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Nursing Care of Patients with Occlusive Cardiovascular Disorders
Artery/Arteriole Walls◦ Thicken◦ Harden◦ Lose Elasticity
Type of Arteriosclerosis Plaque Formation in Arterial Wall Childhood Onset
Non-modifiable Risk Factors◦ Age ◦ Gender◦ Ethnicity◦ Genetic Predisposition for Hyperlipidemia
Modifiable Risk Factors◦ Diabetes Mellitus ◦ Hypertension◦ Smoking◦ Obesity◦ Sedentary Lifestyle◦ Increased Serum Homocysteine
Modifiable Risk Factors (cont’d)◦ Increased Serum Iron Levels◦ Infection◦ Depression ◦ Hyperlipidemia ◦ Elevated Apolipoprotein B ◦ Excessive Alcohol Intake
Diagnostic Tests for Increased CVD◦ Cholesterol
Elevated Increases Risk ◦ Low-density Lipoproteins (LDL)
Increased risk◦ High-density Lipoproteins (HDL)
Protective
Diagnostic Tests (cont’d)◦ Lp(a) Cholesterol
Elevated Increases Risk◦ Apolipoprotein B > Apolipoprotein A
Increased Risk◦ Triglycerides
Increased Risk
Diagnostic Tests (cont’d)◦ C-reactive Protein
Inflammation in C.A. Shows Increased Risk
◦ Elevated Leukocyte Count in Women Increased Risk
Therapeutic Interventions◦ Low-fat Diet◦ Avoid Smoking◦ Exercise◦ Lipid-lowering Agents
Obstruction of Coronary Artery Blood Flow Typically from Atherosclerosis
Contributes to◦ Angina◦ Myocardial Infarction◦ Sudden Death
Modify Risk Factors◦ Low-cholesterol Diet◦ Lipid-lowering Agents
Low Dose Aspirin
Symptom of Ischemia Chest Pain Causes: CAD, Vasospasm, Valvular Heart
Disease, Hypertension, Heart Failure
Stable Angina◦ Arteries Cannot Increase Blood to Heart During
Increased Activity ◦ Usually Stops with Rest/Vasodilator
Variant Angina (Prinzmetal’s Angina)◦ Longer Duration◦ Can Occur at Rest ◦ Often Same Time Each Day◦ Coronary Artery Spasm Cause◦ Serious
Pain◦ Heaviness, Tightness, Viselike, Crushing Pain in
Chest Center◦ In the Morning◦ Radiation
Pale Diaphoretic Dyspneic
Chest Pain, Jaw Pain, Heartburn Atypical Symptoms
◦ Describe Less Severe Pain ◦ Fatigue ◦ Nausea◦ Breathlessness
ECG Exercise ECG (Stress Test) Graded Exercise Testing Stress Echocardiography Chemical Stress Testing Radioisotope Imaging Coronary Angiography
Weight Reduction Low-fat, Low-cholesterol Diet Stress Reduction Medications
Vasodilators◦ Nitroglycerin (NTG)
Calcium Channel Blockers◦ Diltiazem, Amlodipine
Beta blockers◦ Propranolol, Metoprolol, Atenolol
ACEI◦ Captopril, Lisinopril, Ramipril, Enalapril
Statins◦ Atorvastatin, Fluvastatin, Lovastatin, Pravastatin,
Simvastatin, Rosuvastin Antiplatelets
◦ Aspirin, Clopridogrel (Plavix)
Acute Pain Deficient Knowledge
Acute Pain Interventions◦ Oxygen◦ Vital Signs◦ Sublingual NTG◦ Remain with Patient◦ Emotional Support
Caused by Lack of Oxygen to Heart Muscle Conditions
◦ Unstable Angina◦ Myocardial Infarction
Worsening CAD Rest Does Not Relieve Can Occur at Rest Increasing Frequency Risk for Cardiac Damage/Death
Death of Heart Muscle Pathophysiology
◦ Coronary Artery Blockage◦ Decreased Cardiac Blood Supply
Types◦ Non-ST Segment Elevation Myocardial Infarction◦ ST Segment Elevation Myocardial Infarction
Myocardial Ischemia Without Chest Pain
Cardiac Arrest Triggered by Lethal Ventricular Dysrhythmias or Asystole from an Abrupt Occlusion of a Coronary Artery
Crushing, Viselike Pain◦ Radiates to Arm/Shoulder/Neck/Jaw
Shortness of Breath Restlessness Dizziness, Fainting Nausea Sweating
Atypical – Women/Older Adult◦ Absence of Classic Pain◦ Dyspnea◦ Fatigue◦ Anxiety◦ Chest Cramping, Epigastric or Abdominal Pain
Atypical – Women/Older Adult (cont’d)◦ Restlessness◦ Falling
Report Shortness of Breath, Fatigue,Fast/Slow Heartbeats, Chest Discomfort
Silent MI Collateral Circulation
◦“Act in Time to Heart Attack Signs” Call 9-1-1 (or Local Emergency Number) www.nhlbi.nih.gov/actintime/
◦ National Heart Attack Alert Program “60 Minutes to Treatment” www.nhlbi.nih.gov/about/nhaap
Leading Cause of Death African American Women at Higher Risk Higher Mortality Rate, More Complications
Than Men Prodromal Symptoms the Month Before MI
◦ Unusual Fatigue, Sleep Disturbances, Dyspnea
Delay Treatment Less Aggressive Treatment Given
Consider Patient History Serial ECG Cardiac Troponin I or T Myoglobin CK-MB C-reactive Protein Magnesium
“Time is Muscle” Chew One Uncoated Adult Aspirin Call 911 in 5 Minutes for Unrelieved Chest
Pain Do Not Drive Self
Mission: Lifeline ◦ www.americanheart.org/
Door-to-Balloon Time: 90 Minutes◦ www.d2balliance.org/
Oxygen Aspirin Morphine Sulfate Thrombolytics
Vasodilators Nitrates Beta Blockers Antidysrhythmic
PCI◦ Balloon Angioplasty◦ Coronary Artery Stents
Bedrest/Bedside Commode Intra-aortic Balloon Pump Glucose Control Daily Weight Low-sodium Clear Liquids Low-fat, Low-cholesterol, Low-sodium Diet
No Caffeine Fluid Restriction Weight Loss Smoking Cessation
Fab Four Cardiac Drugs◦ Antiplatelets◦ Statins◦ ACEIs◦ Beta Blockers
Coronary Artery Bypass Graft◦ Coronary Artery Occlusions Bypassed with
Vein/Artery Grafts◦ Increases Blood Flow/Oxygen to Myocardium
Thoracoscope No Cardiopulmonary Bypass Small Incisions Two Coronary Arteries Maximum
Combines Peripheral Cardiopulmonary Bypass (CPB) with Minimally Invasive Heart Access
Acute Pain Decreased Cardiac Output Activity Intolerance Deficient Knowledge
Pain Ineffective Airway Clearance Impaired Gas Exchange Decreased Cardiac Output Risk for Infection Deficient Knowledge
Monitor Vital Signs Report Symptoms Incisional Care
Disease Information Medications Diet Activity Rehabilitation
Optimizes Functioning Begins in Hospital Protocols Specify Activities Outpatient Program After Discharge
Arterial Venous
Arterial Blood Clot Can Become Embolus
Six Ps◦ Pain ◦ Pulselessness◦ Paralysis ◦ Pallor ◦ Paresthesia ◦ Poikilothermia
Therapeutic Interventions◦ Anticoagulants◦ Thrombolytics◦ Thrombectomy ◦ Embolectomy
Pathophysiology◦ Chronic, Progressive Arterial Narrowing◦ Reduced Blood Supply◦ Ischemia Develops
Intermittent Claudication Cool Skin Reddish-purple When Dependent Pale When Elevated Diminished/Absent Pulses
Ankle-brachial Index Doppler Ultrasound MRI Arteriography
Low-fat, Low-cholesterol, Low-calorie Diet Medications
◦ Lipid-lowering Agents◦ Pentoxifylline (Trental) ◦ Thrombolytics
Invasive Therapies◦ Percutaneous Transluminal Angioplasty (PTA)◦ Atherectomy◦ Stents ◦ Aortic-femoral Bypass
Ineffective Tissue Perfusion ◦ Do Not Elevate Legs
Pain Activity Intolerance Deficient Knowledge
Vasoconstriction with Cold/Stress Causing Ischemia
Mainly Affects Hands Phases: Blanching, Pain, Reddening Therapeutic Intervention: Keep Warm, Avoid
Vasoconstriction, Take Vasodilators
Nursing Care: Education
Recurring Inflammation of Small and Medium Arteries and Veins of Hands/Feet
Vasospasms, Ischemia, Gangrene Cause is Unknown Heavy Cigarette Smoking Contributes
Signs and Symptoms◦ Intermittent Claudication ◦ Six Ps◦ Lower Extremities Red or Cyanotic in Dependent Position
Therapeutic Interventions◦ Smoking Cessation◦ Calcium Channel Blockers◦ Skin Assessment
Dilation at Weakened Area of Artery Cause Unknown Abdominal Aorta Most Common
Fusiform Saccular Dissecting
None Early Back/Flank Pain Classic Pulsating Abdominal Mass Rupture
◦ Severe, Sudden Back, Flank, or Abdominal Pain◦ Shock
CT Scan Abdominal Ultrasound Aortography
Control Hypertension Bypass Graft
◦ Open◦ Endovascular
Acute Pain Ineffective Tissue Perfusion
Education◦ Medication◦ Avoid Lifting◦ Reduce Stress
Postoperative Care
Elongated, Tortuous, Dilated Veins Cause is Unknown Hereditary Varicosities
◦ Primary ◦ Secondary
Contributing Factors◦ Prolonged Standing◦ Pregnancy◦ Obesity
Signs and Symptoms◦ Disfigurement of Lower Extremity◦ Dull Pain ◦ Edema◦ Ulceration
Therapeutic Interventions◦ Reduce Contributing Factors◦ Compression Stockings ◦ Injection Sclerotherapy ◦ Radiofrequency Ablation◦ Laser◦ Surgical Intervention
Damaged/Aging Valves Cause Pooling of Blood in Lower Extremities
Chronic
Result of Chronic Venous Insufficiency Leg/Foot: Edema; Brownish Discoloration;
Hardened, Leathery Skin Stasis Ulcers at Ankle Patient’s Quality of Life Affected
Goal: Decrease Edema/Heal Ulcerations Compression Wraps Bedrest with Elevation of Legs Avoid Prolonged Standing/Sitting Walk Skin Ulcers: Unna Boot, Skin Grafts
Acute Pain Impaired Tissue Integrity Ineffective Health Maintenance
Wound Care Emotional Support
Education◦ Elevate Legs◦ Protect Legs from Injury◦ Do Not Cross Legs/Wear Tight Clothing◦ Avoid Heating Devices◦ Apply Compression from Foot Upward
Acute or Chronic Pain Anxiety Deficient Knowledge
Restores Blood Flow and Oxygenation Can Be Surgical Emergency
Bypass: Graft Anastomosed to Artery Above and Below Occlusion
Graft Repair: Diseased Area of Blood Vessel Replaced with Graft
Video-assisted Aortofemoral Bypass
Arteriosclerotic Plaques Dissected Carotid Artery Common
Open Plaque-blocked Arteries Balloon or Laser
Support to the Artery Walls to Keep Them Open
Bleeding and Hemorrhage Re-occlusion Hematoma Neurological Dysfunction Volume Deficit
Neurological Checks Neurovascular Checks Incision Care Fluid Status
Pain Ineffective Airway Clearance Risk for Infection Ineffective Tissue Perfusion Deficient Knowledge
Inflammation/Infection of Lymphatic Channels
Pain, Red Streak, Chills and Fever Antibiotic, Heat, Elevation, Pneumatic
Pressure Devices Monitor Site
Acute Pain Risk for Excess Fluid Volume