Disorders of Myocardial Perfusion

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Disorders of Myocardial Perfusion

• Coronary Artery Disease
• Risk factors
• Gender
• Age
• Race/ethnicity
• Heredity

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• Risk Factors cont
• HTN
• DM
• Hyperlipidemia
• Women
• Premature menopause
• Smoking
• Obesity
• Physical inactivity
• Personality type
• Women
• Use of oral contraceptives

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• Pathophysiology
• Unclear understanding of why plaque forms
• Thought to begin with an injury to endothelial
  cells that line the inside of the artery

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Lab and Diagnostic Tests

• Total serum cholesterol
• Elevated in clients with hyperlipidemia
• Lipid Profile
• Identifies triglyceride, HDL, LDL levels

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Treatment

• Control risk factors
• What are some risk factors clients can control?
• 1.
• 2.
• 3.
• 4.
• 5.

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• Pharmacology
• Low dose ASA
• Oral estrogen for women
• Drugs to treat hyperlipidemia
• Patient teaching
• 1.
• 2.
• 3.
• 4.

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The client with Angina Pectoris

• Angina pectoris
• Chest pain resulting from reduction in coronary
  blood flow
• Ischemia
• Deficiency of blood flow to a body part
• Necrosis
• Reduction of blood flow that lasts longer than 30
  minutes tissue death

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• Causes
• Atherosclerosis
• Blood clot
• Lack of O2 supply

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• Three types of Angina
• Progression of disease from stable to unstable
• Stable angina
• Most common and predictable
• Unstable angina
• Occurs with increasing frequency, severity and
  duration
• Pain is unpredictable
• Prinzmetals variant angina
• Causes by coronary artery spasm

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• Clinical Manifestations
• Chest pain
• Location
• Quality
• Associated symptoms
• Precipitating factors
• Relieving factors

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Labs and Diagnostics

• Labs
• Cholesterol levels
• Diagnostic studies
• EKG
• Stress test
• Look for changes in ST segment during exercise
• Thallium scan
• Evaluates myocardial perfusion and left ventricle
  function

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• Echocardiogram
• Ultra sound used to evaluate heart structure
• Coronary artery angiogram
• Catheter introduced thru the femoral artery and
  threaded to the coronary artery
• Post procedure care
• Cardiac catheterization
• Similar to angiogram

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• Pharmacology
• Nitrates
• Beta blockers
• Calcium channel blockers
• ASA

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Revascularization procedures

• PTCA
• Percutaneous transluminal coronary angioplasty
• Temporary fix
• Coronary artery by-pass (CABG)
• Bypass the obstruction

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• Group activity
• Come up with a care plan for a patient who has
  just had a CABG
• 2 nursing diagnosis with goals and interventions

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Acute Myocardial Infarction

• Necrosis of the cells in the cardiac muscle
• Life threatening
• 60 die in the first hour
• 40 die before reaching the hospital

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Pathophysiology

• Occurs when the vessel becomes occluded
• Rupture of plaque
• Clot forms

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Manifestations

• Chest pain
• Not associated with activity
• Longer duration than angina
• Not relieved with rest or nitro

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Other signs

• Sudden death
• CPR doesnt work
• Changes in BP and heart rhythm
• Diaphoresis
• SOB
• Anxiety
• Nausea
• Decreased LOC

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Complications

• Dysrhythmias
• What type of dysrhythmia?
• Pump failure
• Extending infarction
• Scar tissue
• Pericarditis

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Laboratory and Diagnostic Tests

• Labs
• Tropinine level
• CPK
• Diagnostic Tests
• EKG
• Echo, Thallium scan

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Pharmacology

• Thrombolytic therapy
• Streptokinase
• Biological agent
• Given IV
• Given within first 6 hours
• Side effects
• Hypotension
• Anaphylaxis

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• Anagelsia
• Why would we be treating pain?
• What would we give?

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• Antidysrhythmics
• Ventricular dysrhythmias
• Lidocaine drip
• Bradycardia
• Atropine 0.5 1mg
• Tachydysrhythmias (atrial flutter)
• Verapamil 2.5 5mg IVP

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• Other meds
• Beta blockers
• Aspirin
• Heparin drip

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Revascularization Procedures

• PTCA
• Done after thrombolytic therapy
• Done after cardiac cath
• Intra-aortic balloon pump
• Temporarily support the heart
• Inflates during diastole
• Deflates during systole
• Starts as a 11 ratio then gradually decreases

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Cardiac Rehab

• Planned program to help client return to optimal
  level of function
• Can last up to 1 year
• Begins within 3 weeks of the cardiac event

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Nursing Care Diagnosis

• Pain
• What are some nursing interventions?
• Altered tissue perfusion
• Ineffective individual coping
• Fear

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Teaching for home care

• Assess readiness to learn
• Educate on normal physiology of heart and what
  part of theirs is damaged
• The implications of MI
• Purpose of medications
• Importance of cardiac rehab
• Community resources

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Congestive Heart Failure

• Inability of the heart to pump adequate blood to
  meet the metabolic demands of the body
• Long term outcome of an MI
• HTN and CAD are leading causes of CHF

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• Left sided heart failure
• More common because left ventricle does all the
  work
• Results from ventricle muscle damage
• Coronary heart disease
• Hypertension

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Clinical manifestations

• Pulmonary congestion
• SOB
• Cough
• Dyspnea
• Orthopnea
• Fatigue
• Activity intolerance

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• Right sided heart failure
• Most common cause is left sided failure
• Acute or chronic pulmonary disease
• Pulmonary HTN
• Right ventricle and atrium become distended

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Manifestations

• Dependent edema
• Abdominal organs become congested
• Liver engorged
• RUQ pain
• Ascites
• Anorexia and nausea
• Jugular venous distention

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• Biventricle failure
• Both ventricles fail to function properly
• Manifestations
• Paroxysmal nocturnal dyspnea
• Wakes in middle of night with severe shortness of
  breath
• SOB at rest
• Hepatomegaly
• Spleenomegaly
• Ascites
• Fatigue
• Dizziness, synope

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Labs and Diagnostics

• Electrolytes
• Liver function tests
• ABG
• CXR
• Echo
• EKG

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• Hemodynamic monitoring
• Assess cardiovascular function in ICU
• Measures HR, B/P, venous pressure, CO
• Arterial line placed by MD

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Pharmacology

• Used to reduce cardiac work load
• Angiotensin coverting enzyme (ACE) inhibitors
• Reduce afterload and improve cardiac output and
  renal blood flow
• Reduce pulmonary congestion
• Vasotec, Prinival, Nipride
• May cause hyperkalemia

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• Positive Inotropic Agents
• Digitalis
• Improves cardiac contractility
• Increases SV and CO
• Slows conduction through AV nodee

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Nursing responsibilities

• Check apical pulse
• Check electrolytes
• Check therapuetic levels
• Signs of digitalis toxicity
• Anorexia, nausea, abd. Pain, see yellow or white
  halos

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• Diuretics
• Lasix, hydrochlorithiazide, aldactone
• Check daily wt., baseline vs. recent K levels

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Diet and Activity

• Low sodium diet
• Fluid restriction
• Bedrest during acute phase
• HOB elevated, arms and legs elevated

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Surgery

• Cardiomyoplasty
• Wrapping muscle from arm around ventricle
• Cardiac transplant
• Have to wait for an appropriate donor
• Cost

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Nursing care Diagnosis

• 1
• 2
• 3
• 4
• 5

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Pulmonary Edema

• Abnormal accumulation of fluid in the
  interstitial fluid and alveoli of the lung

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Causes

• MI
• Acute fluid volume overload
• Valvular disease
• ARDS
• Trauma
• sepsis

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Manifestations

• Respiratory system
• Tachypnea
• Labored breathing
• Cough
• Pink, frothy sputum
• Rales
• Wheezes
• Orthopnea
• Congestion

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• Cardiovascular system
• Tachycardia
• Hypotension
• Cynosis
• Cool, clammy skin
• Hypoxia
• Ventricular gallop

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• Neurological
• Restless
• Anxiety
• Feeling of Impending Doom

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Treatment Nursing Care

• What do you think some treatment options are?

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• Reduce excess fluid
• O2 by mask
• MS by IV
• Diuretics

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Nursing Care

• Reduce fluid volume
• Improve gas exchange
• Emotional support
• Patent airway
• Crash cart available
• Assess resp. status