Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Cardiovascular System: Coronary

Vascular Disease

LOOKY HERE

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

Arteriosclerosis Lumen Elasticity of blood vessels Aging process 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 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

Clinical Manifestations: F low Blood - Depends on

 Nutrient
Total calories Total fat Saturated fat Polyunsaturated fat Monounsaturated fat Carbohydrate Dietary fiber Protein Cholesterol

Regular exercise Diet Recommended Intake

Alcohol intake

NUTRIENT CONTENT OF THE THERAPEUTIC LIFESTYLE CHANGES (TLC) DIET

Balance intake and expenditure to maintain desirable weight 25% - 35% of total calories Less than 7% of total calories Up to 10% of total calories Up to 20% of total calories 50% - 60% of total calories 20 30 g/day Approximately 15% of total calories Less than 200 mg/day

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

Angina Pectoris Coronary Insufficiency

Myocardial Infarction CONSTANT SEVERE LONGER

Lumen

CHEST PAIN

On and Off Bearable Short Duration

Coronary occlusion (Continuation of coronary insufficiency )

What is Angina Pectoris?

Associated With: Outside factors Mental / Emotional problems Relieved With: Rest Coronary vasodilators Levines Sign Stable Angina Predictable and consistent pain Relieved by rest and / nitroglycerin Unstable Angina / Preinfarction Angina / Crescendo Angina Symptoms increase in frequency May not be relieved by rest and nitroglycerin Variant Angina (Prinzmetals Angina) Pain at rest Reversible ST-segment elevation Silent Ischemia Objective evidence of ischemia

Ischemia L

1.

Types of Angina Pectoris

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

How to Diagnose Clients With MI

1. Presenting Manifestations Chief complaint Previous illnesses ECG: Done in 10 minutes PRIOR to admission
0.08 seconds

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)

ANG HIRAP MAG DROWING NG ECG PQRST SA PC XD

4. ST Segment Length of time for the ventricle to relax (0.12 seconds)

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

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