cardiac disorders 2010

CARDIAC DISORDERSCARDIAC DISORDERS

CORONARY ARTERY DISEASE CORONARY ARTERY DISEASE (CAD)(CAD)

DESCRIPTION◦A narrowing or obstruction of one or more

coronary arteries due to atherosclerosis, an accumulation of lipid-containing plaque in the arteries

◦Causes decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply

◦Leads to hypertension, angina, dysrhythmias, myocardial infarction, heart failure, and death


DESCRIPTION◦Collateral circulation, more than one artery

supplying a muscle with blood, is normally present in the coronary arteries, especially in older persons

◦The development of collateral circulation takes time and develops when chronic ischemia occurs to meet the metabolic demands; therefore, an occlusion of a coronary artery in a younger individual is more likely to be lethal than in an older individual


DESCRIPTION◦Symptoms occur when the coronary artery is

occluded to the point that inadequate blood supply to the muscle occurs, causing ischemia

◦Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75%

◦The goal of treatment is to alter the atherosclerotic progression

ATHEROSCLEROSISATHEROSCLEROSISFrom Thibodeau GA, Patton KT: Anatomy and Physiology, ed. 4, St. Louis, 1999, Mosby.


ASSESSMENT◦Findings may be normal during asymptomatic

periods◦Chest pain◦Palpitations◦Dyspnea◦Syncope◦Cough or hemoptysis◦Excessive fatigue


ECG◦When blood flow is reduced and ischemia

occurs, ST segment depression or T wave inversion is noted; the ST segment returns to normal when the blood flow returns

◦With infarction, cell injury results in ST segment elevation, followed by T wave inversion


CARDIAC CATHETERIZATION◦Provides the most definitive source for

diagnosis◦Shows the presence of atherosclerotic lesions


BLOOD LIPID LEVELS◦May be elevated◦Cholesterol-lowering medications may be

prescribed to reduce the development of atherosclerotic plaques


IMPLEMENTATION◦Assist the client to identify risk factors that can

be modified◦Assist the client to set goals to promote

lifestyle changes that will reduce the impact of risk factors

◦Assist the client to identify barriers to compliance with the therapeutic plan and to identify methods to overcome barriers


IMPLEMENTATION◦Instruct the client regarding a low-calorie, low-

sodium, low-cholesterol, and low-fat diet, with an increase in dietary fiber

◦Stress to the client that dietary changes are not temporary and must be maintained for life; instruct the client regarding prescribed medications

◦Provide community resources to the client regarding exercise, smoking reduction, and stress reduction


SURGICAL PROCEDURES◦PTCA to compress the plaque against the walls

of the artery and dilate the vessel◦Laser angioplasty to vaporize the plaque◦Atherectomy to remove the plaque from the

artery◦Vascular stent to prevent the artery from

closing and to prevent restenosis◦Coronary artery bypass graft to improve blood

flow to the myocardial tissue that is at risk for ischemia or infarction due to the occluded artery


MEDICATIONS◦Nitrates to dilate the coronary arteries and to

decrease preload and afterload◦Calcium channel blockers to dilate coronary

arteries and reduce vasospasm◦Cholesterol-lowering medications to reduce the

development of atherosclerotic plaques◦Beta-blockers to reduce blood pressure in

individuals who are hypertensive

ANGINAANGINA

DESCRIPTION◦Chest pain resulting from myocardial ischemia

caused by inadequate myocardial blood and oxygen supply

◦Caused by an imbalance between oxygen supply and demand

◦Causes include obstruction of coronary blood flow due to atherosclerosis, coronary artery spasm, and conditions increasing myocardial oxygen consumption

ANGINAANGINA

DESCRIPTION◦The goal of treatment is to provide relief of an

acute attack, correct the imbalance between myocardial oxygen supply and demand, prevent the progression of the disease and further attacks to reduce the risk of MI

ANGINAANGINA

STABLE ANGINA◦Also called exertional angina◦Occurs with exertion or emotional stress, and is

relieved with rest or nitroglycerin◦It usually has a stable pattern of onset,

duration, severity, and relieving factors

ANGINAANGINA

UNSTABLE ANGINA◦Also called preinfarction angina◦Occurs with an unpredictable degree of

exertion or emotion and increases in occurrence, duration, and severity over time

◦Pain may not be relieved with nitroglycerin

ANGINAANGINA

INTRACTABLE ANGINA◦A chronic, incapacitating angina that is

unresponsive to interventionsPOSTINFARCTION ANGINA

◦Occurs after an MI, when residual ischemia may cause episodes of angina

ANGINAANGINA

ASSESSMENT: PAIN◦Can develop slowly or quickly◦Usually described as mild or moderate pain◦Substernal, crushing, squeezing pain◦May radiate to the shoulders, arms, jaw, neck,

back◦Usually lasts less than 5 minutes; however, can

last up to 15 to 20 minutes◦Relieved by nitroglycerin or rest

ANGINAANGINA

ASSESSMENT◦Dyspnea◦Pallor◦Sweating◦Palpitations and tachycardia◦Dizziness and faintness◦Hypertension◦Digestive disturbances

ANGINAANGINA

ECG◦Normal during rest, with ST depression or

elevation and/or T wave inversion during an episode of pain

STRESS TEST◦Chest pain or changes in the ECG or vital signs

during testing may indicate ischemiaCARDIAC ENZYMES

◦Normal findings in anginaCARDIAC CATHETERIZATION

◦Provides a definitive diagnosis

ANGINAANGINA

IMMEDIATE MANAGEMENT◦Assess pain◦Provide bed rest◦Administer oxygen at 3 L via nasal cannula as

prescribed◦Administer nitroglycerin as prescribed to dilate

the coronary arteries, reduce the oxygen requirements of the myocardium, and relieve the chest pain

◦Obtain a 12-lead ECG◦Provide continuous cardiac monitoring

ANGINAANGINA

FOLLOWING ACUTE EPISODE◦Assist the client to identify angina-precipitating

events◦Instruct the client to stop activity and rest if

chest pain occurs and to take nitroglycerin as prescribed

ANGINAANGINA

FOLLOWING ACUTE EPISODE◦Instruct the client to seek medical attention if

pain persists◦Instruct the client regarding prescribed

medications◦Provide diet instructions to the client, stressing

that dietary changes are not temporary and must be maintained for life

◦Assist the client to identify risk factors that can be modified

ANGINAANGINA

FOLLOWING ACUTE EPISODE◦Assist the client to set goals that will promote

changes in lifestyle to reduce the impact of risk factors

◦Assist the client to identify barriers to compliance with therapeutic plan and to identify methods to overcome barriers

◦Provide community resources to the client regarding exercise, smoking reduction, and stress reduction

ANGINAANGINA

SURGICAL PROCEDURES◦Same procedures performed to treat CAD

MEDICATIONS◦Same medications used to treat CAD◦Antiplatelet therapy may be prescribed to

inhibit platelet aggregation and reduce the risk of developing an acute MI

MYOCARDIAL INFARCTION (MI)MYOCARDIAL INFARCTION (MI)

DESCRIPTION◦Occurs when myocardial tissue is abruptly and

severely deprived of oxygen◦Ischemia can lead to necrosis of myocardial

tissue if blood flow is not restored◦Infarction does not occur instantly, but evolves

over several hours◦Obvious physical changes do not occur in the

heart until 6 hours after the infarction, when the infarcted area appears blue and swollen


DESCRIPTION◦After 48 hours, the infarct turns gray with

yellow streaks as neutrophils invade the tissue◦By 8 to 10 days after infarction, granulation

tissue forms◦Over 2 to 3 months, the necrotic area develops

into a scar; scar tissue permanently changes the size and shape of the entire left ventricle

ACUTE MYOCARDIAL INFARCTIONACUTE MYOCARDIAL INFARCTION5 TO 7 DAYS OLD5 TO 7 DAYS OLD

From Kumar V, Cotran RS, Robbins SL: Basic Pathology, ed. 6, Philadelphia, 1997, W.B. Saunders.


LOCATION OF MI◦Obstruction of the left anterior descending

(LAD) artery results in anterior and/or septal MI or both

◦Obstruction of the circumflex artery results in posterior wall MI or lateral wall MI

◦Obstruction of the right coronary artery results in inferior wall MI

COMMON LOCATIONS OF MICOMMON LOCATIONS OF MIFrom Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.


TOTAL CK LEVELS◦Rise within 3 hours after the onset of chest pain◦Peak within 24 hours after damage and death

of cardiac tissue CK-MB ISOENZYME

◦Peak elevation occurs 12 to 24 hours after the onset of chest pain

◦Levels return to normal 48 to 72 hours later


TROPONIN LEVELS◦Rise within 3 hours◦Remain elevated for up to 7 days

MYOGLOBIN◦Rises within 1 hour after cell death, peaks in 4

to 6 hours, and returns to normal within 24 to 36 hours or less


LDH LEVELS◦Rise within 12 to 24 hours after MI◦Peak between 40 and 72 hours and fall to

normal in 7 days◦Serum levels of LDH1 isoenzyme rise higher

than serum levels of LDH2

WHITE BLOOD CELL (WBC) COUNT ◦An elevated count of 10,000 to 20,000

cells/mm3 appears on the second day following the MI and lasts up to a week


ECG◦ST segment elevation, T wave inversion,

abnormal Q wave◦Hours to days after the MI, ST and T wave

changes will return to normal but the Q wave usually remains permanently abnormal

ECG PATTERNSECG PATTERNSFrom Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders


DIAGNOSTIC TESTS FOLLOWING ACUTE STAGE◦ Exercise tolerance test or stress test: prescribed to

assess for ECG changes and ischemia and to evaluate for medical therapy or identify clients who may need invasive therapy

◦ Thallium scans: prescribed to assess for ischemia or necrotic muscle tissue

◦ MUGA scans: Used to evaluate left ventricular function◦ Cardiac catheterization: Performed to determine the

extent and location of obstructions of the coronary arteries


ASSESSMENT: PAIN ◦Crushing substernal pain◦May radiate to the jaw, back, and left arm◦Occurs without cause, primarily early in the

morning◦Is unrelieved by rest or nitroglycerin, and

relieved only by opioids◦Lasts 30 minutes or longer

POSSIBLE EXTENT OF PAIN FROM POSSIBLE EXTENT OF PAIN FROM MIMI From Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6,

Philadelphia: W.B. Saunders


ASSESSMENT◦Nausea and vomiting◦Diaphoresis◦Dyspnea◦Dysrhythmias◦Feelings of fear and anxiety◦Pallor, cyanosis, coolness of extremities


COMPLICATIONS OF MI◦Dysrhythmias◦Heart failure◦Pulmonary edema◦Cardiogenic shock◦Thrombophlebitis◦Pericarditis◦Mitral valve insufficiency


COMPLICATIONS OF MI◦Postinfarction angina◦Ventricular rupture◦Dressler’s syndrome (a combination of

pericarditis, pericardial effusion, and pleural effusion, which can occur several weeks to months following an MI)

MAJOR COMPLICATIONS OF ACUTE MAJOR COMPLICATIONS OF ACUTE MIMI From O’Rourke RA (1982) The bedside diagnosis of the complications of myocardial

infarction. In R.S. Eliot (ed.) Cardiac Emergencies. Mount Kisco, NY: Futura Publishing.


ACUTE STAGE◦Obtain a description of the chest discomfort◦Assess vital signs◦Assess cardiovascular status and maintain

cardiac monitoring◦Obtain a 12-lead ECG◦Administer nitroglycerin as prescribed ◦Administer morphine sulfate as prescribed to

relieve chest discomfort that is unresponsive to nitroglycerin


ACUTE STAGE◦Administer oxygen at 2 to 4 liters by nasal

cannula as prescribed◦Place the client in semi-Fowler’s position to

enhance comfort and tissue oxygenation◦Establish an IV access route◦Administer IV nitroglycerin and

antidysrhythmics as prescribed


ACUTE STAGE◦Monitor thrombolytic therapy, which may be

prescribed within the first 6 hours of the coronary event

◦Monitor for signs of bleeding if the client is receiving thrombolytics

◦Monitor laboratory values as prescribed◦Administer beta-blockers to slow the heart rate

and increase myocardial perfusion, while reducing the force of myocardial contraction, as prescribed


ACUTE STAGE◦Monitor for complications related to the MI◦Monitor for cardiac dysrhythmias, since

tachycardia and PVCs frequently occur in the first few hours after MI

◦Assess distal peripheral pulses and skin temperature, since poor cardiac output may be identified by cool, diaphoretic skin and diminished or absent pulses


ACUTE STAGE◦Monitor I&O◦Assess respiratory rate and breath sounds for

signs of heart failure, as indicated by the presence of crackles or wheezes or dependent edema

◦Monitor the BP closely after the administration of medications; if the BP is less than 100 systolic or 25 mmHg lower than the previous reading, lower the head of the bed and notify the physician

◦Provide reassurance to the client and family


FOLLOWING ACUTE STAGE◦Maintain bed rest for the first 24 to 36 hours◦Allow the client to stand to void or use a

bedside commode if prescribed◦Provide range-of-motion exercises to prevent

thrombus formation and maintain muscle strength

◦Progress to dangling at the side of the bed or out of bed to the chair for 30 minutes three times a day as prescribed


FOLLOWING ACUTE STAGE◦Progress to ambulation in the client’s room and

to the bathroom, then in the hallway, three times a day

◦Monitor for complications ◦Encourage the client to verbalize feelings

regarding the MICARDIAC REHABILITATION

◦Process of actively assisting the client with cardiac disease to achieve and maintain a vital and productive life within the limitations of the heart disease

HEART FAILUREHEART FAILURE DESCRIPTION

◦The inability of the heart to maintain adequate circulation to meet the metabolic needs of the body, due to an impaired pumping capability

◦Cardiac output is diminished, and peripheral tissue is not adequately perfused

◦Congestion of the lungs and periphery may occur

HEART FAILUREHEART FAILURE

ACUTE◦Occurs suddenly

CHRONIC◦Develops over time; however, a client with

chronic heart failure can develop an acute episode

TYPES OF HEART FAILURETYPES OF HEART FAILURERIGHT-SIDED/LEFT-SIDED HEART FAILURE

◦Because the two ventricles of the heart represent two separate pumping systems, it is possible for one to fail alone for a short period

◦Most heart failure begins with left ventricular failure and progresses to failure of both ventricles

◦Acute pulmonary edema, a medical emergency, results from left ventricular failure

◦If pulmonary edema is not treated, death will occur from suffocation as the client literally drowns in own fluids

TYPES OF HEART FAILURETYPES OF HEART FAILURE

FORWARD FAILURE/BACKWARD FAILURE◦In forward failure, an inadequate output of the

affected ventricle causes decreased perfusion to vital organs

◦In backward failure, blood backs up behind the affected ventricle, causing increased pressure in the atrium behind the affected ventricle

TYPES OF HEART FAILURETYPES OF HEART FAILURELOW OUTPUT/HIGH OUTPUT

◦In low-output failure, not enough cardiac output is available to meet the demands of the body

◦High-output failure occurs when a condition causes the heart to work harder to meet the demands of the body

TYPES OF HEART FAILURETYPES OF HEART FAILURE

SYSTOLIC FAILURE/DIASTOLIC FAILURE◦Systolic failure leads to problems with

contraction and the ejection of blood◦Diastolic failure leads to problems with the

heart relaxing and filling with blood

Include increased heart rate, improved stroke volume, arterial vasoconstriction, sodium and water retention, and myocardial hypertrophy

Act to restore cardiac output to near normal levels

Initially these mechanisms increase cardiac output; however, they eventually have a damaging effect on pump action

Contribute to an increase in myocardial oxygen consumption and when this occurs, myocardial reserve is exhausted and clinical manifestations of heart failure develop

HEART FAILURECOMPENSATORY MECHANISMS

HEART FAILUREHEART FAILURE ASSESSMENT: RIGHT-SIDED HEART

FAILURE◦Signs will be evident in the systemic circulation◦Pitting, dependent edema in the feet, legs,

sacrum, back, buttocks◦Ascites from portal hypertension◦Tenderness of right upper quadrant,

organomegaly◦Distended neck veins

HEART FAILUREHEART FAILURE ASSESSMENT: RIGHT-SIDED HEART

FAILURE◦Pulsus alterans (regular alteration of weak and

strong beats noted in the pulse)◦Abdominal pain, bloating◦Anorexia, nausea◦Fatigue◦Weight gain◦Nocturnal diuresis

RIGHT-SIDED HEART RIGHT-SIDED HEART FAILUREFAILURE

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

HEART FAILUREHEART FAILURE ASSESSMENT: LEFT-SIDED HEART FAILURE

◦Signs will be evident in the pulmonary system◦Cough, which may become productive with

frothy sputum◦Dyspnea upon exertion◦Orthopnea◦Paroxysmal nocturnal dyspnea◦Presence of rales or crackles on auscultation◦Tachycardia


ASSESSMENT: LEFT-SIDED HEART FAILURE◦Pulsus alterans◦Fatigue◦Pallor◦Cyanosis◦Confusion and disorientation◦Signs of cerebral anoxia

LEFT-SIDED HEART FAILURELEFT-SIDED HEART FAILUREFrom Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

APPEARANCE OF A CLIENT WITH APPEARANCE OF A CLIENT WITH HEART FAILUREHEART FAILURE

From Mayo Clinic Health Letter (1997) 15:1-3. Mayo Foundation for Medical Education and Research, Rochester, MN. By permission of Mayo Foundation.

HEART FAILUREHEART FAILURE ASSESSMENT: ACUTE PULMONARY EDEMA

◦Severe dyspnea and orthopnea◦Pallor◦Tachycardia◦Expectoration of large amounts of blood-tinged,

frothy sputum◦Wheezing and rales◦Bubbling respirations

HEART FAILUREHEART FAILURE ASSESSMENT: ACUTE PULMONARY EDEMA

◦Acute anxiety, apprehension, restlessness◦Profuse sweating◦Cold, clammy skin◦Cyanosis◦Nasal flaring◦Use of accessory breathing muscles◦Tachypnea◦Hypocapnia evidenced by muscle cramps, weakness,

dizziness, and paresthesias


ACUTE STAGE◦Place the client in high-Fowler's position with

the legs in a dependent position to reduce pulmonary congestion and relieve edema

◦Administer oxygen in high concentrations by mask or cannula as prescribed to improve gas exchange and pulmonary function

◦Prepare for intubation and ventilator support if required; monitor lung sounds for rales and decreased breath sounds


ACUTE STAGE◦Suction as needed to maintain a patent airway◦Assess level of consciousness◦Provide reassurance to the client◦Monitor vital signs closely noting tachycardia or

pulsus alterans◦Monitor for hypotension due to decreased

tissue perfusion, or hypertension due to anxiety or history of hypertension


ACUTE STAGE◦Monitor heart rate and dyrhythmias using a cardiac

monitor ◦Assess for edema in dependent areas and in the sacral,

lumbar, and posterior thigh region in the client on bed rest

◦Insert a Foley catheter as prescribed and monitor urine output closely following administration of a diuretic

◦Monitor I&O


ACUTE STAGE◦Avoid the administration of unnecessary IV

fluids◦Administer morphine sulfate as prescribed to

provide sedation and vasodilation, and monitor for respiratory depression or hypotension after administration

◦Administer diuretics as prescribed to reduce preload, enhance renal excretion of sodium and water, reduce circulating blood volume, and reduce pulmonary congestion

HEART FAILUREHEART FAILURE ACUTE STAGE

◦Administer digitalis as prescribed to increase ventricular contractility and improve cardiac output

◦Administer bronchodilators as prescribed for severe bronchospasm or bronchoconstriction

◦Administer additional inotropic medications such as dopamine (Intropin) or dobutamine (Dobutrex) as prescribed to facilitate myocardial contractility and enhance stroke volume


ACUTE STAGE◦Administer vasodilators as prescribed to

reduce afterload, increase the capacity of the systemic venous bed, and decrease venous return to the heart

◦Monitor weight to determine a response to treatment

◦Assess for hepatomegaly and ascites and measure and record abdominal girth


ACUTE STAGE◦Monitor peripheral pulses◦Analyze arterial blood gas results and evaluate

electrolyte values for imbalances◦Monitor potassium level closely, which may decrease

due to diuretic therapy, and administer potassium supplements as prescribed to prevent digitalis toxicity


FOLLOWING ACUTE STAGE◦Encourage the client to verbalize feelings about

the lifestyle changes required as a result of the heart failure

◦Assist the client to identify precipitating risk factors of heart failure and methods of eliminating these risk factors

HEART FAILUREHEART FAILURE CLIENT EDUCATION

◦Prescribed medication regimen, which may include digoxin (Lanoxin), a diuretic, and vasodilators

◦Notify the physician if side effects occur from the medications

◦Avoid over-the-counter medications◦Contact the physician if unable to take

medications due to illness


◦Avoid large amounts of caffeine found in coffee, tea, cocoa, chocolate, and some carbonated beverages

◦Prescribed low-sodium, low-fat, and low-cholesterol diet

◦Provide the client with a list of potassium-rich foods because diuretics will cause hypokalemia (except for potassium-sparing diuretics)


◦Fluid restriction, if prescribed, advising the client to spread the fluid out during the day, and to suck on hard candy to reduce thirst

◦Space periods of activity and rest◦Avoid isometric activities that increase pressure in

the heart◦Monitor daily weight and report signs of fluid

retention such as edema or weight gain

CARDIOGENIC SHOCKCARDIOGENIC SHOCK

DESCRIPTION◦Failure of the heart to pump adequately,

thereby reducing cardiac output and compromising tissue perfusion

◦Necrosis of more than 40% of the left ventricle occurs usually as a result of occlusion of major coronary vessels

◦The goal of treatment is to maintain tissue oxygenation and perfusion and improve the pumping ability of the heart


ASSESSMENT◦Hypotension: BP less than 90 mmHg systolic or

30 mmHg less than the client’s baseline◦Urine output of less than 30 ml/hour◦Cold, clammy skin◦Poor peripheral pulses◦Tachycardia, tachypnea◦Pulmonary congestion◦Disorientation, restlessness, and confusion◦Continuing chest discomfort


IMPLEMENTATION◦Administer IV morphine sulfate as prescribed to

decrease pulmonary congestion and relieve pain

◦Administer oxygen as prescribed◦Prepare for intubation and mechanical

ventilation◦Administer diuretics and nitrates as prescribed

while monitoring blood pressure constantly


IMPLEMENTATION◦Administer vasopressors and positive inotropics

as prescribed to maintain organ perfusion◦Prepare the client for insertion of an intraaortic

balloon pump (IABP), if prescribed, to facilitate emptying of the left ventricle and improve cardiac output

◦Prepare the client for immediate reperfusion procedures such as PTCA or CABG

INTRAAORTIC BALLOON PUMPINTRAAORTIC BALLOON PUMPFrom Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.


IMPLEMENTATION◦Monitor urinary output ◦Monitor arterial blood gas levels and prepare to

treat imbalances◦Assist with the insertion of Swan-Ganz catheter

to assess heart failure◦Monitor distal pulses and maintain the

transducer at the level of the right atrium if the client has a Swan-Ganz catheter

cardiac disorders 2010

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