Transcript 3._coronary_heart_disease_and_dysrhythmias.ppt

Caring for Patients With Coronary
Heart Disease and Dysrhythmias
Learning Outcomes
1. Describe the causes, pathophysiology, effects, and
manifestations of coronary heart disease and heart
rhythm disruptions.
2. Differentiate among the effects of coronary heart
disease: angina pectoris, acute coronary syndrome,
and myocardial infarction.
Learning Outcomes
3. Discuss nursing implications, and safely administer
drugs commonly prescribed for patients with
coronary heart disease or dysrhythmias.
4. Provide culturally sensitive individualized nursing
care for patients undergoing invasive procedures or
surgery of the heart.
Learning Outcomes
5. Use the nursing process to conduct a focused
assessment, contribute to care planning, and provide
nursing care based on patient values, preferences,
and expressed needs for patients with coronary
heart disease and dysrhythmias.
Learning Outcomes
6. Provide and reinforce appropriate and evidencebased teaching for patients with coronary heart
disease or dysrhythmias and their families.
7. Use electronic resources to plan and document
nursing care and teaching for patients with coronary
heart disease or dysrhythmias.
Coronary Heart Disease
• Leading cause of death in U.S.
• Narrowing coronary arteries
• Atherosclerosis
• May have:
• No symptoms
• Angina pectoris
• An event such as ACS or myocardial infarction
Risk Factors
• Age
• Gender
• Ethnicity
• Heredity
Risk Factors
• Physiologic risk factors
•
•
•
•
Hypertension
Diabetes
High blood lipids (hyperlipidemia)
Metabolic syndrome
Risk Factors
• Lifestyle risk factors
•
•
•
•
Smoking
Obesity
Diet
Physical inactivity
Classification of Cholesterol and LDL Levels
Pathophysiology
• Atherosclerosis
• Atheromas develop in lining of medium, large arteries.
• Cause unknown
• Plaque occludes vessel lumen.
• Leads to ischemia
• Cells do not have enough blood and oxygen to meet their
metabolic needs.
Manifestations
• Symptom free until about 75% of lumen of affected
vessels occluded
• Symptoms indicating myocardial ischemia
• Angina pectoris
• Acute myocardial infarction
Collaborative Care
• Diagnostic tests
•
•
•
•
•
Total serum cholesterol
Lipid panel
Plasma levels of C-reactive protein
Blood glucose levels
Ankle-brachial index
Collaborative Care
• Risk factor management
•
•
•
•
Smoking
Diet
Exercise
Blood pressure and diabetes
Collaborative Care
• Medications
• Statins
• Teach common side effects
• Headache, gastrointestinal upset
• Rhabdomyolysis
• Muscle aches, skin rashes
• Liver function tests and muscle enzymes are monitored.
Collaborative Care
• Medications
• Nicotinic acid
• Flushing, pruritis
• Cholesterol binding
• Gastrointestinal side effects
Nursing Care
• Teach smoking cessation
• Healthy weight
• Exercise
• Control high blood pressure, diabetes, lipid levels
• Reduce stress
Angina Pectoris
• Chest pain that occurs when there is a temporary
imbalance between myocardial blood supply and
demand
• Pattern
• Exercise brings on pain.
• Rest relieves pain.
Pathophysiology
• Obstructed coronary artery
• Increased myocardial oxygen demand
• Lactic acid release leads to pain.
• Three types
• Stable
• Unstable
• Prinzmetal
Manifestations
• Chest pain
• Radiates
• Onset
• With exercise
• In women, associated with stress, strong emotions
• Relieved by rest, nitroglycerin (NTG)
• SOB, pallor, fear
Collaborative Care
• Diagnostic tests
• Electrocardiography
• May be normal if patient resting
• Imaging studies
•
•
•
•
•
PET or EBCT
Echocardiogram
TEE
Radionuclear scanning
Coronary angiography
Collaborative Care
• Medications
• Acute management
• Sublingual nitroglycerin (NTG)
• Rapid-acting spray
• Chronic management
•
•
•
•
NTG
Beta blockers
Calcium channel blockers
Low-dose aspirin
Nursing Care
• Prioritizing nursing care
• Maintain adequate coronary blood flow, perfusion of heart
muscle.
• Health promotion
• Managing risk factors
• Assessing
• Pain
• History of heart disease
• Risk factors
Nursing Care
• Identifying potential complications
• Acute myocardial infarction
• Other acute cardiac events
• Promptly report chest pain unrelieved by BTG or accompanied
by SOB, anxiety, clammy skin.
Nursing Care
• Diagnosing, planning, and implementing
• Risk for acute pain
• Readiness for enhanced self-health management
• Angina teaching
• Medications
• Cardiac rehabilitation program
Nursing Care
• Evaluating
• Management of episodes
• Documenting
• Frequency, duration, and precipitating factors
• Continuity of care
• Safe medication storage and use
• When to go to ED
Acute Coronary Syndrome/Unstable
Angina
• Condition that includes:
• Unstable angina (UA)
• Acute myocardial ischemia with or without muscle damage
• Associated with coronary artery stenosis and
atherosclerotic plaque
Pathophysiology
• Coronary artery stenosis
• Atherosclerotic plaque
• Rupture, erosion of plaque
• Blood clot at the site
• Coronary muscle spasm
Collaborative Care
• Diagnostic tests
• ECG
• Serum markers
• Medications
• Nitrates and beta blockers to reduce myocardial ischemia
• Fibrinolytic drugs to prevent clotting
Collaborative Care
• Surgery and revascularization procedures
• Percutaneous coronary intervention (PCI)
• Balloon angioplasty
• Atherectomy
• Coronary artery bypass graft (CABG)
Collaborative Care
• Surgery and revascularization procedures
• Cardiopulmonary bypass pump
• Minimally invasive coronary artery surgery
• Transmyocardial laser revascularization
Nursing Care
• Prioritizing nursing care
• Restore blood flow, oxygenation of heart
• Prevent complications, future episodes
• Health promotion
• Prevent, slow progression of CHD
• Assessing
• Symptoms, previous episodes
• Medications
Nursing Care
• Identifying potential complications
• Dysrhythmias, sudden cardiac death
• Diagnosing, planning, and implementing
• Risk for acute pain
• Risk for bleeding
• Managing nursing care
• Vital signs once stable
Nursing Care
• Evaluating
• Free from complications
• Documenting
• Apparent understanding of information, need for follow-up
treatment
• Continuity of care
• Teaching to slow progression
• Preoperative teaching when surgery anticipated
Acute Myocardial Infarction
• Cells in area of cardiac muscle infarct or necrose (die)
due to lack of blood, oxygen
• Life-threatening event leading to cardiogenic shock and
death
• Most deaths within first hour of manifestations
Pathophysiology
• Occluded coronary artery stops blood flow to part of
cardiac muscle.
• Cellular death
• Tissue necrosis
• Description of heart area affected
• Classification
Manifestations
• Chest pain
• Radiates to shoulder, neck, jaw, arms
• Lasting longer than 15–20 minutes
• Not relieved with NTG
• Sense of impending doom
• SOB
• Diaphoresis
• Nausea and vomiting
Manifestations
• In women and elderly
• May be atypical
• Upper abdominal pain
• No chest pain but other symptoms
• Cocaine-induced myocardial infarction
• Increased workload of heart
• Risk of dysrhythmias
Complications
• Related to size and location of infarct
• Dysrhythmias
• Sinus tachycardia
• Pump failure
• Cardiogenic shock
• Other complications
• Pericarditis
• Extension or expansion
Collaborative Care
• Diagnostic tests
•
•
•
•
•
Serum cardiac markers
Electrocardiography
Echocardiography
Myocardial nuclear scans
Myocardial perfusion imaging scans
Collaborative Care
• Medical management
•
•
•
•
•
Monitoring
IVF
Oxygen
Bed rest with bedside commode
Quiet calm environment
Collaborative Care
• Medications
• Pain relief
• Antianxiety
• Fibrinolytic agents
• Bleeding disorders
• Care during infusion
• Care postinfusion
Collaborative Care
• Medications
•
•
•
•
•
•
Aspirin
Heparin
Antidysrhythmic medications
Beta blockers
ACE inhibitors
IV NTG
Collaborative Care
• Revascularization
• Immediate, early intervention
• Angioplasty with stent
• Other invasive procedures
• IABP (intra-aortic balloon pump)
• VADs (vascular assist devices)
Collaborative Care
• Cardiac rehabilitation
• Planned program of activity, psychologic support, and
education
• Supervised outpatient program
• Lifetime maintenance
• Interprofessional team
Nursing Care
• Prioritizing nursing care
• Reduce workload of heart
• Eliminate pain
• Maintain CO and tissue perfusion
• Health promotion
• Risk factor management
• Importance of promptly seeking medical care
Nursing Care
• Assessing
•
•
•
•
•
Pain
Evidence of adequate tissue perfusion
Physical assessment findings
Immediate and hourly
ECG
• Identifying potential complications
• Continuously monitor heart rhythm
Nursing Care
• Diagnosing, planning, and implementing
• Acute pain
•
•
•
•
•
Signs of pain
Oxygen
Physical and psychologic rest
Morphine
Ongoing chest pain
Nursing Care
• Diagnosing, planning, and implementing
• Decreased cardiac output
•
•
•
•
•
Change in heart rate, rhythm
LOC
Skin appearance
Heart and breath sounds
ECG
Nursing Care
• Diagnosing, planning, and implementing
• Decreased cardiac output
• Antidysrhythmics as prescribed
• Ineffective coping
•
•
•
•
Trust
Denial
Anger
Coping skills
Nursing Care
• Diagnosing, planning, and implementing
• Ineffective coping
• Privacy
• Fear
•
•
•
•
Patient's perception
Encourage questions
Antianxiety medications
Stress reduction
Nursing Care
• Managing nursing care
• As appropriate
• Evaluating
• Effectiveness of interventions
• Documenting
• Details of pain
• ECG rhythm, per protocol
Nursing Care
• Continuity of care
•
•
•
•
•
•
•
Reduce risk of future events
Diet
Activity
Medications
Refer to cardiac rehabilitation
Community resources
Learn CPR
Cardiac Rhythm Disorders
Cardiac Dysrhythmias
• Arrhythmia
• Disturbance or irregularity in electrical system of the
heart
• May be benign or life threatening
• "Normal" events such as exercise or fear
• Pathologic changes
Pathophysiology
• Due to altered formation of impulses or altered
conduction of the impulse through the heart
• Ectopic beats
• Heart block
Pathophysiology
• Reentry phenomenon
• Classified to the site of impulse formation or the site
and degree of conduction block
Pathophysiology
• Supraventricular dysrhythmias
•
•
•
•
•
•
Sinus tachycardia
Sinus bradycardia
PAC
Atrial flutter
Atrial fibrillation
Junctional
Pathophysiology
• Ventricular dysrhythmias
•
•
•
•
Premature ventricular contractions (PVCs)
Ventricular tachycardia
Ventricular fibrillation
AV conduction blocks
• First degree
• Second degree
• Third degree
Pathophysiology
• Atrioventricular conduction blocks
• First-degree AV block
• Second-degree AV block
• Type I
• Type II
• Third-degree AV block
Collaborative Care
• Diagnostic tests
• Cardiac monitoring
• Continuous cardiac monitoring
• Portable cardiac monitoring (telemetry)
• Medications
• Antidysrhythmics
Collaborative Care
• Cardioversion/defibrillation
•
•
•
•
•
Electrical shock depolarizes all cells.
Synchronized
Defibrillation an emergency treatment
Premedicate with anticoagulants
Automatic implantable cardioverter–defibrillator (AICD)
Collaborative Care
• Pacemakers
• Temporary
• Permanent
• Both sensing and pacing functions
• Surgery
• Ablation when site of ectopic focus can be identified
Nursing Care
• Prioritizing nursing care
• Maintain adequate cardiac output to ensure delivery of
oxygen, nutrients
• Health promotion
• Measures to reduce risks for CHD
• Limit caffeine
• Stop smoking
• Eliminate other sympathetic nervous system stimulants
Nursing Care
• Assessing
•
•
•
•
•
•
•
Before treating with dysrhythmia medications
Chest pain
SOB
Palpitations
VS
Skin color
LOC, mental status
Nursing Care
• Assessing
• Heart sounds, peripheral pulses
• Respiratory status
• Anxiety
• Identifying potential complications
• Regular focused assessment of cardiovascular status
• Report changes in vital signs, anxiety.
Nursing Care
• Diagnosing, planning, and implementing
• Decreased cardiac output
•
•
•
•
•
Assess for manifestations of decreased cardiac output
ECG
VS
Lab values
IV access
Nursing Care
• Diagnosing, planning, and implementing
• Decreased cardiac output
• Emergency procedures prn
• Risk for ineffective cerebral tissue perfusion
• LOC, orientation × 3
• Neurologic status
• Oxygen therapy
Nursing Care
• Diagnosing, planning, and implementing
• Risk for ineffective cerebral tissue perfusion
• HOB 15-degree angle
• Rest
• Anxiety
• Keep family and patient informed.
Nursing Care
• Managing nursing care
• Trained monitor technician
• Evaluating
• Effectiveness based on data on cardiac output, cerebral
perfusion
• Documenting
• During episodes
• Response, presence of family, significant other(s)
Nursing Care
• Continuity of care
•
•
•
•
Coping strategies
Specific treatments
Teach about pacemaker if applicable.
Encourage training in and maintenance of current CPR
techniques.
Sudden Cardiac Death
• Death within 1 hour after onset of cardiac S/S
• V-fibrillation and cardiac arrest
• CPR started within 2 to 4 minutes
• AED
Using an automated external defibrillator (AED) for sudden cardiac
death.