowing of coronary arteries

How to Diagnose Clients With MI1. Presenting Manifestations

Chief complaint Previous illnesses ECG: Done in 10 minutes PRIOR to admission

P

Q

R

S

T

ANG HIRAP MAG DROWING NG ECG PQRST SA PC XDComponents

1. P Wave Atrial Contraction / Depolarization (0.08 seconds)2. PR Interval Time for impulses to travel from Artery to Ventricle (0.16 seconds)3. QRS Complex Ventricular Contraction / Depolarization (0.08 seconds)4. ST Segment Length of time for the ventricle to relax (0.12 seconds)5. T Wave Ventricular relaxation / Repolarization (0.16 seconds)

0.08

seconds

2

seconds

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Diagnosing Myocardial Infarction Inverted T Wave

Injury becomes ischemic, myocardial Repolarization is altered and delayed Which causes the T Wave to invert

Elevated ST-segment Injured myocardial cells depolarize normally, but repolarize more rapidly than normal

cells

Causing the ST-segment to rise at least 1 mm above the isoelectric line Laboratory Results

Creatinine Kinase (CK-MB) Lactic Dehydrogenase Myoglobin Troponin T and I

Management1. Minimize Myocardial damage

a. Cardiac overload Place patient on absolute bed rest

NO VISITORS ALLOWED (NEAREST RELATIVE ONLY) Health team should be calm

b. Get baseline Vital Signs TPR

Temperature = Due to cell death Pulse = Respiration = Blood Pressure =

Baseline ECG Basic serum electrolytes

c. Administration of Drugs Thrombolytic Drugs (Alteplase)

1st Drug To dissolve the blood clot The faster it is given, it is better

Analgesics To relieve chest pain Morphine - Pain and Anxiety related to MI

ACE Inhibitors To prevent BP

2. Cardiac Rehabilitation Main objective: To extend the life of the patient and improve the quality of life of

patients

Consists of different activities3 Phases of Cardiac Rehabilitation

1. Phase I Time of diagnosis of atherosclerosis Found out by lipid profile Management:

Preventive measures1. Level of activities (Walking)2. Initial education of patient and family (For self care)3. Quit Smoking!4. DIET > NO FATTY FOODS

If patient is not compliant, there

would be repeated attacks of

angina pectoris and myocardialinfarction.

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2. Phase II Time the patient has been discharged from the hospital All activities are supervised; support from an outside person Based on the stress test of the client Dietitian would make a list of foods to be eaten and not eaten

3. Phase III Maintain cardiovascular stability Patient can still be on diet and exercise, but no longer supervised

Reperfusion Therapy- Procedures wherein to further improve the blood flow to the myocardium such as:

o Angioplasty: Repair of blood vessel PTA (Percutaneous Transluminal Angioplasty) PTCA (Percutaneous Transluminal Coronary Angioplasty) It is the inflation of a balloon pushing atheromas to the side, done not to attain

100%

o Coronary Stent Inserted through the femur Placement of a spring Can cause thrombus formation But eventually becomes part of the endothelial tissue

o Atherectomy Removal of atheromas Hollow cylinder Diamond chip-blade Rotation: Scrape atheromas Not full scraping of atheromas

o Coronary Artery Bypass Graft (CABG) They cannot perform not until there are still very minimal amount of blood to

the myocardium

Harvest a Graft Artery Vein

o Common blood vessel used Internal mammary artery Saphenous vein

Nursing Care Patient should be VERY compliant

Drugs be taken religiously Thrombolytics Beta blockers Digitalis

Compliance to diet FAT Na

Ambulation Gradually increasing

Sexual Intercourse Patient should be able to make 5 7 steps in the stairs without fatigability