Caring for Patients With Coronary Heart Disease and Dysrhythmias

1. Caring for Patients With Coronary Heart Disease and Dysrhythmias

2. Learning Outcomes • Describe the causes, pathophysiology, effects, and manifestations of coronary heart disease and heart rhythm disruptions. • Differentiate among the effects of coronary heart disease: angina pectoris, acute coronary syndrome, and myocardial infarction.

3. Learning Outcomes • Discuss nursing implications, and safely administer drugs commonly prescribed for patients with coronary heart disease or dysrhythmias. • Provide culturally sensitive individualized nursing care for patients undergoing invasive procedures or surgery of the heart.

4. Learning Outcomes • Use the nursing process to conduct a focused assessment, contribute to care planning, and provide nursing care based on patient values, preferences, and expressed needs for patients with coronary heart disease and dysrhythmias.

5. Learning Outcomes • Provide and reinforce appropriate and evidence-based teaching for patients with coronary heart disease or dysrhythmias and their families. • Use electronic resources to plan and document nursing care and teaching for patients with coronary heart disease or dysrhythmias.

6. Coronary Heart Disease • Leading cause of death in U.S. • Narrowing coronary arteries • Atherosclerosis • May have: • No symptoms • Angina pectoris • An event such as ACS or myocardial infarction

7. Risk Factors • Age • Gender • Ethnicity • Heredity

8. Risk Factors • Physiologic risk factors • Hypertension • Diabetes • High blood lipids (hyperlipidemia) • Metabolic syndrome

9. Risk Factors • Lifestyle risk factors • Smoking • Obesity • Diet • Physical inactivity

10. Classification of Cholesterol and LDL Levels

11. Pathophysiology • Atherosclerosis • Atheromas develop in lining of medium, large arteries. • Cause unknown • Plaque occludes vessel lumen. • Leads to ischemia • Cells do not have enough blood and oxygen to meet their metabolic needs.

12. Manifestations • Symptom free until about 75% of lumen of affected vessels occluded • Symptoms indicating myocardial ischemia • Angina pectoris • Acute myocardial infarction

13. Collaborative Care • Diagnostic tests • Total serum cholesterol • Lipid panel • Plasma levels of C-reactive protein • Blood glucose levels • Ankle-brachial index

14. Collaborative Care • Risk factor management • Smoking • Diet • Exercise • Blood pressure and diabetes

15. Collaborative Care • Medications • Statins • Teach common side effects • Headache, gastrointestinal upset • Rhabdomyolysis • Muscle aches, skin rashes • Liver function tests and muscle enzymes are monitored.

16. Collaborative Care • Medications • Nicotinic acid • Flushing, pruritis • Cholesterol binding • Gastrointestinal side effects

17. Nursing Care • Teach smoking cessation • Healthy weight • Exercise • Control high blood pressure, diabetes, lipid levels • Reduce stress

18. Angina Pectoris • Chest pain that occurs when there is a temporary imbalance between myocardial blood supply and demand • Pattern • Exercise brings on pain. • Rest relieves pain.

19. Pathophysiology • Obstructed coronary artery • Increased myocardial oxygen demand • Lactic acid release leads to pain. • Three types • Stable • Unstable • Prinzmetal

20. Manifestations • Chest pain • Radiates • Onset • With exercise • In women, associated with stress, strong emotions • Relieved by rest, nitroglycerin (NTG) • SOB, pallor, fear

21. Collaborative Care • Diagnostic tests • Electrocardiography • May be normal if patient resting • Imaging studies • PET or EBCT • Echocardiogram • TEE • Radionuclear scanning • Coronary angiography

22. Collaborative Care • Medications • Acute management • Sublingual nitroglycerin (NTG) • Rapid-acting spray • Chronic management • NTG • Beta blockers • Calcium channel blockers • Low-dose aspirin

23. Nursing Care • Prioritizing nursing care • Maintain adequate coronary blood flow, perfusion of heart muscle. • Health promotion • Managing risk factors • Assessing • Pain • History of heart disease • Risk factors

24. Nursing Care • Identifying potential complications • Acute myocardial infarction • Other acute cardiac events • Promptly report chest pain unrelieved by BTG or accompanied by SOB, anxiety, clammy skin.

25. Nursing Care • Diagnosing, planning, and implementing • Risk for acute pain • Readiness for enhanced self-health management • Angina teaching • Medications • Cardiac rehabilitation program

26. Nursing Care • Evaluating • Management of episodes • Documenting • Frequency, duration, and precipitating factors • Continuity of care • Safe medication storage and use • When to go to ED

27. Acute Coronary Syndrome/Unstable Angina • Condition that includes: • Unstable angina (UA) • Acute myocardial ischemia with or without muscle damage • Associated with coronary artery stenosis and atherosclerotic plaque

28. Pathophysiology • Coronary artery stenosis • Atherosclerotic plaque • Rupture, erosion of plaque • Blood clot at the site • Coronary muscle spasm

29. Collaborative Care • Diagnostic tests • ECG • Serum markers • Medications • Nitrates and beta blockers to reduce myocardial ischemia • Fibrinolytic drugs to prevent clotting

30. Collaborative Care • Surgery and revascularization procedures • Percutaneous coronary intervention (PCI) • Balloon angioplasty • Atherectomy • Coronary artery bypass graft (CABG)

31. Collaborative Care • Surgery and revascularization procedures • Cardiopulmonary bypass pump • Minimally invasive coronary artery surgery • Transmyocardial laser revascularization

32. Nursing Care • Prioritizing nursing care • Restore blood flow, oxygenation of heart • Prevent complications, future episodes • Health promotion • Prevent, slow progression of CHD • Assessing • Symptoms, previous episodes • Medications

33. Nursing Care • Identifying potential complications • Dysrhythmias, sudden cardiac death • Diagnosing, planning, and implementing • Risk for acute pain • Risk for bleeding • Managing nursing care • Vital signs once stable

34. Nursing Care • Evaluating • Free from complications • Documenting • Apparent understanding of information, need for follow-up treatment • Continuity of care • Teaching to slow progression • Preoperative teaching when surgery anticipated

35. Acute Myocardial Infarction • Cells in area of cardiac muscle infarct or necrose (die) due to lack of blood, oxygen • Life-threatening event leading to cardiogenic shock and death • Most deaths within first hour of manifestations

36. Pathophysiology • Occluded coronary artery stops blood flow to part of cardiac muscle. • Cellular death • Tissue necrosis • Description of heart area affected • Classification

37. Manifestations • Chest pain • Radiates to shoulder, neck, jaw, arms • Lasting longer than 15–20 minutes • Not relieved with NTG • Sense of impending doom • SOB • Diaphoresis • Nausea and vomiting

38. Manifestations • In women and elderly • May be atypical • Upper abdominal pain • No chest pain but other symptoms • Cocaine-induced myocardial infarction • Increased workload of heart • Risk of dysrhythmias

39. Complications • Related to size and location of infarct • Dysrhythmias • Sinus tachycardia • Pump failure • Cardiogenic shock • Other complications • Pericarditis • Extension or expansion

40. Collaborative Care • Diagnostic tests • Serum cardiac markers • Electrocardiography • Echocardiography • Myocardial nuclear scans • Myocardial perfusion imaging scans

41. Collaborative Care • Medical management • Monitoring • IVF • Oxygen • Bed rest with bedside commode • Quiet calm environment

42. Collaborative Care • Medications • Pain relief • Antianxiety • Fibrinolytic agents • Bleeding disorders • Care during infusion • Care postinfusion

43. Collaborative Care • Medications • Aspirin • Heparin • Antidysrhythmic medications • Beta blockers • ACE inhibitors • IV NTG

44. Collaborative Care • Revascularization • Immediate, early intervention • Angioplasty with stent • Other invasive procedures • IABP (intra-aortic balloon pump) • VADs (vascular assist devices)

45. Collaborative Care • Cardiac rehabilitation • Planned program of activity, psychologic support, and education • Supervised outpatient program • Lifetime maintenance • Interprofessional team

46. Nursing Care • Prioritizing nursing care • Reduce workload of heart • Eliminate pain • Maintain CO and tissue perfusion • Health promotion • Risk factor management • Importance of promptly seeking medical care

47. Nursing Care • Assessing • Pain • Evidence of adequate tissue perfusion • Physical assessment findings • Immediate and hourly • ECG • Identifying potential complications • Continuously monitor heart rhythm

48. Nursing Care • Diagnosing, planning, and implementing • Acute pain • Signs of pain • Oxygen • Physical and psychologic rest • Morphine • Ongoing chest pain

49. Nursing Care • Diagnosing, planning, and implementing • Decreased cardiac output • Change in heart rate, rhythm • LOC • Skin appearance • Heart and breath sounds • ECG

50. Nursing Care • Diagnosing, planning, and implementing • Decreased cardiac output • Antidysrhythmics as prescribed • Ineffective coping • Trust • Denial • Anger • Coping skills