Management of Clients  with Functional Cardiac Disorders
<ul><li>Also known as coronary HEART disease (CHD) </li></ul><ul><li>Describes heart disease caused by impaired coronary b...
Risk Factors Non-modifiable Modifiable Age, gender,  race, heredity Endothelial injury Stress, diet, sedentary living, Smo...
Increased permeability/  adhesion of molecules LDLs & platelets assimilate into the area Plaques begins to form Decreased ...
<ul><li>Inspection: </li></ul><ul><ul><li>Skin color </li></ul></ul><ul><ul><li>Neck vein distention (jugular vein) </li><...
<ul><li>Auscultation: </li></ul><ul><ul><li>Heart sounds (presence of S 3  in adults & S 4 ) </li></ul></ul><ul><ul><li>Mu...
<ul><li>Dyspnea  </li></ul><ul><ul><li>Dyspnea on exertion – may indicate decreased cardiac reserve </li></ul></ul><ul><ul...
<ul><li>ECG (Electrocardiography) – graphical recording of the heart’s electrical activities; 1 st  diagnostic test done w...
<ul><li>Abnormalities:  </li></ul><ul><ul><li>absent P wave = atrial fibrillation </li></ul></ul><ul><ul><li>saw-tooth pat...
 
 
<ul><li>Cardiac Enzymes (Cardiac Markers): </li></ul><ul><ul><li>1 st :  Myoglobin </li></ul></ul><ul><ul><li>a. urine  = ...
<ul><li>Stress Test / Treadmill Test (Treadmill Stress Test) – ECG monitoring during a series of activities of patient on ...
<ul><li>Pharmacologic Stress Test – use of intravenous injection of pharmacologic vasodilator (dipyridamole, adenosine, or...
<ul><li>Cardiac Catheterization – involves passage of  flexible catheters  into great vessels & heart chambers under local...
 
<ul><li>Before Procedure: </li></ul><ul><ul><li>Check consent  form </li></ul></ul><ul><ul><li>√  for allergies to  seafoo...
<ul><li>Swan-Ganz Catheterization – to determine & monitor cardiovascular status; inserted via antecubital vein into the r...
<ul><li>Echocardiography – uses ultrasound to assess cardiac structure & mobility </li></ul><ul><li>Doppler U/S – to detec...
CHD Chronic Ischemic Heart Disease Acute Coronary  Syndrome Stable  Angina Variant  Angina Silent  Myocardial Ischemia Non...
<ul><li>Ischemia – suppressed blood flow </li></ul><ul><li>Angina – to choke </li></ul><ul><li>Occurs when blood supply is...
Causes: Atherosclerosis, HPN, DM, Buerger’s Disease, Polycythemia Vera, Aortic regurgitation Reduced coronary tissue perfu...
<ul><li>Stable angina – the common initial manifestation of  a heart disease </li></ul><ul><ul><li>Common cause: atheroscl...
<ul><li>Variant/Vasospastic Angina (Prinzmetal Angina) </li></ul><ul><ul><li>1 st  described by Prinzmetal & Associates in...
<ul><li>Nocturnal Angina -  frequently occurs  nocturnally (may be  associated with  REM stage of sleep) </li></ul><ul><li...
<ul><li>Dx: detailed pain history, ECG, TST,  angiogram  may be used to confirm & describe type of angina </li></ul><ul><l...
<ul><li>Nitroglycerin (NTGs) – vasodilators:  </li></ul><ul><ul><li>patch (Deponit, Transderm-NTG) </li></ul></ul><ul><ul>...
<ul><li>Class I – angina  occurs with strenuous, rapid, or  prolonged  exertion at work or recreation </li></ul><ul><li>Cl...
<ul><li>Diet instructions  (low salt, low fat,  low cholesterol , high fiber); avoid animal fats </li></ul><ul><ul><li>E.g...
<ul><li>Unstab le Angina/Non ST-Segment Elevation MI –  a clinical   syndro me of myocardial ischemia </li></ul><ul><ul><l...
<ul><li>ST-Segment Elevation MI (Heart Attack) </li></ul><ul><ul><li>Characterized by ischemic death of myocardial  tis su...
<ul><ul><li>Manifestations:  </li></ul></ul><ul><ul><ul><li>chest pain – severe crushing, constricting, “someone sitting o...
Causes: atherosclerotic heart disease, thrombosis/embolism,  shock &/or hemorrhage, direct trauma Myocardial ischemia ↑ ce...
Time after Onset Type of Injury & Gross Tissue Changes 0-0.5hrs Reversible injury 1-2hrs Onset of irreversible injury 4-12...
<ul><li>Initial  Management:  OMEN </li></ul><ul><li>  -  O 2  therapy via nasal prongs  </li></ul><ul><li>- adequate anal...
<ul><li>Surgery : </li></ul><ul><ul><li>Revascularization </li></ul></ul><ul><ul><ul><li>PTCA </li></ul></ul></ul><ul><ul>...
 
<ul><li>Promote oxygenation & tissue perfusion (place client on semi-fowler’s, O 2  via nasal cannula, monitor v/s changes...
 
<ul><li>Also known as Thromboangiitis obliterans </li></ul><ul><li>Usually a disease of heavy cigarette smoker/tobacco use...
<ul><li>Pain –  predominant symptom; R/T distal arterial i schemia </li></ul><ul><ul><li>Intermittent claudication in the ...
<ul><li>Diagnostic methods – those that assess blood flow (Doppler ultrasound & MRI) </li></ul><ul><li>Tx: mandatory to st...
<ul><li>Mechanism: intensive  vasospasm of arteries &  arterioles in the   fi ngers </li></ul><ul><li>Cause: unknown </li>...
<ul><li>Period of ischemia (ischemia due to vasospasm)  </li></ul><ul><ul><li>change in skin color = pallor to cyanotic </...
<ul><li>Dx: initial = based on Hx of vasospastic attacks </li></ul><ul><ul><li>Immersion of hand in cold water to initiate...
<ul><li>Assessment: </li></ul><ul><ul><li>Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea) </li></ul></ul><ul...
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Cardio2

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Cardio2

  1. 1. Management of Clients with Functional Cardiac Disorders
  2. 2. <ul><li>Also known as coronary HEART disease (CHD) </li></ul><ul><li>Describes heart disease caused by impaired coronary blood flow </li></ul><ul><li>Common cause: atherosclerosis </li></ul><ul><li>CAD can cause the following: </li></ul><ul><ul><li>Angina </li></ul></ul><ul><ul><li>Myocardial Infarction (MI) = heart attack </li></ul></ul><ul><ul><li>Cardiac dysrhythmias </li></ul></ul><ul><ul><li>Conduction defects </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul><ul><ul><li>Sudden death </li></ul></ul><ul><li>Men are more often affected than women </li></ul><ul><li>Approximately 80% who die of CHD are 65+ y/o </li></ul>
  3. 3. Risk Factors Non-modifiable Modifiable Age, gender, race, heredity Endothelial injury Stress, diet, sedentary living, Smoking, Alcohol, HPN, DM, Obesity, Contraceptive pills, Hyperlipidemia/hypercholesterolemia Desquamation of endothelial lining (peeling off)
  4. 4. Increased permeability/ adhesion of molecules LDLs & platelets assimilate into the area Plaques begins to form Decreased coronary tissue perfusion Coronary ischemia Decreased myocardial oxygenation ANGINA PECTORIS MYOCARDIAL INFARCTION
  5. 5. <ul><li>Inspection: </li></ul><ul><ul><li>Skin color </li></ul></ul><ul><ul><li>Neck vein distention (jugular vein) </li></ul></ul><ul><ul><li>Respiration </li></ul></ul><ul><ul><li>Peripheral edema </li></ul></ul><ul><li>Palpation: </li></ul><ul><ul><li>Peripheral pulses </li></ul></ul>
  6. 6. <ul><li>Auscultation: </li></ul><ul><ul><li>Heart sounds (presence of S 3 in adults & S 4 ) </li></ul></ul><ul><ul><li>Murmurs – audible vibrations of the heart & great vessels produced by turbulent blood flow </li></ul></ul><ul><ul><li>Pericardial friction rub – extra heart sound originating from the pericardial sac </li></ul></ul><ul><ul><li>- may be a sign of inflammation, infection, or infiltration </li></ul></ul><ul><ul><li>- described as a short, high-pitched scratchy sound </li></ul></ul>
  7. 7. <ul><li>Dyspnea </li></ul><ul><ul><li>Dyspnea on exertion – may indicate decreased cardiac reserve </li></ul></ul><ul><ul><li>Orthopnea – a symptom of more advanced heart failure </li></ul></ul><ul><ul><li>Paroxysmal nocturnal dyspnea – severe SOB that usually occurs 2-5hrs after onset of sleep </li></ul></ul><ul><li>Chest Pain – may be due to decreased coronary tissue perfusion or compression & irritation of nerve endings </li></ul><ul><li>Edema – increased hydrostatic pressure in venous system causes shifting of plasma resulting to interstitial fluid accumulation </li></ul><ul><li>Syncope – due to decreased cerebral tissue perfusion </li></ul><ul><li>Palpitations </li></ul><ul><li>Fatigue </li></ul>
  8. 8. <ul><li>ECG (Electrocardiography) – graphical recording of the heart’s electrical activities; 1 st diagnostic test done when cardiovascular disorder is suspected </li></ul><ul><ul><li>Waves: P wave – atrial depolarization (contraction/stimulation) </li></ul></ul><ul><ul><ul><li>QRS complex – ventricular depolarization (changes are irreversible) </li></ul></ul></ul><ul><ul><ul><li>ST segment – ventricular repolarization (changes are reversible) </li></ul></ul></ul><ul><ul><ul><li>U wave – hypokalemia </li></ul></ul></ul><ul><ul><li>PR interval (time for impulse to travel) = 0.12-0.20s (3-5 squares) √ for AV block </li></ul></ul><ul><ul><li>QRS = 0.10s or (<2squares) √ for electrolyte &/or ventricular imbalance </li></ul></ul>
  9. 9. <ul><li>Abnormalities: </li></ul><ul><ul><li>absent P wave = atrial fibrillation </li></ul></ul><ul><ul><li>saw-tooth pattern = atrial flutter </li></ul></ul><ul><ul><li>elevated ST segment = MI </li></ul></ul><ul><ul><li>3rd degree heart block = prolonged PR then progressively prolonged </li></ul></ul>
  10. 12. <ul><li>Cardiac Enzymes (Cardiac Markers): </li></ul><ul><ul><li>1 st : Myoglobin </li></ul></ul><ul><ul><li>a. urine = 0 – 2mg/dL (↑within 30mins – 2hrs after MI) </li></ul></ul><ul><ul><li>b. blood = <70mg/dL </li></ul></ul><ul><li>2 nd : Troponin* - regulates calcium-mediated contractile process released during MI (Troponin T & I) </li></ul><ul><li> - blood = <0.6mg/dL - ↑ within 3-6hrs after MI & remains elevated for 21 days upon onset of attack </li></ul><ul><li>3 rd : Creatinine kinase (CK) – intracellular enzymes found in muscles converting ATP to ADP </li></ul><ul><li> CK-MB – specific to myocardial tissue (↑within 4-6hrs & decreases to normal within 2-3days) </li></ul><ul><ul><ul><li>male = 12-70 mg/dL </li></ul></ul></ul><ul><ul><ul><li>female = 10-55 mg/dL </li></ul></ul></ul><ul><li>4 th : LDH (specifically LDH 1 - most sensitive indicator of myocardial damage) = 45-90mg/dL - ↑within 3-4 days & remains elevated for 14 days </li></ul>
  11. 13. <ul><li>Stress Test / Treadmill Test (Treadmill Stress Test) – ECG monitoring during a series of activities of patient on a treadmill </li></ul><ul><ul><li>Purposes: identify ischemic heart disease </li></ul></ul><ul><ul><li>evaluate patients with chest pain </li></ul></ul><ul><ul><li>evaluate effectiveness of therapy </li></ul></ul><ul><ul><li>develop appropriate fitness program </li></ul></ul><ul><ul><li>Instructions to patient: get adequate sleep prio r to test </li></ul></ul><ul><ul><li>- avoid: caffeinated beverages, tea, alcohol, on the day before until the test day </li></ul></ul><ul><ul><li>- wear comfortable, loose-fitting clothes & rubber-soled shoes on the test day </li></ul></ul><ul><ul><li>- light breakfast on the day of the test </li></ul></ul><ul><ul><li>- inform physician of any unusual sensations during the test </li></ul></ul><ul><ul><li>- rest after the test </li></ul></ul>
  12. 14. <ul><li>Pharmacologic Stress Test – use of intravenous injection of pharmacologic vasodilator (dipyridamole, adenosine, or dobutamine) in combination of radionuclide myocardial imaging </li></ul><ul><ul><li>To evaluate presence of significant CHD for patients contraindicated in TST </li></ul></ul><ul><ul><li>Dipyradamole blocks cellular re-absorption of adenosine (endogenous vasodilator) & increases coronary blood flow 3-5x above baseline levels </li></ul></ul><ul><ul><li>If with CHD, the resistance vessels distal to the stenosis already are maximally dilated to maintain normal resting flow, thus, further vasodilatation does not produce increased blood flow </li></ul></ul><ul><ul><li>Dobutamine – used in patients with bronchospastic pulmonary disease </li></ul></ul><ul><ul><li> - increases myocardial O 2 demand by increasing cardiac contractility, HR, & BP </li></ul></ul>
  13. 15. <ul><li>Cardiac Catheterization – involves passage of flexible catheters into great vessels & heart chambers under local anesthesia </li></ul><ul><li>- lab is equipped for viewing & recording fluoroscopic images & for measuring pressures in the heart & great vessels, cardiac output studies, & for obtaining ABG samples </li></ul><ul><li>- Epinephrine – to counteract possible allergic reactions </li></ul><ul><ul><li>Right heart Catheterization – catheter inserted into peripheral veins (basilic or femoral) then advanced into the right heart </li></ul></ul><ul><ul><li>Left heart Catheterization – catheter inserted retrograde through peripheral artery (brachial or femoral) into the aorta & left heart </li></ul></ul><ul><li>Coronary Angiogram – injection of radiographic contrast medium into the heart so that an outline of moving structures are visualized & filmed </li></ul><ul><li>Coronary Arteriography - injection of radiographic contrast medium into the coronary arteries permits visualization of lesions in these vessels </li></ul>
  14. 17. <ul><li>Before Procedure: </li></ul><ul><ul><li>Check consent form </li></ul></ul><ul><ul><li>√ for allergies to seafood & iodine </li></ul></ul><ul><ul><li>NPO post midnight </li></ul></ul><ul><ul><li>Baseline V/S </li></ul></ul><ul><ul><li>Explain that warm or flushing sensation may be felt upon administr ation of the dye; “fluttering” sensation may be felt as catheter enters the heart </li></ul></ul><ul><ul><li>Administer sedatives as ordered </li></ul></ul><ul><ul><li>Have the client void prior to transport to cath lab </li></ul></ul><ul><li>After Procedure: </li></ul><ul><ul><li>Bed rest – upper extremity catheter = until stable v/s, HOB not more than 30 ° </li></ul></ul><ul><ul><li> - lower extremity = 24hrs, flat on bed for 6hrs </li></ul></ul><ul><ul><li>Apply pressure (5lb-sand bag) over puncture site & monitor for bleeding </li></ul></ul><ul><ul><li>Monitor v/s q15 for 1 st 2hrs then q1 until stable v/s, esp. peripheral pulses </li></ul></ul><ul><ul><li>Immobilize affected extremity in extension for adequate circulation </li></ul></ul><ul><ul><li>Monitor for color & temperature changes of extremities </li></ul></ul><ul><ul><li>Instruct client to report tingling sensations </li></ul></ul>
  15. 18. <ul><li>Swan-Ganz Catheterization – to determine & monitor cardiovascular status; inserted via antecubital vein into the right side of the heart & is floated into the pulmonary artery </li></ul><ul><li>4 lumens: </li></ul><ul><li>1. CVP – specific to right heart RA = 0-12 RV = 5-12 </li></ul><ul><ul><li>Indications: increased CVP = heart failure </li></ul></ul><ul><li>-decreased CVP = hypovolemia </li></ul><ul><li>2. Pulmonary pressures: </li></ul><ul><ul><li>PAP (pulmonary artery pressure) = 20-30mmHg </li></ul></ul><ul><ul><li>PCWP (pulmonary capillary wedge pressure) = 8-13mmHg (√ for pulmonary edema) </li></ul></ul><ul><li>3. Specimen collection tube – also used for administering meds </li></ul><ul><li>4. Balloon </li></ul>
  16. 19. <ul><li>Echocardiography – uses ultrasound to assess cardiac structure & mobility </li></ul><ul><li>Doppler U/S – to detect blood flow of artery & vein specifically of lower extremities (No smoking 1hr before the test) </li></ul><ul><li>Holter Monitoring – portable 24hr ECG monitoring which attempts to assess activities which precipitate dysrhythmias & its time of the day </li></ul><ul><li>MRI – magnetic fields & radiowaves are used to detect & define abnormalities in tissues (aorta, tumors, cardiomyopathy, pericardiac disease) </li></ul><ul><li>- shows actual beating & blood flow; image over 3 spatial dimensions </li></ul><ul><ul><li>Secure consent </li></ul></ul><ul><ul><li>Assess for claustrophobia </li></ul></ul><ul><ul><li>Remove metal items (jewelries, eyeglasses) </li></ul></ul><ul><ul><li>Instruct client to remain still during the entire procedure </li></ul></ul><ul><ul><li>Inform client of the duration (45-60mins) </li></ul></ul><ul><ul><li>CI: clients with pacemakers, prosthetic valves, recently implanted clips or wires </li></ul></ul>
  17. 20. CHD Chronic Ischemic Heart Disease Acute Coronary Syndrome Stable Angina Variant Angina Silent Myocardial Ischemia Non ST-segment Elevation MI (Unstable Angina) ST-segment Elevation MI
  18. 21. <ul><li>Ischemia – suppressed blood flow </li></ul><ul><li>Angina – to choke </li></ul><ul><li>Occurs when blood supply is inadequate to meet the heart’s metabolic demands </li></ul><ul><li>Symptomatic paroxysmal chest pain or pressure sensation associated with transient ischemia </li></ul>
  19. 22. Causes: Atherosclerosis, HPN, DM, Buerger’s Disease, Polycythemia Vera, Aortic regurgitation Reduced coronary tissue perfusion Decreased myocardial oxygenation Anaerobic metabolism Increased lactic acid production (lactic acidosis) Chest pain
  20. 23. <ul><li>Stable angina – the common initial manifestation of a heart disease </li></ul><ul><ul><li>Common cause: atherosclerosis (although those with advance atherosclerosis do not develop angina) </li></ul></ul><ul><ul><li>Pain is precipitated by increased work demands of the heart (i.e.. physical exertion, exposure to cold, & emotional stress) </li></ul></ul><ul><ul><li>Pain location: precordial or substernal chest area </li></ul></ul><ul><ul><li>Pain characteristics: </li></ul></ul><ul><ul><ul><li>con stricting, squeezing, or suffocating sensation </li></ul></ul></ul><ul><ul><ul><li>Usua lly steady, increasing in intensity only at the onset & end of attack </li></ul></ul></ul><ul><ul><ul><li>May radiate to left shoulder, arm, jaw, or other chest areas </li></ul></ul></ul><ul><ul><ul><li>Dura tion: < 15mins </li></ul></ul></ul><ul><ul><ul><li>Relie ved by rest (preferably sitting or standing with support) or by use of NTG </li></ul></ul></ul>
  21. 24. <ul><li>Variant/Vasospastic Angina (Prinzmetal Angina) </li></ul><ul><ul><li>1 st described by Prinzmetal & Associates in 1659 </li></ul></ul><ul><ul><li>Cause: spasm of coronary arteries (vasospasm) due to coronary artery stenosis </li></ul></ul><ul><ul><ul><li>Mechanism is uncertain (may be from hyperactive sympathetic responses, mishandling defects of calcium in smooth vascular muscles, reduced prostaglandin I 2 production) </li></ul></ul></ul><ul><ul><li>Pain Characteristics: occurs during rest or with minimal exercise </li></ul></ul><ul><ul><li>- commonly follows a cyclic or regular pattern of occurrence (i.e.. Same time each day usually at early hours) </li></ul></ul><ul><ul><li>If client is for cardiac cath, Ergonovine (nonspecific vasoconstrictor) may be administered to evoke anginal attack & demonstrate the presence & location of spasm </li></ul></ul>
  22. 25. <ul><li>Nocturnal Angina - frequently occurs nocturnally (may be associated with REM stage of sleep) </li></ul><ul><li>Angina Decubitus – paroxysmal chest pain occurs when client sits or stands up </li></ul><ul><li>Post-infarction Angina – occurs after MI when residual ischemia may cause episodes of angina </li></ul>
  23. 26. <ul><li>Dx: detailed pain history, ECG, TST, angiogram may be used to confirm & describe type of angina </li></ul><ul><li>Tx: directed towards MI prevention </li></ul><ul><ul><li>Lifestyle modification (individualized regular exercise program, smoking cess a tion) </li></ul></ul><ul><ul><li>Stress reduction </li></ul></ul><ul><ul><li>Diet changes </li></ul></ul><ul><ul><li>Avoidance of cold </li></ul></ul><ul><ul><li>PTCA (percutaneous transluminal coronary angioplasty) may be indicated if with severe artery occlusion </li></ul></ul>
  24. 27. <ul><li>Nitroglycerin (NTGs) – vasodilators: </li></ul><ul><ul><li>patch (Deponit, Transderm-NTG) </li></ul></ul><ul><ul><li>sublingual (Nitrostat) </li></ul></ul><ul><ul><li>oral (Nitroglyn) </li></ul></ul><ul><ul><li>IV (Nitro-Bid) </li></ul></ul><ul><li>Β -adrenergic blockers: </li></ul><ul><ul><li>Propanolol (Inderal) </li></ul></ul><ul><ul><li>Atenolol (Tenormin) </li></ul></ul><ul><ul><li>Metoprolol (Lopressor) </li></ul></ul><ul><li>Calcium channel blockers: </li></ul><ul><ul><li>Nifedipine (Calcibloc, Adalat) </li></ul></ul><ul><ul><li>Diltiazem (Cardizem) </li></ul></ul><ul><li>Lipid lowering agents –statins: </li></ul><ul><ul><li>Simvastatin </li></ul></ul><ul><li>Anti-coagulants: </li></ul><ul><ul><li>ASA (Aspirin) </li></ul></ul><ul><ul><li>Heparin sodium </li></ul></ul><ul><ul><li>Warfarin (Coumadin) </li></ul></ul>
  25. 28. <ul><li>Class I – angina occurs with strenuous, rapid, or prolonged exertion at work or recreation </li></ul><ul><li>Class II – angina occurs on walking or going up the stairs rapidly or after meals, walking uphill, walking more than 2 blocks on the level or going more than 1 flight of ordinary stairs at normal pace, under emotional stress, or in cold </li></ul><ul><li>Class III – angina occurs on walking 1-2 blocks on the level or going 1 flight of ordinary stairs at normal pace </li></ul><ul><li>Class IV – angina occurs even at rest </li></ul>
  26. 29. <ul><li>Diet instructions (low salt, low fat, low cholesterol , high fiber); avoid animal fats </li></ul><ul><ul><li>E.g.. White meat – chicken w/o skin, fish </li></ul></ul><ul><li>Stop smoking & avoid alcohol </li></ul><ul><li>Activity restrictions are placed within client’s limitations </li></ul><ul><li>NTGs – max of 3doses at 5-min intervals </li></ul><ul><ul><li>Stinging sensation under the tongue for SL is normal </li></ul></ul><ul><ul><li>Advise clients to always carry 3 tablets </li></ul></ul><ul><ul><li>Store meds in cool, dry place, air-tight amber bottles & change stocks every 6months </li></ul></ul><ul><ul><li>Inform clients that headache, dizziness, flushed face are common side effects. </li></ul></ul><ul><ul><li>Do not discontinue the drug. </li></ul></ul><ul><ul><li>For patches, rotate skin sites usually on chest wall </li></ul></ul><ul><ul><li>Instruct on evaluation of effectiveness based on pain relief </li></ul></ul><ul><li>Propanolols causes bronchospasm & hypoglycemia, do not administer to asthmatic & diabetic clients </li></ul><ul><li>Heparin – monitor bleeding tendencies (avoid punctu res , use of soft-bristled toot hbrush ); monitor PTT levels; use d for 2wks max; do not massage if via SC; have protamine sulfate available </li></ul><ul><li>Coumadin – monitor for bleeding & PT; always have vit K readily available (avoid green leafy veggies) </li></ul>
  27. 30. <ul><li>Unstab le Angina/Non ST-Segment Elevation MI – a clinical syndro me of myocardial ischemia </li></ul><ul><ul><li>Causes: atherosclerotic plaque disruption or significant CHD, cocaine use (risk factor) </li></ul></ul><ul><ul><li>Defining guidelines: (3 presentations) </li></ul></ul><ul><ul><ul><li>Symptoms at rest (usually prolonged, i.e.. >20mins) </li></ul></ul></ul><ul><ul><ul><li>New onset exertional angina (increased in severity of at least 1 class – to at least class III) in <2months </li></ul></ul></ul><ul><ul><ul><li>Recent acceleration of angina to at least class III in <2months </li></ul></ul></ul><ul><ul><li>Dx: based on pain severity & presenting sympto ms , ECG findings & serum cardiac markers </li></ul></ul><ul><ul><li>When chest pain has been unremitting for >20mins, possibility of ST-Segment Elevation MI is usually considered </li></ul></ul>
  28. 31. <ul><li>ST-Segment Elevation MI (Heart Attack) </li></ul><ul><ul><li>Characterized by ischemic death of myocardial tis sue associated with atherosclerotic disease of coro nar y arteries </li></ul></ul><ul><ul><li>Area of infarction is determined by the affected coronary artery & its distribution of blood flow (right coronary artery, left anterior descending artery, left circumflex artery) </li></ul></ul><ul><ul><li>Dx: based on presenting S/Sx, serum markers, & ECG (changes may not be present immediately after symptoms except dysrhythmias; PVCs/premature ventricular contractions are common after MI) </li></ul></ul><ul><ul><ul><li>Typical ECG changes: ST-segment elevation, Q wave prolongation, T wave inversion </li></ul></ul></ul>
  29. 32. <ul><ul><li>Manifestations: </li></ul></ul><ul><ul><ul><li>chest pain – severe crushing, constricting, “someone sitting on my chest” </li></ul></ul></ul><ul><ul><ul><li>- substernal radiating to left arm, neck or jaw </li></ul></ul></ul><ul><ul><ul><li>- prolonged (>35mins) & not relieved by rest </li></ul></ul></ul><ul><ul><ul><li>Shortness of breath, profuse perspiration </li></ul></ul></ul><ul><ul><ul><li>Feeling of impending doom </li></ul></ul></ul><ul><ul><li>Complications: death (usually within 1 hr of onset) </li></ul></ul><ul><ul><ul><li>Heart fail ure & cardiogenic shock – profound LV failure from massive MI resulting to low cardiac output </li></ul></ul></ul><ul><ul><ul><li>Thromboe mboli – leads to immobility & impaired cardiac function contributi ng to blood stasis in veins </li></ul></ul></ul><ul><ul><ul><li>Rupture of myocardium </li></ul></ul></ul><ul><ul><ul><li>Ventricul ar aneurysms – decreases pumping efficiency of heart & increase s work of LV </li></ul></ul></ul>
  30. 33. Causes: atherosclerotic heart disease, thrombosis/embolism, shock &/or hemorrhage, direct trauma Myocardial ischemia ↑ cellular hypoxia ↓ myocardial O 2 supply ↓ myocardial contractility ↓ cardiac output ↓ arterial pressure Stimulation of sympathetic receptors ↑ peripheral vasoconstriction ↑ myocardial contractility ↑ afterload ↑ myocardial O 2 demand ↑ HR ↑ diastolic filling ↓ myocardial tissue perfusion
  31. 34. Time after Onset Type of Injury & Gross Tissue Changes 0-0.5hrs Reversible injury 1-2hrs Onset of irreversible injury 4-12hrs Beginning of coagulation necrosis 18-24hrs Continued necrosis; gross pallor of infected tissue 1-3days Total necrosis; onset of acute inflammatory process 3-7days Infarcted area becomes soft with a yellow-brown center & hyperemic edges 7-10days Minimally soft & yellow with vascularized edges; scar tissue generation begins (fibroplastic activity) 8 th week Complete scar tissue replacement
  32. 35. <ul><li>Initial Management: OMEN </li></ul><ul><li> - O 2 therapy via nasal prongs </li></ul><ul><li>- adequate analgesia ( M orphine via IV – also has vasodilator property) </li></ul><ul><li>- E CG monitoring </li></ul><ul><li>-sublingual N TG (unless contraindicated; IV may be given to limit infarction size & most effective if given within 4hrs of onset) </li></ul><ul><li>Thrombolytic Therapy – best results occur if initiated within 60-90mins of onset (Streptokinase & Urokinase – promote conversion of plasminogen to plasmin) </li></ul><ul><li>Anti-arrhythmics: lidocaine, atropine, propano lol </li></ul><ul><li>Anticoagulants & antiplatelets: ASA, heparin </li></ul><ul><li>Stool softeners </li></ul>
  33. 36. <ul><li>Surgery : </li></ul><ul><ul><li>Revascularization </li></ul></ul><ul><ul><ul><li>PTCA </li></ul></ul></ul><ul><ul><ul><li>Coronary stent implantation </li></ul></ul></ul><ul><ul><ul><li>Coronary Artery Bypass Graft (CABG) – no response to medical treatment & PTCA </li></ul></ul></ul><ul><ul><li>Resection – aneurysm </li></ul></ul>
  34. 38. <ul><li>Promote oxygenation & tissue perfusion (place client on semi-fowler’s, O 2 via nasal cannula, monitor v/s changes, remind client on his activity limitations & restrictions) </li></ul><ul><li>Promote comfort & rest </li></ul><ul><li>Monitor the ff perimeters: v/s, ECG, rate & rhythm of pulse, effects of ADLs on cardiac status </li></ul><ul><li>Diet: low salt, low cholesterol, low calories, avoid alcohol & smoking </li></ul><ul><li>Take prescribe meds at regular basis </li></ul><ul><li>Stress management </li></ul><ul><li>Resume sexual activity after 4-6wks from discharge or when client can go up 2 flights of stairs without difficulty </li></ul><ul><ul><li>Assume less tiring position (non-MI partner takes active role). </li></ul></ul><ul><ul><li>Perform sexual activity in a cool, familiar place. </li></ul></ul><ul><ul><li>Take prescribed NTG before sexual activity </li></ul></ul><ul><ul><li>Refrain from sexual activity after a large meal or during a tiring day. </li></ul></ul><ul><ul><li>Moderation should be observed if palpitations, dizziness or dyspnea is observed </li></ul></ul>
  35. 40. <ul><li>Also known as Thromboangiitis obliterans </li></ul><ul><li>Usually a disease of heavy cigarette smoker/tobacco user men, 25-40y/o </li></ul><ul><li>Inflammatory arterial disorder that causes thrombus formation often extends to adjacent veins & nerves </li></ul><ul><li>Affects medium-sized arteries (usually plantar & digital vessels in the foot or lower legs) </li></ul><ul><li>unknown pathogenesis but it had been suggested that: </li></ul><ul><ul><li>tobacco may trigger an immune response or </li></ul></ul><ul><ul><li>unmask a clotting defect; </li></ul></ul><ul><ul><li>-> these 2 can incite an inflammatory reaction of the vessel wall </li></ul></ul>
  36. 41. <ul><li>Pain – predominant symptom; R/T distal arterial i schemia </li></ul><ul><ul><li>Intermittent claudication in the arch of foot & digits </li></ul></ul><ul><li>Increased sensitivity to cold (due to impaired circulation </li></ul><ul><li>Absent/diminished peripheral pulses </li></ul><ul><li>Color changes in extremity (cyanotic on dependent position; digits may turn reddish blue) </li></ul><ul><li>Thick malformed nails (chronic ischemia) </li></ul><ul><li>Disease progression ulcerate tissues & gangrenous changes may arise; may necessitate amputation </li></ul>
  37. 42. <ul><li>Diagnostic methods – those that assess blood flow (Doppler ultrasound & MRI) </li></ul><ul><li>Tx: mandatory to stop smoking or using tobacco </li></ul><ul><ul><li>Meds to increase blood flow to extremities </li></ul></ul><ul><ul><li>Surgery (surgical sympathectomy) </li></ul></ul><ul><ul><li>amputation </li></ul></ul>
  38. 43. <ul><li>Mechanism: intensive vasospasm of arteries & arterioles in the fi ngers </li></ul><ul><li>Cause: unknown </li></ul><ul><li>Usually affects young women </li></ul><ul><li>Precipitated by exposure to cold & strong emotions </li></ul><ul><li>Raynaud’s phenomenon – associated with previous injury (i.e.. Frostbite, occupation al trauma associated with use of heavy vibr ating tools, collagen diseases, neuro d/o, chro nic arterial occlusive d/o) </li></ul>
  39. 44. <ul><li>Period of ischemia (ischemia due to vasospasm) </li></ul><ul><ul><li>change in skin color = pallor to cyanotic </li></ul></ul><ul><ul><li>1 st noticed at the fingertips later moving to distal phalanges </li></ul></ul><ul><ul><li>Cold sensation </li></ul></ul><ul><ul><li>Sensory perception changes (numbness & tingling) </li></ul></ul><ul><li>Period of hyperemia – intense redness </li></ul><ul><ul><li>Throbbing </li></ul></ul><ul><ul><li>Paresthesia </li></ul></ul><ul><li>Return to normal color </li></ul><ul><li>Note: although all of the fingers are affected symmetrically, only 1-2digits may be involved </li></ul><ul><li>Severe cases: arthritis may arise (due to nutritional impairment) </li></ul><ul><ul><li>Brittle nails </li></ul></ul><ul><ul><li>Thickening of the skin of fingertips </li></ul></ul><ul><ul><li>Ulceration & superficial gangrene of fingers (rare occasions) </li></ul></ul>
  40. 45. <ul><li>Dx: initial = based on Hx of vasospastic attacks </li></ul><ul><ul><li>Immersion of hand in cold water to initiate attack aids in the Dx </li></ul></ul><ul><ul><li>Doppler flow velocimetry – used to quantify blood flow during temperature changes </li></ul></ul><ul><ul><li>Serial Computed thermography (finger skin temp) – for diagnosing the extent of disease </li></ul></ul><ul><li>Tx: directed towards eliminating factors causing vasospasm & protecting fingers from injury during ischemic attacks </li></ul><ul><ul><li>PRIORITIES: Abstinence in smoking & protection from cold </li></ul></ul><ul><ul><li>Avoidance of emotional stress (anxiety & stress may precipitate vascular spasm) </li></ul></ul><ul><ul><li>Meds: avoid vasoconstrictors (i.e.. Decongestants) </li></ul></ul><ul><ul><li>-Calcium channel blockers (Diltiazem, Nifedip ine , Nicardipine) – decrease episodes of attacks </li></ul></ul>
  41. 46. <ul><li>Assessment: </li></ul><ul><ul><li>Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea) </li></ul></ul><ul><ul><li>v/s </li></ul></ul><ul><li>Nursing Dx: </li></ul><ul><ul><li>ineffective tissue perfusion (cardio pulmonary) </li></ul></ul><ul><ul><li>Impaired gas exchange </li></ul></ul><ul><ul><li>Anxiety due to fear of death (clients with MI or An gina) </li></ul></ul><ul><li>Goals: </li></ul><ul><ul><li>Relief of pain & symptoms </li></ul></ul><ul><ul><li>Prevention of further cardiac damage </li></ul></ul><ul><li>Nursing Interventions: </li></ul><ul><ul><li>Pain control </li></ul></ul><ul><ul><li>Proper medications </li></ul></ul><ul><ul><li>Decrease client’s anxiety </li></ul></ul><ul><ul><li>Health teachings (meds, activities, diet, exercise, etc) </li></ul></ul>
  42. 47. Thank You for Listening!
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