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Vascular Disease
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Coronary Atherosclerosis
Definition: Abnormal accumulation of fatty substances Creates BLOCKAGE Repetitious inflammatory response o Obstruction + Inflammation = Blood Flow MI or AP
1. 2. 3. 4. Definition Cause Age Layer Atherosclerosis Lumen Deposition of fatty substances Toddlers Tunica intima
Topics Discussed Here Are: 1. Coronary Atherosclerosis 2. Angina Pectoris 3. Myocardial Infarction
Risk Factors: Blood lipid level Smoking lumen; vasoconstriction Hypertension Narrowing down of blood vessels Diabetes / Hyperlipidemia Obesity Metabolic Syndrome o Hyperglycemia FBS, Glucose Tolerance Test o Hypertension o Level of lipids in blood o Presence of elevation CRP
Pathop hysiology of Coron ary Athero sclerosis Deposition of fatty substances
1.
Location and degree of narrowing 2. Thrombus formation and obstruction of blood CHEST PAIN~ Asymptomatic~ Prevention: Control of cholesterol level Get lipid profile once ever 5 years (20 y/o and above) a. Diet b. Physical Activity c. Medications Anti-lipid Drugs d. Promoting cessation of tobacco Nicotine!! Viscosity of blood Vasoconstric tion of Blood Vessels e. Managing Hypertension Religious intake of DRUGS
Inflammatory process
Infiltration of macrophages
Atheromas
Obstruction
Thrombus formation
Nutrient
Total calories Total fat Saturated fat Polyunsaturated fat Monounsaturated fat Carbohydrate Dietary fiber Protein Cholesterol
Alcohol intake
Angina Pectoris
Factors: Blood Flow due to Lumen Non-modifiable Factors 1. Age 2. Sex 3. Race 4. Family History Modifiable Factors 5. Diet ( Na, Fat, Nicotine) 6. Alcohol 7. Obesity 8. Sedentary activity 9. Stress
Lumen
CHEST PAIN
Ischemia L
1.
2.
3.
4.
But NO PAIN :o
Management:
1. Medical Management a. Rest Minimum of 2 hours
Hypoxia (Chest Pain )
Demand
Ischemia
b.
c.
Infarct L Drugs 1. 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 8:00 1st Tablet Take the medications 8:05 2nd Tablet before any stressful event 8:10 3rd Tablet Loses potency when exposed in the sun; store 8:00 1st Tablet in dark colored bottles 8:05 2nd Tablet 3:30 1st Tablet If head gets big, warm, and flushing 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 HEMATURIA o WOF: BLACK STOOLS NO PARENTERAL ADMINISTRATION OF DRUGS; if needed, apply pressure after!! Dont use dental floss 3. Beta Blockers To reduce O2 demand of myocardium 4. Ca+ Channel Blocking Agent Relaxes the Blood Vessel to BP Take 30 60 cc of BRANDY/WHISKY To reduce chest pain by vasodilation Amount = Vasoconstriction Amount = Vasodilation
2.
Prevention of Succeeding Attacks to Angina Pectoris a. Diet Fat Diet (THE FOLLOWING FOODS ARE NOT ALLOWED OR MODERATE) 4 Legged animals
b.
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 food 2. Na Nitrite Tocino, Tapa 3. Na HCO3 Baking Soda, bread, biscuit, pastries 4. NaCl Fish sauce, soy sauce, dried fish 5. Na Saccharin Must be with the patient all the time!! Coronary Vasodilators DONT EXPOSE IN THE SUN!! DONT LEAVE IN THE CAR!!
Myocardial Infarction
Pain: -
Brought about by lack of blood supply going to the myocardium A.k.a. Coronary occlusion or Heart Attack 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 metabolism 2. O2 / Blood demand Patients with hyperthyroidism 3. O2 Supply (Anemia, BP)
4. Vasospasm Sudden constriction / narrowing of coronary arteries
2 seconds
R P T
Components 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. 5. QRS Complex Ventricular Contraction / Depolarization (0.08 seconds) T Wave Ventricular relaxation / Repolarization (0.16 seconds)
Management
1. Minimize Myocardial damage a. Cardiac overload L Place patient on absolute bed rest NO VISITORS ALLOWED (NEAREST RELATIVE ONLY) Health team should be calm b. Get baseline Vital Signs L TPR Temperature = Due to cell death Pulse = Respiration = Blood Pressure = L Baseline ECG L 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
2.
ACE Inhibitors To prevent BP Cardiac Rehabilitation Main objective: To extend the life of the patient and improve the quality of life of patients Consists of different activities 3 Phases of Cardiac Rehabilitation If patient is not compliant, there 1. Phase I would be repeated attacks of Time of diagnosis of atherosclerosis pectoris and myocardial angina infarction L. Found out by lipid profile Management: Preventive measures 1. Level of activities (Walking) 2. Initial education of patient and family (For self care) 3. Quit Smoking! 4. DIET > NO FATTY FOODS
2.
3.
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 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 vain
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