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BROAD OBJECTIVES• By the end of this presentation the learners must be able to acquire knowledge and skills on coronary artery disease, causes and its management.
SPECIFIC OBJECTIVES• Definition of coronary artery disease.• Describe etiology.• Describe the risk factors.• explain the pathophysiology.• Describe the clinical manifestation.• Describe the diagnostic studies.• .Describe the medical management.• Describe the nursing management.• Describe the nursing assessment.• Discuss the nursing diagnosis• Explain patient education.• Describe the complications
DEFINITION• It is the accumulation of plaque in the coronary artery.• This condition can occur in any artery of the body but has preference for the coronary artery.
• CAD can also be described as a blood vessel disorder that is included in the general category of atherosclerosis.• CAD is also known as cardiovascular heart disease
ETIOLOGY• Atherosclerosis is the main cause of coronary artery disease.• It is characterized by the deposition of cholesterol and lipids primarily in the intimal wall of the artery.
RISK FACTORS.• Factors that increase the risk of atherosclerosis includes;• Smoking, high blood pressure, diabetes mellitus, obesity, age and gender, family history and genetics and stress.
PATHOPHYSIOLOGY.• Atherosclerosis is the major cause of CAD which is characterized by focal deposits of cholesterol and lipids in the intimal wall of the artery• Coronary artery atherosclerosis is a progressive disease that begins early in life.• Although several risk factors are present , endothelial injury is caused by an inflammatory response in the intimal layer of the artery and the deposition of the lipids in the wall.
PATHO CONT....• The process has been shown to occur in three developmental stages and these are;• Fatty streak• Fibrous plaque• Complicated lesion
PATHO CONT Fatty streak.• Early lesion of atherosclerosis by lipid filled smooth muscle cells. Fatty streak can be observed in the coronary arteries by the age of 15 and progresses as patient ages.• It is thought to be reversible.
PATHO CONT…. Fibrous plaque.• This develops over time.• The smooth muscle cells stimulated by low density of lipo proteins and platelets activated growth factors proliferate, produce collagen and migrate over the fatty streak.• This forms a fibrous plaque. The fibrous plaque is whitish or grayish in color.
PATHO CONT….• It may develop in one portion of the artery or circle the entire lumen.• Fibrous plaque contributes to loss of arterial elasticity and impairs vessel ability to vasodilate to meet increased oxygen need.
PATHO CONT…… Complicated lesion.• This involves the development of an ulceration or rupture of plaque. Platelets adhere to the lesion. Platelets adherence trigger the coagulation cascade with the development of thrombus that obstructs the artery.
DIAGNOSTIC STUDIES• Chest x-ray for cardiac enragement• Aortic calcifications and pulmonary congestion.• ECG• Lab test for lipid profile.
MEDICAL MANAGEMENT• Administer Digoxin IV digitalised dose 0.6 -1 mg 50% of the dose initially, additional fractions are given at 4- 8 hour intervals.• Administer aspirin po 325 -650 mg per day.• Administer Prednisalone 5.0 mg.• Administer Hydrcortisone 20.0 mg.
NURSING MANAGEMENTHEALTH HISTORY• Assess for chest pain : focus on the location, severity, intensity, duration and onset.• Precipitating factors ; exercises, stress and smoking.• Measures attempted, to control pain for example, lying down, eating or drinking, using of anti-acids.• Assess for other symptoms ; in digestion, heartburn, nausea, abdominal pain• Assess for risk factors for CAD; positive family history, lipid profile, tobacco use, stress level and exercise pattern.• Assess for other illnesses lines diabetes, hypertension and sleeping disorder.
PHYSICAL EXAMINATIONAssessing for the following ;• Posture indicating chest pain e.g. rubbing chest, leaning forward.• Changes in vital signs ; tachycardia, bradycardia, hypertension or hypotension• Dyspnea, crackles, dsyrhythmia.• Levels of consciousness• Vomiting• Decline in urine output.
NURSING DIAGNOSIS• Altered breathing pattern related to imbalance between myocardial oxygen supply and demand as evidenced by an increase in respiratory rate. Goal• The patient will have normal respirations Intervention• Nurse the patient in a high fowler’s position to allow maximum lung expansion• Administer oxygen therapy, 4-6litres/minute to supplement oxygen supply. Discontinue oxygen therapy if oxygen saturation is greater than 90%.
CONT……• Altered comfort (chest pain) related to inflammatory response of the arteries as evidenced by patient rubbing the chest.Goal• Pain relief ; patient should be free from chest pain
CONT…… Intervention• Nurse the patient in a position which he/she is feeling comfortable• Administer prescribed analgesics e.g. pcm 1 gram po
CONT…..• Activity intolerance related to dyspnea as evidenced by inability to perform some of ADLs Goal• Patient will tolerate gradually with increasing levels of activities. Intervention• Promote , encourage and provide activities of daily living.
CONT…• Anxiety related to unknown outcome of the disease as evidenced by patient repetitive question. Goal• Patient will experience manageable level of anxiety .
CONT…. Interventions• Provide calm environment.• Explain every procedure to the patient.• Keep family members informed of the disease process.
PATIENT/ FAMILY EDUCATION• Provide specific verbal and written instructions on smoking cessation, stress management and diet modification.• Encourage adherence to a diet low in saturated fats and cholesterol.• Discuss benefits of stress management techniques in decreasing negative effort on oxygen demand.
COMPLICATIONS 0F CAD• Heart failure : It occurs in response to decreased contractility secondary to ischemic myocardium .• Dsyrithmia : this the disturbance in heart rhythms.• Pericarditis : the heart pericardial lining can become inflamed and fluid may accumulate between the pericardial and the visceral layers so, the patient complaints severe of pericardial chest pain.• Other complications include; cardiogenic shock and ischemic cardiomapathy
SUMMARY• Coronary artery disease is caused by accumulation of cholesterol and lipids in the artery of the heart.• The development of the condition occurs in three stages, namely fatty streak, fibrous plaque and complicated lesion.• The diet which is high in lipids and cholesterol increases susceptibility of coronary artery disease.
References• S. Lewis, M. Heitkemper, S. Dirksen, P. Obrien and L. Bucher (2007) Medical Surgical Nursing; Assessment and Management of Clinical problems (7th edition)St Louisi, Mosby.• A.D. LINTON (2007) Introduction to medical Surgical Nursing, (4th edition), St Louis Mosby.• Phipps’ (2007) Medical Surgical Nursing. Health and Illness