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Angina pectoris :
Angina meaning
Translated as pain (angina) in the chest (pectoris).
Usually last a few minutes (3 to 5 minutes) and subsides with rest.
Precipitating factors
o Physical exertion o cigarette smoking
o strong emotions o sexual activity
o consumption of heavy meals o stimulants (cocaine)
o temperature extremes
Types of Angina
I. Stable angina
II. unstable angina (unpredictable)
III. Prinzmental’s angina (occurs a rest usually in response to spasm of a major
coronary artery.
Clinical Manifestations
Risk Factors:
Modifiable Unmodifiable
Cigarette smoking Genetic disposition
Drugs and alcohol Diabetes
Hypertension Age
Elevated Serum lipids Gender (men>women until
Stressful lifestyle 60 yr of age)
Obesity Race (african-
Physical inactivity amercians<Caucasians)
Complications
o Arrhythmia’s
o Premature contractions
o Fibrillation
Diagnostic studies
History and physical lipid levels
CXR Stress test
EKG Nuclear studies
CK-MB PET Scan
Cardiac troponin Echo
Collaborative Care
1. PTCA (Percutaneous transluminal coronary angioplasty)
2. Stent placement
3. Angioplasty
4. CABG(Coronary Artery Bypass Grafting)
Drug Therapy
Antiplatelet
ASA - Acetylsalicylic acid (drug of choice)
Nitrates
Nitroglycerin (can be give sublingually, IV, ointment, transdermal)
Sublingually give 1 tablet under the tongue every 5 minutes X 3.
Beta blockers (Lopressor, Inderal, Tenormin)
calcium channel blockers (Verapmil, Procardia, Cardizem.
Nursing Diagnosis
Pain related to ischemic myocardium
Anxiety related to awareness of having a heart disease, uncertainty about
the future
decreased Cardiac output related to myocardial ischemia affecting
contractility
Activity intolerance related to myocardial ischemia
Nursing Implementation
If the nurse is present during an anginal attack
administer o2
get vital signs
12 lead EKG
nitrates
physical assessment of the chest
make patient comfortable
Ambulatory and Home Care
Myocardial Infarction
Clinical Manifestations
o Pain
o Nausea and vomiting
o Diaphoresis
o Fever
o Elevated BP, heart rate then later it drops because of decreased in cardiac
output
Complications
Arrhythmias Ventricular aneurysm
CHF Pericarditis
Cardiogenic shock Dressler’s syndrome
Papillary muscle Right Ventricular Failure
dysfunction Pulmonary Emboli
Diagnostic Studies
12 lead EKG
Cardiac enzymes
Troponin levels
Collaborative Care
Take to CCU Antiarrythmic drugs
IV route Bed rest
Morphine Recording I/O’s
O2 PTCA (Percutaneous
Monitor V/S transluminal coronary angioplasty)
Lidocaine drip CABG(Coronary Artery Bypass
Thrombolytic therapy Grafting)
Anticoagulant therapy (ASA)
Drug therapy
Nursing Implementation
o Pain
o monitoring
o rest and comfort
o anxiety
o Emotional and behavioral reactions
Ambulatory and Home Care
ASA (Acetylsalicylic acid) Diet
80-325 mg per day Dietary restrictions
Patient education (cause Management of risk factors
and effect, terms, s/s, risk Exercise
factors) Sexual activity
Rest
Sudden Cardiac death
-Unexpected death from cardiac causes.
-In SCD there is a disruption in cardiac function, producing an abrupt loss of
cerebral blood flow.
-Death occurs within 1 hour of the onset of acute symptoms.
Occurs to approximately 350,000 deaths a year in the U.S.
Only 20% of SCD are discharge form the hospital without neurological
problems.
Risk Factors
-Male gender -HTN
-Family history of -Cardiomeagely
premature atherosclerosis -Ejection fraction of less
-Cigarette smoking than 40%
_DM -History of ventricular
-Hypercholesterolemia arrhythmia
Collaborative Management
o -Several cardiac enzymes o -24 hour holter monitor if
o -EKG they are known to have
o -Cardiac cath arrhythmia’s
o -PTCA o -Electrophysiology study
o -CABG (EPS)
Nursing Care
*Mostly talking to patients and educating the patient and families to relieve
some anxieties and fears.
-Must patients have a feeling that they are a “time bomb” waiting to
happen.
-Wives usually blames themselves for this occurrence.
-Patients and families have a lot of fear and anxiety.
-Depression
Definition
o CHF is a cardiovascular condition in which the heart is unable to pump an
adequate amount of blood to met the metabolic needs of the body’s tissue.
o It is not a disease……..IT IS A SYNDROME
o CHF is characterized by LVH, reduced exercise intolerance, diminished
quality of life, and shortened life expectancy.
CHF
֎ Is associated with HTN and CAD.
֎ More than half of the deaths from heart disease is associated to end-stage
CHF.
֎ 23 million people in the world wide have CHF.
֎ AHA says that about 400,000 get CHF/year.
֎ Mortality rate is 50%
֎ About 20% of people who had MI will be disabled with heart failure within 6
years.
CHF
‡ CHF is the single most frequent cause of hospitalization for people age 65
and older.
‡ CHF has a poor prognosis and is likely to remain a major clinical and health
care problem.
Risk factors
¤ CAD
¤ HTN
¤ diabetes
¤ cigarette smoking
¤ obesity
¤ High cholesterol
¤ proteinuria
Etiology
† CHF may be caused by any interference with the normal mechanisms
regulating cardiac output.
† CO depends on: Preload, afterload, myocardial contractility, heart rate and
metabolic state of the individual.
† Any alteration of these results in CHF.
Compensatory Mechanisms
· Dilation
· Hypertrophy
· Sympathetic nervous system
· Hormonal response
Common causes
· CAD · Acute MI
· HTN · Arrhythmias
· Rheumatic heart disease · Pulmonary emboli
· Congenital heart disease · Hypertensive crisis
· Cor Pulmonale · Ventricular septal defect
· Anemia
Type of CHF
· Left sided CHF
· Right sided CHF
Left sided
· Results from LV dysfunction, which causes blood to back up through the left
atrium and into the pulmonary veins.
· This increase causes to go from the pulmonary capillaries bed to the
interstitium and then the alveoli, causing pulmonary congestion and edema.
· Pulmonary congestion
· pulmonary edema
· Fatigue
· Dyspnea
· dry, hacking cough
· Nocturia
· Crackles
Right-sided heart failure
· Failure from the right ventricular that causes backflow to the right atrium
and venous circulation.
· The primary cause of right-sided failure is left sided failure
Diagnostic studies
¤ History and physical
¤ ABG’s
¤ Liver profile
¤ CXR
¤ 12 lead EKG
¤ Echo
¤ Nuclear studies
¤ Cardiac cath
Nutritional therapy
o Diet education
o Weight management
o Low sodium (2 g NA diet)
¤ More severe is 500-1000mg.
o Fluid restrictions
o Weight Daily (THIS IS IMPORTANT)
¤ same day everyday, preferably before breakfast.
Nursing Diagnosis
· Activity intolerance
· sleep pattern disturbance
· fluid volume excess
· Risk for skin integrity
· Impaired gas exchange
· Anxiety
Patient teaching
· Rest · Activity program
· Drug therapy · Ongoing monitoring
· Dietary therapy
VENTRICULAR TACHYCARDIA
Rhythm is usually regular
Ventricular rate is greater than 100 beats/min
QRS is wide and is greater than 0.12 seconds
There is no P wave
Can be stable or unstable
Can have a pulse or no pulse
If have more than 3 is a run of v-tach
VENTRICULAR FIBRILLATION
o Rhythm is chaotic and no regularity noted
o No identifiable QRS complexes
o No P waves
o Total chaotic electrical activity creates the baseline
o Can be coarse or fine
o No pulse
ASYSTOLE
o No PQRST
o Baseline straight or slightly wavy
o Must be confirmed in 2 leads
o No pulse
Pulmonary Embolism
· Other sites are the right side of the heart (AFIB), upper ext. (rare) and
pelvic veins (especially after childbirth).
Emboli
· Mobil clot that generally do not stop moving until they lodge at a narrowed
part of the circulatory system.
· The lungs are an ideal location for emboli to lodge because of their
extensive arterial and capillary network.The presence of a deep vein
thrombosis is usually unsuspected until a pulmonary embolism occurs.
· Thrombi in the deep vein can dislodge spontaneously.
Assessment of DVT: a warm, reddish blue extremity.
· More common mechanism that throws a clot is sudden standing and changes
of the rate of blood flow, such as valsalva’s maneuver.
Clinical Manifestations
This depends on the size of the emboli and the number of blood vessels occluded.
· Sudden onset of unexplained dyspnea
· Tachypnea
· Tachycardia
· Cough
· Chest pain
· hemoptysis
· crackles
· fever
· changes in mental status
Massive Emboli
The patient will suddenly collapse and experience.
· shock, pallor, have sever dyspnea, and crushing chest pain.
· Pulse is rapid and weak
· BP is low
When rapid obstruction of 50% or more occurs, acute Cor Pulmonale may result because
of right ventricle can no longer pump blood into the lungs.
Death occurs in over 60% of patients.
Medium-sized emboli
Can cause pleuritic chest pain accompanied by:
· Dyspnea
· slight fever
· productive cough with blood streaked sputum
· Tachycardia
· Friction rub
Small emboli
· Undetected or produce vague, transient symptoms.
Complications
1. Pulmonary Infarction
· Death of lung tissue occurs in less than 10% of patients with emboli.
Pulmonary Hypertension
· Occurs when more than 50% of the area of the pulmonary bed is
compromised.
· Also results form hypoxemia.
· Only if the emboli is massive will this occur.
· But small to medium emboli that are recurrent can cause pulmonary
hypertension.
Diagnostic test
· History and physical
· Venous studies (venous Doppler’s, lung scans, pulmonary arteriogram).
· CXR
· ABG’s
· CBC
Collaborative care
· Oxygen mask or cannula.
· IV site
· IV heparin
· Bed rest
· Narcotics for pain
· Thrombolytic agents
· Vena cava filter
· Pulmonary embolectomy
Drug therapy
· Diuretics (if heart failure occurs).
· Heparin
· Coumadin
HEPARIN
¤ It is an anticoagulant.
¤ Should be started immediately.
¤ The dosage of heparin is adjusted according to its effect on the PTT.
¤ Normal PTT is 35-45
¤ Bolus is always given first
¤ PTT should be one and half to two and half times normal to be therapeutic.
Coumadin
Anticoagulant
PT is monitored
Doc adjusted according to PT levels. The most significant is the INR.
PT is always drawn with the INR.
Nursing management
Health promotion
Bed rest
Semi-fowler’s position.
Education
Educate patient with s/s and explain what is going on because they feel:
‡ Pain
‡ sense of doom
‡ inability to breathe
‡ explain situation and provide emotional support.
Diagnosis
Adequate tissue perfusion.
Adequate cardiac output
Increased level of comfort