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By: zmiraflores
Angina
· Translated as pain (angina) in the chest (pectoris).
· Usually last a few minutes (3 to 5 minutes) and subsides with rest.
Precipitating factors
· Physical exertion
· strong emotions
· consumption of heavy meals
· temperature extremes
· cigarette smoking
· sexual activity
· stimulants (cocaine)
Types of Angina
· Stable angina
· Prinzmental’s angina (occurs a rest usually in response to spasm of a major coronary artery.
Signs and Symptoms
1. Levine’s Sign – initial sign that shows the hand clutching the chest
2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back,
shoulder, arms, axilla and jaw muscles, usually relieved by rest or taking nitroglycerine
3. Dyspnea
4. Tachycardia
5. Palpitations
6. Diaphoresis
Risk Factors
Modifiable
· Cigarette smoking
· Drugs and alcohol
· Hypertension
· Elevated Serum lipids
· Stressful lifestyle
· Obesity
· Physical inactivity
Unmodifiable
· Genetic disposition
· Diabetes
· Age
· Gender (men>women until 60 yr of age)
· Race (african-amercians<Caucasians)
Complications
· Arrhythmia’s
· Premature contractions
· Fibrillation
Diagnostic studies
· History and physical
· CXR
· EKG
· CK-MB
· Cardiac troponin
· lipid levels
· Stress test
· Nuclear studies
· PET Scan
· Echo
Collaborative Care
· PTCA
· Stent placement
· Angioplasty
· CABG
Nursing Management :
Give second dose of NTG if pain persist after giving first dose with interval of 3 5 minutes
Give third and last dose of NTG if pain still persists at 3 – 5 minutes interval
Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug.
Monitor side effects Orthostatic hypotension Transient headache and dizziness.
Instruct the client to rise slowly from sitting position.
Assist or supervise in ambulation.
When giving nitrol or transdermal patch :
Avoid placing near hairy areas as it may decrease drug absorption
.Avoid rotating transdermal patches as it may decrease drug absorption.
Avoid placing near microwave ovens or duringdefibrillation as it may lead to burns (most important
thing to remember)
b. Betablockers (lol)
Propanolol side effects PNS : broncho constriction, vasodilation
Not given to COPD cases because it causes Bronchospasm
c. ACE Inhibitors (pril)
Enalapril, captopril
d. Calcium Antagonist
calciblock Nifedipine, diltiazem
Nursing Diagnosis
Nursing Implementation
A. Types
1. Transmural Myocardial Infarction-
most dangerous type characterized by occlusion of both right and left coronary artery
1. Chest pain Excruciating visceral, viselike pain located at substernal and rarely in precordial
Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal
ischemia) and hands Not usually relieved by rest or by nitroglycerine
2. Dyspnea
3. Increase in blood pressure (initial sign)
4. Hyperthermia
5. Ashen skin (pale), cool, clammy, diaphoretic
6. Mild restlessness and apprehension, anxiety
7. Occasional findings
a. Pericardial friction rub
b. Split S1 and S2
c. Rales/Crackles upon auscultation
d. S4 or atrial gallop
Diagnostic Procedure:
1. Cardiac Enzymes
a. CPK – MB Creatinine phosphokinase is increased Heart only, 12 – 24 hours
b. LDH – Lactic dehydroginase is increased
c. SGPT – Serum glutamic pyruvate transaminase is increased
d. SGOT – Serum glutamic oxalacetic transaminase is increased
Nursing Management
4. Instruct client to avoid forms of valsalva maneuver 5. Place client on semi fowler’s position
6. Monitor strictly vital signs, intake and output and ECG tracing
7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine
8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce vasodilation
b. Anti Arrythmic Agents Lidocaine (Xylocane Side Effects: confusion and dizziness Brutylium
g. Anti Coagulant
…Heparin (check for partial thrombin time) Antidote: protamine sulfate
…Coumadin/ Warfarin Sodium (check for prothrombin time) Antidote: Vitamin K
h. Anti Platelet …PASA (Aspirin) Anti thrombotic effect Side Effects of Aspirin Tinnitus
Heartburn Indigestion/Dyspepsia Contraindication Dengue Peptic Ulcer Disease
Unknown cause of headache
Nutritional Therapy
h. dietary modification
Risk Factors
· -Male gender
· -Family history of premature atherosclerosis
· -Cigarette smoking
· _DM
· -Hypercholesterolemia
· -HTN
· -Cardiomeagely
· -Ejection fraction of less than 40%
· -History of ventricular arrhythmia
Collaborative Management
· -Several cardiac enzymes
· -EKG
· -Cardiac cath
· -PTCA
· -CABG
· -24 hour holter monitor if they are known to have arrhythmia’s
· -Electrophysiology study (EPS)
Nursing Care
· *Mostly talking to patients and educating the patient and families to relieve some anxieties and fears.
· -Must patients have a feeling that they are a “time bomb” waiting to happen.
· -Wives usually blames themselves for this occurrence.
· -Patients and families have a lot of fear and anxiety.
· -Depression
ODE to a Node
Have a heart, and have no fear
The SA node is over here
Beating at a constant rate
60-100 is really great.
The AV node can make a show
If SA node has gone too slow.
40-60 is not bad
If it’s all you’ve got you will be glad.
Should the whole thing drop its speed
His and bundle branches will take the lead.
And that, my friend is the whole and part,
Of the conduction system of your heart.
CHF
· Is associated with HTN and CAD.
· More than half of the deaths from heart disease is associated to end-stage CHF.
· 4.9 million people in the U.S. have CHF.
· AHA says that about 400,000 get CHF/year.
· Mortality rate is 50%
· About 20% of people who had MI will be disabled with heart failure within 6 years.
CHF
· CHF is the single most frequent cause of hospitalization for people age 65 and older.
· CHF has a poor prognosis and is likely to remain a major clinical and health care problem.
Risk factors
· CAD
· HTN
· diabetes
· cigarette smoking
· obesity
· High cholesterol
· proteinuria
Etiology
· CHF may be caused by any interference with the normal mechanisms regulating cardiac output.
· CO depends on: Preload, afterload, myocardial contractility, heart rate and metabolic state of the
individual.
· Any alteration of these results in CHF.
Compensatory Mechanisms
· Dilation
· Hypertrophy
· Sympathetic nervous system
· Hormonal response
Common causes
· CAD
· HTN
· Rheumatic heart disease
· Congenital heart disease
· Cor Pulmonale
· Anemia
· Acute MI
· Arrhythmias
· Pulmonary emboli
· Hypertensive crisis
· Ventricular septal defect
Type of CHF
· Left sided CHF
· Right sided CHF
Left sided
· Results from LV dysfunction, which causes blood to back up through the left atrium and into the
pulmonary veins.
· This increase causes to go from the pulmonary capillaries bed to the interstitium and then the alveoli,
causing pulmonary congestion and edema.
· Pulmonary congestion
· pulmonary edema
· Fatigue
· Dyspnea
· dry, hacking cough
· Nocturia
· Crackles
· Failure from the right ventricular that causes backflow to the right atrium and venous circulation.
· The primary cause of right-sided failure is left sided failure
· Dependent edema
· Weight gain
· Juglar vein distention
· Hepatomegaly (liver engorgement)
· Fatigue
· Right upper quadrant pain
· Anorexia and GI bloating
· Nausea
· Pleural effusion
· Arrhythmia’s
· Left Ventricular thrombus
· Hepatomegaly
Diagnostic studies
Nutritional therapy
· Diet education
· Weight management
· Low sodium (2 g NA diet)
More severe is 500-1000mg.
· Fluid restrictions
· Weight Daily (THIS IS IMPORTANT)
same day everyday, preferably before breakfast.
Nursing Diagnosis
· Activity intolerance
· sleep pattern disturbance
· fluid volume excess
· Risk for skin integrity
· Impaired gas exchange
· Anxiety
Patient teaching
· Rest
· Drug therapy
· Dietary therapy
· Activity program
· Ongoing monitoring
ECG reading
· Rhythm is regular
· Rate is 60-100 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
Sinus Bradycardia
· Rhythm is regular
· Definition : rate is lower than normal ; Rate is below 60 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
· Resting heart rates below 60 might be normal in athletes
· Watch for hypotension
Sinus Tachycardia
· Rhythm is regular
· Def; sinus rhythm with an elevated rate of impuses ; Rate is between 101 and 150 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
· Is considered SVT when greater than 150 unless in children
· ATRIAL FLUTTER
Atrial Flutter
Atrial Fib
VENTRICULAR FIBRILLATION
· Heart quivers instead of pumping due to disorganized electrical activity of the ventricles. Rhythm is
chaotic and no regularity noted
· No identifiable QRS complexes
· No P waves
· Total chaotic electrical activity creates the baseline
· Can be coarse or fine
· No pulse
ASYSTOLE
· No PQRST
· Baseline straight or slightly wavy
· Must be confirmed in 2 leads
· No pulse
Definition
Pulses
· 0- absent
· 1t= weak, thready
· 2t= normal
· 3t= full, bounding
Auscultation
· If the artery is narrowed or bulging it will create an abnormal buzzing sound (BRUIT).
Other things you can hear:
· Bounding: sharp and brisk rising pulse
· thready: weak, slow rising pulse
· Thrill: vibration
Pulmonary Embolism
· Mobil clot that generally do not stop moving until they lodge at a narrowed part of the circulatory
system.
· The lungs are an ideal location for emboli to lodge because of their extensive arterial and capillary
network.The presence of a deep vein thrombosis is usually unsuspected until a pulmonary embolism
occurs.
· Thrombi in the deep vein can dislodge spontaneously.
Assessment of DVT: a warm, reddish blue extremity.
· More common mechanism that throws a clot is sudden standing and changes of the rate of blood flow,
such as valsalva’s maneuver.
Clinical Manifestations
This depends on the size of the emboli and the number of blood vessels occluded.
· Sudden onset of unexplained dyspnea
· Tachypnea
· Tachycardia
· Cough
· Chest pain
· hemoptysis
· crackles
· fever
· changes in mental status
Massive Emboli
Medium-sized emboli
Can cause pleuritic chest pain accompanied by:
· Dyspnea
· slight fever
· productive cough with blood streaked sputum
· Tachycardia
· Friction rub
Small emboli
Pulmonary Infarction
· Death of lung tissue occurs in less than 10% of patients with emboli.
· It is more likely to occur in patients with:
occlusion of a large or medium-sized pulmonary vessel (<2mm)
Insufficient collateral blood flow from the bronchial circulation
Preexisting lung disease
Pulmonary Hypertension
· Occurs when more than 50% of the area of the pulmonary bed is compromised.
· Also results form hypoxemia.
· Only if the emboli is massive will this occur.
· But small to medium emboli that are recurrent can cause pulmonary hypertension.
Diagnostic test
· History and physical
· Venous studies (venous Doppler’s, lung scans, pulmonary arteriogram).
· CXR
· ABG’s
· CBC
Collaborative care
Drug therapy
HEPARIN
· It is an anticoagulant.
· Should be started immediately.
· The dosage of heparin is adjusted according to its effect on the PTT.
· Normal PTT is 35-45
· Bolus is always given first
· PTT should be one and half to two and half times normal to be therapeutic.
Coumadin
· Anticoagulant
· PT is monitored
· Doc adjusted according to PT levels. The most significant is the INR.
· PT is always drawn with the INR.
Nursing management
· Health promotion
· Bed rest
· Semi-fowler’s position.
· IV line for medications and fluid therapy.
· Careful monitoring of ABG’s, ECG, and lung sounds.
· Nurse should explain the situation to patient/family.
Education
Educate patient with s/s and explain what is going on because they feel:
· Pain
· sense of doom
· inability to breathe
· explain situation and provide emotional support.
· Emotional support
· teach, teach, teach
Diagnosis
· Adequate tissue perfusion.
· Adequate cardiac output
· Increased level of comfort
Ph- 7.35-7.45
Sat- 95-100%
PaO2- 80-100
pCO2- 35-45
HCO3- 22-28
Ma’am Zar