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Care of Clients with Problems In Oxygenation,

Fluids and Electrolytes, Metabolism and Endocrine
(NCM103)
Cardiovascular System: Coronary Vascular Disease

Coronary Atherosclerosis
Definition:
Abnormal accumulation of fatty substances
Creates BLOCKAGE
Repetitious inflammatory response
o Obstruction + Inflammation = Blood Flow MI or AP

Atherosclerosis Arteriosclerosis
1. Definition Lumen Lumen
2. Cause Deposition of fatty substances Elasticity of blood vessels
3. Age Toddlers Aging process
4. Layer Tunica intima 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



Clinical Manifestations:
- Depends on
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
Regular exercise
Diet
Alcohol intake
Topics Discussed Here Are:
1. Coronary Atherosclerosis
2. Angina Pectoris
3. Myocardial Infarction
LOOKY
HERE

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NUTRIENT CONTENT OF THE THERAPEUTIC LIFESTYLE CHANGES (TLC) DIET
Nutrient Recommended Intake
Total calories Balance intake and expenditure to maintain desirable weight
Total fat
Saturated fat
Polyunsaturated fat
Monounsaturated fat
25% - 35% of total calories
Less than 7% of total calories
Up to 10% of total calories
Up to 20% of total calories
Carbohydrate 50% - 60% of total calories
Dietary fiber 20 30 g/day
Protein Approximately 15% of total calories
Cholesterol 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


Coronary
Insufficiency
Coronary occlusion
(Continuation of coronary insufficiency)
Lumen
CHEST
PAIN On and Off
Bearable
Short Duration
Angina Pectoris
CONSTANT
SEVERE
LONGER
Myocardial
Infarction
Ischemia

What is Angina Pectoris?
Associated With:
+ Outside factors
+ Mental / Emotional problems
Relieved With:
+ Rest
+ Coronary vasodilators
Levines Sign

Types of Angina Pectoris
1. Stable Angina
` Predictable and consistent pain
` Relieved by rest and / nitroglycerin
2. Unstable Angina / Preinfarction Angina / Crescendo Angina
` Symptoms increase in frequency
` May not be relieved by rest and nitroglycerin
3. Variant Angina (Prinzmetals Angina)
` Pain at rest
` Reversible ST-segment elevation
4. Silent Ischemia
` Objective evidence of ischemia
` But NO PAIN :o

Management:
1. Medical Management
a. Rest Minimum of 2 hours

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b. Drugs
1. Coronary Vasodilators
O Dilates lumen of blood vessels in the myocardium
O Drugs:
o Nitroglycerin
+ 1 Tab, SL q5 min PRN for chest pain
+ Maximum of 3 Tablets; if not resolved considered
MI
+ Take the medications before
any stressful event
+ Loses potency when
exposed in the sun; store in
dark colored bottles
+ If head gets big, warm, and
flushing of face it is
NORMAL, not SIDE EFFECT or ADVERSE
EFFECT
2. Anti-platelet Drugs
O Aspirin (Produces GIT disturbance; Coated Aspirin New)
O Heparin
o Side Effect = Bleeding (Petechiae, Ecchymosis, Hematoma)
o WOF: Tea colored urine for HEMATURIA
o WOF: BLACK STOOLS
O NO PARENTERAL ADMINISTRATION OF DRUGS; if needed,
apply pressure after!!
O Dont use dental floss
3. Beta Blockers To reduce O
2
demand of myocardium
4. Ca
+
Channel Blocking Agent Relaxes the Blood Vessel to BP
c. 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
- 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 HCO
3
Baking Soda, bread, biscuit, pastries
8:00 1
st
Tablet
8:05 2
nd
Tablet
8:10 3
rd
Tablet
8:00 1
st
Tablet
8:05 2
nd
Tablet
3:30 1
st
Tablet

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4. NaCl Fish sauce, soy sauce, dried fish
5. Na Saccharin
b. Must be with the patient all the time!!
Coronary Vasodilators
- DONT EXPOSE IN THE SUN!!
- DONT LEAVE IN THE CAR!!

Myocardial Infarction
Brought about by lack of blood supply going to the myocardium
A.k.a. Coronary occlusion or Heart Attack

Pain:
- 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. O
2
/ Blood demand Patients with hyperthyroidism
3. O
2
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


P
Q
R
S
T
ANG HIRAP MAG DROWING NG ECG PQRST SA PC XD
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. QRS Complex Ventricular Contraction / Depolarization (0.08 seconds)
4. ST Segment Length of time for the ventricle to relax (0.12 seconds)
5. T Wave Ventricular relaxation / Repolarization (0.16 seconds)








0.08
seconds
2
seconds

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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
Place patient on absolute bed rest
- NO VISITORS ALLOWED (NEAREST RELATIVE ONLY)
- Health team should be calm
b. Get baseline Vital Signs
TPR
- Temperature = Due to cell death
- Pulse =
- Respiration =
- Blood Pressure =
Baseline ECG
Basic serum electrolytes
c. Administration of Drugs
Thrombolytic Drugs (Alteplase)
- 1
st
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
ACE Inhibitors
- To prevent BP
2. 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
1. Phase I
Time of diagnosis of atherosclerosis
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
If patient is not compliant, there
would be repeated attacks of
angina pectoris and myocardial
infarction .

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2. 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
3. Phase III
e Maintain cardiovascular stability
e 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 vein

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