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Chapter025 Presentation Transcript

  • 1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 25: Caring for Clients with Disorders of Coronary and Peripheral Blood Vessels Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 2. Arteriosclerosis; Atherosclerosis • Arteriosclerosis: Loss of elasticity, artery hardening which accompanies aging – Calcium deposition in the cytoplasm – Reduced volume of oxygenated blood delivered to organs • Atherosclerosis: Condition where artery lumens fill with plaque • Mechanisms by which lipids are formed and metabolized • Causes contributing to higher risk factors for vascular diseases Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 3. Question Is the following statement true or false? Arteriosclerosis is a vascular condition that is caused by the natural aging process. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 4. Answer True. Arteriosclerosis is a hardening of the arteries and a loss of vascular elasticity that accompany aging. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 5. Atherosclerosis • Pathophysiology and Etiology – Hyperlipidemia • High levels of blood fat • Contributing factors • Gender, heredity, diet, and diseases • Obese people with metabolic syndrome • Homocysteine: Scarring of arterial walls – Infection: Chlamydia pneumoniae • Blood test: HS-CRP and WBC Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 6. Atherosclerosis • Pathophysiology and Etiology (Cont’d) – Inflammation • Body fat: Production of inflammatory and thrombotic proteins • Proinflammatory proteins • Client with elevated lipid levels • Endothelial: Derived relaxing factors • Coronary thrombosis Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 7. Atherosclerosis Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 8. Coronary Artery Disease • Coronary Occlusion: Closing of a coronary artery • Coronary Artery Disease: Arteriosclerotic and atherosclerotic changes – If untreated, leads to MI – Pathophysiology and Etiology • Many factors • Inherited, behavioral risk factors • Angina pectoris Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 9. Question Is the following statement true or false? Not treating arteriosclerotic and/or atherosclerotic changes can result in angina pectoris. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 10. Answer True. Leaving arteriosclerotic and/or atherosclerotic vascular changes untreated not only can result in angina pectoris, myocardial infarction could result. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 11. Coronary Artery Disease • Assessment Findings: Signs and Symptoms – Mild CAD • Classic symptom: Angina; Sites of pain; Obese person; Atypical symptoms in women; Arcus senilis; Xanthelasma • Assessment Findings: Diagnostic Findings – Lab tests; Hyperlipidemia – ECG; Coronary arteriography – Electron beam computed tomography (EBCT) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 12. Coronary Artery Disease Figure 25-2 Pain patterns with myocardial ischemia Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 13. Coronary Artery Disease Figure 25-3 Arcus senilis, an opaque ring in the periphery of the cornea, is a sign of systemic fat deposits Figure 25-4 Xanthelasma, yellowish plaques about the eyelids, is a sign of lipid accumulation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 14. Coronary Artery Disease • Medical and Surgical Management – Lifestyle changes; Drug therapy – Exercise; Weight reduction – HDL, LDL, and homocysteine levels – Prevention of plaque formation – Soy products • Reverse Lipid Transport – Administration of synthetic HDL Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 15. Question Is the following statement true or false? The initial responses to coronary artery disease is medication and surgery. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 16. Answer False. While in an emergency situation surgery is an initial response, typically nonmedical interventions (changes in diet, smoking, exercise) are implemented to assess their efficacy. Conservative treatment is the recommended modality, whenever possible. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 17. Coronary Artery Disease • Enhanced External Counterpulsation – Noninvasive and nonsurgical – Relieves angina; Drug therapy and lifestyle modifications – Function-pressure suit; Promotes collateral circulation • Advantages and Disadvantages – Invasive perfusion techniques • Nonsurgical and surgical procedures Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 18. Coronary Artery Disease • Invasive Perfusion Techniques (Cont’d) – Percutaneous transluminal coronary angioplasty – Coronary stent; Atherectomy; Laser angioplasty – Coronary artery bypass graft surgery (CABG) – Transmyocardial revascularization • Nursing Management – Assess chest pain, prescribed drugs, oxygen, pattern of angina, CAD risk factors, and hemorrhage – Monitor urine and mental status Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 19. Myocardial Infarction • Occurrence of Heart Attack • Infarct: Area of necrosis • Larger necrotic area = more serious damage • Location of the Infarction – Transmural and subendocardial • Depends where blood supply interrupted • Pathophysiology and Etiology – Coronary thrombosis; arterial spasms – Proinflammatory chemicals – Damaged cells Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 20. Myocardial Infarction • Pathophysiology and Etiology (Cont’d) – Depolarization and repolarization of myocardial cells, potassium, and lactic acid – Dysrhythmias; Cardiomyopathy and heart failure – Thrombolytic drugs; Leukocytosis – Infarction process; Cardiac patch • Complications – Dysrhythmias: Can be fatal – Cardiogenic shock • Early detection; treatment Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 21. Question Is the following statement true or false? After an MI, dysrhythmias are to be expected and part of the recovery process. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 22. Answer False. After an MI, dysrhythmias can lead to cardiomyopathy and death and should be aggressively treated. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 23. Myocardial Infarction • Complications (Cont’d) – Ventricular rupture • Soft necrotic area from MI ruptures • Dyspnea; poor prognosis • Hemopericardium and cardiac tamponade – Ventricular aneurysm • Bulging of portion of heart • Area of poorly contractile tissue • Predisposes heart to failure; fatal Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 24. Myocardial Infarction • Complications (Cont’d) – Arterial embolism • Clot formation; Symptoms depend on location of the affected artery • Arteriotomy and embolectomy – Venous thrombosis: Veins of lower extremities • Prevention: Antiembolism stockings • Medication – Pulmonary embolism • Formation; Symptoms; Treatment Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 25. Myocardial Infarction • Complications (Cont’d) – Pericarditis • Mild or severe • Pericardial effusion — cardiac tamponade – Mitral insufficiency • Occurrence; Incompetent mitral valve • Assessment Findings: Signs and Symptoms – Chest pain, pale, diaphoretic, vomiting, hypotension, faint, and abnormal pulse – Signs of left-sided heart failure Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 26. Myocardial Infarction • Assessment Findings: Diagnostic Findings – Laboratory tests • Myoglobin • Troponin: T, I: Gold standard (early) • Cardiac isoenzymes – Injured myocardial cells – Characteristic changes after MI • Medical Management – Reduce tissue hypoxia; Relieve pain; Treat shock and dysrhythmias Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 27. Myocardial Infarction • Medical Management (Cont’d) – Thrombolytic therapy: Within specified time • Zone of necrosis; Treatment • Disqualifying factors – Symptomatic treatment • IV infusion; Drug therapy; Diet • Hypoxemia: Oxygen therapy • Coffee consumption; Stool softener; Permanent smoking cessation • Intra-aortic balloon pump Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 28. Myocardial Infarction • Surgical Management – CABG surgery • Revascularize myocardium – Clients experiencing cardiogenic shock • Ventricular assist device • Cardiomyoplasty • Cardiac Rehabilitation – Components of the program • Exercise; Educational activities • Duration of therapy; Client education Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 29. Peripheral Vascular Disease • Affects distal blood vessels • Common types: Raynaud’s disease; Embolism; Thrombosis; Phlebothrombosis • Raynaud’s Disease – Periodic constriction of arteries that supply extremities; Most common in young women – Pathophysiology and Etiology • Characterization; Ischemia; Causes • Vasospasms: Impaired release of prostaglandins • Vasodilation: Inflammatory response Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 30. Peripheral Vascular Disease • Raynaud’s Disease (Cont’d) – Assessment Findings: Signs and Symptoms • Exposure to cold • Symptoms of occurrence in hand • Hallmark symptoms: Ischemia, pain, and paresthesias • Relief measures; Early stages • Mild and long-term symptoms – Assessment Findings: Diagnostic Findings • History of the symptoms and examination • Laboratory blood tests Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 31. Peripheral Vascular Disease • Raynaud’s Disease (Cont’d) – Medical and Surgical Management • Treatment: Avoid factors that precipitate attacks • IV infusion of prostaglandin E • Amputation of gangrenous areas – Nursing Management • Physiology of blood flow; Smoking cessation; McIntyre maneuver; Ischemic episodes • Client and family education; Nail care • Avoid OTC decongestants; Sympathectomy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 32. Thrombosis, Phlebothrombosis, and Embolism • Clot formed in blood vessel; Clot development in vein without inflammation; Moving “clot “ within bloodstream • Pathophysiology and Etiology – Location; Occurrence; Orthopedic surgical procedures – Precipitation: Arterial thrombosis and subsequent embolization; Occluded blood flow • Assessment Findings: Signs and Symptoms – Arterial clot; Total occlusion; Cramping – Loss of sensation and ability; Shock – Clients with phlebothrombosis; DVT Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 33. Thrombosis, Phlebothrombosis, and Embolism • Assessment Findings: Diagnostic Findings – Arteriography or venography – Doppler ultrasonography – Plethysmography • Medical and Surgical Treatment – Treatment depends on vessel, degree of occlusion – Arterial occlusive disease • Vasodilating drugs; Heparin; Sympathetic nerve block; Narcotics; Thrombolytic agents; Pulmonary embolism; Surgery Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 34. Thrombosis, Phlebothrombosis, and Embolism • Medical and Surgical Treatment (Cont’d) – Venous occlusive disease • Treatment: Bed rest, elevation, heat, analgesics, heparin therapy • DVT: Surgical removal of the clot • Nursing Management – History: Characteristics of pain – Homans’ sign: Palpate peripheral pulses – Examine extremities, skin color, and calf – Heparin; Anticoagulation therapy; Client teaching Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 35. Venous Insufficiency • Impaired flow of venous blood, usually through lower extremities • Pathophysiology and Etiology – Consequences; venous congestion – Increased hydrostatic fluid pressure – Localized edema; fluid-filled space – Cells subjected to accumulating amounts of CO2; Unoxygenated cells – Hemoglobin from blood cells – Serous fluid oozes from skin – Venous stasis ulcer Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 36. Venous Insufficiency • Assessment Findings: Signs and Symptoms – Swollen foot or feet; Testing for pitting – Superficial veins; Skin color; Serous fluid – Infection; Pedal, tibial pulses – Congestion of venous fluid • Assessment Findings: Diagnostic Findings – Doppler ultrasound – Photoplethysmography: Venous pathology – Air plethysmography: Measures venous pressure, cuff with air Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 37. Venous Insufficiency • Medical and Surgical Management – Promote venous circulation; Elastic compression stockings; Unna boot – Pneumatic compression pump therapy – Mild analgesics; Vascular surgery – Stasis ulcer; Chronic, nonhealing skin lesions • Topical hyperbaric O2 (THBO) • Nursing Management – Assesses: Extremities and circulation – Ulcers; Rate of pain; Application of stockings; Wound care; Client teaching Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 38. Varicose Veins • Dilated veins; Both genders suffer equally • Saphenous leg veins commonly affected • Pathophysiology and Etiology – Varicosities: Dilated, torturous veins – Cause: Interfere with venous return – Thrombophlebitis; Infection; Slow healing • Assessment Findings: Signs and Symptoms – Heaviness in the legs; Variations in skin color – Swelling on leg; Distended leg veins – Abnormal capillary refill Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 39. Varicose Veins • Assessment Findings: Diagnostic Findings – Brodie-Trendelenburg test • Incompetence of the superficial veins – Ultrasonography and venography • Medical Management – Treatment of mild varicose veins – Defective veins: Injection of chemical to sclerose or occlude to promote collateral circulation • Surgical Management – Vein ligation; Procedure – Vein stripping Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 40. Varicose Veins • Nursing Management – Assess skin, distal circulation, peripheral edema, and ability to perform isometric leg exercises – Post-operative measures – Consult physician; Ambulate – Application of elastic antiembolism stockings – Adequate fluid to decrease potential thrombosis; Client and family teaching – Treatment by the physician • Elastic support stockings Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 41. Aneurysms • Stretching and bulging of arterial wall • Most Common: Aneurysms of the aorta • Pathophysiology and Etiology – Elasticity of the tunica media affected – Blockage of the vessel; Leakage of blood into surrounding cavities; Tissue necrosis • Assessment Findings: Signs and Symptoms – Identification of disease; Massive hemorrhage; Pressure; Hypertensive – Pulsating mass; Sudden illness; Shock – BP on both arms and legs; Severe pain Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 42. Aneurysms • Assessment Findings: Diagnostic Findings – Radiographs: Demonstrate aneurysm I calcium deposit present – Aortography: Size and location • Medical and Surgical Management – Drug therapy: Antihypertensives – Surgically treated; Repair: Bypass or replacement grafting • Nursing Management – Measures to control hypertension; Monitor vital signs, urine output, pain – Client preparation: Diagnostic testing Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 43. End of Presentation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins