Cardio Vascular Disorders
Assessment of Chest Pain: From Chart on page 692
Location CM Agg. Factors alleviating factors notes
Angina Pectoris/ Acute Coronary Syndrome Angina= Pressure or fullnesss in the substernal area which can radiate across the chest to the medial aspect of one or both arms (numbness or tingling).
ACS= same as above in addition to SOB, diaphoresis, palpitations, fatigue, nausea and/or vomiting. Angina= Physical exertion, emotional upset, or exposure to extreme temperatures.
ACS= Can occur at rest or while asleep, emotional upset, physical exertion occurring w 24 hr onset of symptoms. Angina= Rest, nitroglycerin, oxygen
ACS= Morphine, reperfusion of coronary artery with thrombolytic agent or percutaneous coronary intervention.
Pericarditis Sharp, severe substernal or epigastric pain that can radiate to the neck, arms or back. S/S=fever, malaise, palpitations, dyspnea, cough, nausea and dizziness. Sudden onset, pain increases with inspiration, swallowing etc. Sitting upright analgesia, anti inflammatory meds.
Angina: chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply, caused by an imbalance between oxygen supply and demand.
Goal: the goal of treatment of angina is to provide relief of the acute attack, correct the imbalance between myocardial oxygen supply and demand and prevent the progression of the disease and further attacks to reduce the risk of MI.
Types of angina: Stable (Typical) angina: exertional angina, occurs with activities that involve exertion or emotional stress and is relieved with nitroglycerin, rest and oxygen.
Unstable: preinfarction angina, occurs with unpredictable degree of exertion or emotion and increases in occurance, duration and severity over time, pain may not be relieved with nitro and rest (decreases myocardial consumption), the plaque ruptures but is not completely occluded. REQUIRES MEDICAL INTERVENTION Give antiplatelett therapy (plavix, heparin and aspirin), anti ischemic therapy (nitro, beta blockers, cc blockers) and oxygen.
Variant angina: vasospastic angina, results from coronary artery spasm, may occur @ rest, may be associated with ST segment elevation seen on ecg.
Intractable angina: chronic, incapacitating angina unresponsive to interventions.
Medications: antiplatelet and anticoagulant medications (block platelet aggregation)
Clopidogrel (plavix) and ticiopidine (ticlid): oral antiplatelet agent to inhibit blood clots in coronary artery disease.
Glycoprotein agents (repro, integrillin, aggrastat): antiplatelett agents given IV which prevent platelet aggregation and thrombus formation.
Facts to know:
• Coronary Arteriosclerosis (narrowing of the arteries) is the most common cause.
• Physical exerction or emotional stress increases myocardial oxygen demand and consumption.
• Atypical symptoms are more common in women- may just present with weakness, dyspnea and nausea
• Treatment seeks to decrease myocardial oxygen demand and consumption and to increase oxygen supply with medications, oxygen, reduce and control risk factors, reperfusion therapy may also be done.
o Treatment includes: stop all activity and sit or rest in bed, assess patient, admin oxygen and administer NTG (which decreases myocardial oxygen consumption)
Cholesterol:
Coronary Athersclerosis is composed of lipid deposits and fibrous tissue.
• Cant change: gender and family hx
• Can change: obesity, inactivity, stress, smoking and diet
• LDL- low density lipoprotein- lowsy/ bad, causes plaque and atherosclerosis
• HDL- High density lipoprotein- heaven/ good, protects against heart attacks
• Triglycerides
• Exercise = increases HDL and lowers triglycerides
• Patents who have had an acute event (MI), PCI or CABG require assessment of their LDL levels within a few months after the event or procedure because LDL may be low immediately after the acute event or procedure.
• Monitor levels every 6 weeks until desired level is reached and every 4-6 months there after.
• LDL should be less than 100mg/dl and less than 70 for high risk patients
• HDL should be greater that 60mg/dl
• Total should be less than 200mg/dl
• Triglyceride should be less than 150mg/dl
• Diet and exercise are very important to maintaining healthy cholesterol levels.
• Exercise: should be taught to exercise to an intensity that does not preclude their ability to talk; if they cannot have a conversation while exercising, they should slow down or switch to a less intensive activity. When weather is hot and humid patients should exercise during the early morning, indoors and wear loose fitting clothing.
CAD: Coronary Artery Disease is a narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis (which is an accumulation of lipid- containing plaque in the arteries), the disease causes decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply leading to hypertension, angina, dysrhmias, MI, heart failure and death. S/S occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs causing ischemia. > the goal of treatment is to alter the atherosclerotic progression.
S/S= chest pain, palpitations, dyspnea, syncope, cough or hemoptysis and excessive fatigue.
Diagnostics: ECG, Cardiac catheterization and blood lipid levels (may be elevated- cholesterol lowering medications may be prescribed).
Diet: low calorie, low sodium, low cholesterol, low fat diet and increase in dietary fiber. Diet must be maintained for life and are not temporary.
Sx: PTCA to compress the plaque against the walls of the artery and dilate the vessel, vascular stent to prevent the artery from closing and to prevent restenosis. PTCA Post op nursing interventions: sheath removal and the applicationof pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vaso vagal response). An IV bolus of atropine is usually given to treat this response. Patients resume self care and ambulate unassisted within a few hours of this procedure. The duration of immobilization depends on the size of the sheath inserted, the amount of anticoagulant administered, the method of hemostasis, the patients underlying condition and the physicians preference.
Meds: Nitrates- decrease myocardial oxygen requirements and increase oxygen supply dilate the coronary arteries and decrease preload and afterload, calcium channel blockers, cholesterol lowering meds, and B-Blockers in hypertensive patients.
Myocardial Infarction: an area of the myocardium is permanently destroyed, usually caused by reduced blood flow in a coronary artery due to rupture of an atheroscleric plaque and subsequent occlusion of the artery by a thrombus.
ECG: Lead 1 and aVL= lateral wall, Lead 2,3 and aVF= inferior wall
ECG changes:
Ischemia= T wave inversion or ST depression
Injury= ST elevation (heart attack)
Infarction (necrosis)= large Q wave (post heart attack)
No R wave = No anterior septal wall
Treatment= MONA
Morphine
Oxygen
Nitroglycerin
Aspirin
Acute Coronary Syndrome (angina or MI)
S/S= chest pain that often radiates to the shoulders, arms, neck and jaw, women diabetic and elderly do not typically present with symptoms, they may present with SOB, fatigue, diaphoresis and atypical discomfort.
Lab tests/ Bio markers
Troponins: can be elevated with any kind of cardiac injury: ischemia due to occlusion, spasm, supply-demand mismatch( bleeding, tachycardia)- initial and again 8 hours later before you can release a patient, they are released within 4-12 hours, can remain elevated for up to 1 week.
CK_MB and myoglobin can b elevated with any muscle injury.
CHEST PAIN: Nursing responsibilities:
1. ECG within 10 minutes of admission, cardiac monitoring, VS and BP both arms
2. Oxygen, IV administration
3. Pain Relief- NTG or morphine sulfate
4. Aspirin
5. Labs- Troponin levels, CBC and Elec.
6. Bed Rest
Physician responsibilities:
• Fibrinolytics (TPA): 30 minutes from door to needle, within 3 hours of the onset of pain.
• PCTA (percutaneous transluminal coronary angioplasty)
• PCI (percutaneous coronary intervention)
• Fibrinolytics and PCI procedures are performed to reperfuse the myocardium deprived of oxygen.
o Nursing care post procedure: Manual pressure for 20- 30 minutes until bleeding is controlled (assistive devices can be used), VS and distal pulse checks, observation of access site for bleeding or hematoma formation, observation of extremity below the access site for color, temp and movement, Q 15min for the first hour and every 30 minutes the second hour then hourly, bed rest with the affected leg straight for 2-4 hours.
Valvular disorders:
• The mitral valve is an atrioventricular valve located between the left atrium and left ventricle. The pulmonic valve is a semilunar valve located between the right ventricle and the pulmonary artery. The tricuspid valve is between the right atrium and the right ventricle.
• Regurgitation (insufficiency): the valve does not close properly and blood backflows through the valve. (CLOSED)
• Stenosis: the valve does not open completely and blood flow through the valve is reduced. (OPEN)
• Valve prolapse: the stretching of the atrioventricular valve leaflet into the atrium during diastole. (Think Boggy Valve).
• A patient with valvular heart disease should be placed on ABX prophylactically before dental work.
• Mitral Stenosis: distends the atrium and may lead to atrial arythmias and back up pressure into the pulmonary system= increase in RR, rales, difficulty in breathing. OPEN Diastolic murmur, low pitched, crescendo, rumbling noise heard at the apex, AFib is a common arrhythmia, and calcifications of leaflets, anticoagulation therapy and balloon valvoplasty is indicated.
• Aortic insuffiency: may initially demonstrate a widened pulse pressure due to the increase volume in the left ventricle that is ejected. Closed diastolic murmur, decrescendo, blowing noise heard @ 2 RICS and is due to left ventricular hypertrophy (confirmed by an echocardiogram), hypertension or rheumatic heart disease.
• Aortic stenosis: causes distension and hypertrophy of left ventricle thus increasing the myocardial oxygen demand, OPEN, systolic murmur medium pitched, crescendo-descendo, radiating to the neck and right carotid, decreases cardiac output commonly caused by angina pectoris, calcification of valves and rheumatic fever.
• Mitral insuffiency: Closed systolic murmur high pitched, plateau blowing quality heard at the apex which radiates to the axilla, causes include MI and rheumatic heart disease.
CABG (coronary artery bypass graft): a surgical procedure in which a blood vessel from another part of the body is grafted onto the occluded coronary artery below the occlusion in such a way that blood flow bypasses the blockage.
Vessel most commonly used= the greater and lesser saphenous veins are commonly used in bypass graft procedures.
Cardiopulmonary bypass: mechanically circulates and oxygenates blood for the body while bypassing the heart and lungs. The heart is stopped during the procedure and and post the procedure the pt is given protamine sulfate and disconnected from the bypass machine to allow the heart to return to its regular rhythm.
Valve Sx:
Patients with valve defect are on ABX every time they go to the dentist.
Patients with valve replacements are always on ABX prophylaxis.
Complication = heart failure
On anticoagulation therapy for the rest of their lives post op valve replacement.
Types of replacement valves:
• mechanical valves: do not deteriorate or become infected as easily, but are thrombogenic and require life long anticoagulation therapy (makes a very loud sound)
• Tissue valves: biologic
o Xenograft: pig or cow valve
o Homograft/ allograft: human valve
o Auto graft: patients own valve
Cardiomyopathy; Types:
• Dilated Cardiomyopathy = fatigue
• Hypertrophy Cardiomyopathy = Chest Pain
• Restrictive Cardiomyopathy = exertional dyspnea
Endocarditis: a microbial infection of the endothelial surface of the heart, usually develops in people with prosthetic heart valves or structural cardiac defects.
Pericarditis: inflammation of the pericardium, complications include pericardial effusion, cardiac tamponade= narrowing pulse pressure, distended neck veins and pulsus paradoxus
• Patients with myocarditis are sensitive to digitalis. Nurses must closely monitor these patients for digitalis toxicity, which is evidenced by dysrythmia, anorexia, nausea, vomiting, headache and malaise.
Heart Failure: inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
Problems with:
• contraction of the heart= systolic failure
• filling of the heart = diastolic failure
•
Right Sided Failure is commonly seen in COPD, pulmonary hypertension, edema and ascities.
Left Sided Failure is commonly seen in congestive heart failure and pulmonary edema due to the decrease in cardiac output and the kidneys holding Na and H20
Medications:
• ACE (angiotension converting enzyme) inhibitors play a pivotal role in the management of heart failure due to systolic dysfunction, they prevent vasoconstriction making cardiac output easier, can cause orthostatic hypotension or dizziness.
• Beta Blockers: have been found to reduce mortality and morbidity in patients with class 2 or 3 heart failure by reducing the adverse effects from the constant stimulation of the sympathetic nervous system.
• Diuretics are prescribed to reduce excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload.
• Digitalis increases the force of myocardial contraction and slows conduction through the atrioventricular node.
BNP:
• BNP is released by the ventricles in response to increased wall stress, causes vasodilation, decreases resistance and increases sodium excretion.
• Uses of plasma BNP test: severity of left ventricular failure and estimate prognosis.
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