coronary disease management - nursececoronary artery disease. identify the signs and symptoms of...

Coronary Disease Management

© National Center of Continuing Education Coronary Disease Management Page 1

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Copyright © 2012W.S. Keefer All rights reserved Published by the National Center of Continuing Education, Inc., Lakeway, Texas. Printed in the United States of America.

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HEART SMART: CORONARY DISEASE MANAGEMENT

Course # 207

Contact Hours: 5 Hours

Author:

Course Material valid through 07/2015

©

E L SEnhanced Learning & Skills...

No Exams,

Just Learning!Testing Mandatory

For Florida & Electrologists Only

Coronary Disease Management © National Center of Continuing Education

About the Author and Editor ...........................3

Purpose and Goals ............................................3

Instructional Objectives ....................................3

Introduction .......................................................3

Pathophysiology Review of Atherosclerosis and

Coronary Artery Disease ..................................3

Risk Factors .......................................................4

..........................................................4

Hypertension ...........................................4

Table 1 .....................................................4

Cigarette Smoking ..................................5

Elevated Serum Cholesterol ................... 5

Diabetes Mellitus ....................................5

Obesity .....................................................5

Table 2 .....................................................5

Diet High in Saturated Fat ..................... 6

Elevated Serum Triglycerides ................ 6

Lack of Exercise .......................................6

Oral Contraceptives ................................6

Stress .......................................................6

Symptoms ..........................................................6

Stable Angina ..........................................6

Table 3 .....................................................6

Unstable Angina ......................................7

Variant Angina ........................................7

Test & Exams ....................................................7

Stress Testing ..........................................7

Electrocardiogram (EKG) .......................7

Echocardiography ....................................7

Coronary Arteriography ..........................7

Nuclear Scan ...........................................7

Physical Examination .............................7

Laboratory Tests .....................................7

Strategies for Effective Patient Education ...... 7

The Adult and Elderly Learner .............. 8

Principles of Teaching/Learning ............. 8

Motivation for Lifestyle Changes ........... 9

Effective Programs to

Promote Wellness ..................................10

Heart Risk Assessment Tool ................. 10

Managing Risks: Strategies for Success ........ 10

Hypertension .........................................10

Are you at Risk for Heart Disease? ...... 11

Table 4 ...................................................12

Smoking .................................................13

Elevated Serum Cholesterol ................. 13

Type 2 Diabetes .....................................14

Obesity ...................................................14

Table 5 ...................................................15

Diet High in Saturated Fat ...................16

Elevated Serum Triglycerides .............. 16

Lack of Exercise .....................................16

Stress .....................................................17

Pharmaceutical Management ........................17

Beta Blockers .........................................17

Statins ....................................................17

Ace Inhibitors ........................................17

Antiplated Agents .................................17

Calcium Channel Blockers ...................17

Nitrates ..................................................17

Alternative Treatments ..................................17

Summary .........................................................19

Resources .........................................................19

Play It Smart, Take Care of Your Heart ....... 19

Nutrient Breakdown .................................20-21

References and Suggested Readings .............. 22


Denise Warren, RN, BSN, has been a nurse educator in a hospital setting. In this capacity, she has authored con-tinuing education materials for nursing staff as well as training and competency manuals for Med/Surg Units. She has worked closely and counseled patients on heart disease in an outpatient setting. She continues to write health-related ar-ticles and continuing education courses.

Shelda L. Hudson, RN, BSN, PHN, completed her Baccalaureate Degree

National Center of Continuing Educa-tion. In this capacity, she is responsible

-

authors for the courses offered by the

of required course design and criteria. -

in continuing education for health care professionals with the National Center.

Coronary artery disease (CAD) affects

course will help you identify symptoms of CAD, and become well-acquainted

goal of this course will also assist you with patient education to help identify

modifying them. Many CAD risk factors are within the client’s control. Now you can help your clients regain control of their health.

1. Recall the pathophysiology of coronary artery disease.Identify the signs and symptoms of coronary artery disease.

3. Identify the major and secondary risk factors associated with coronary artery disease.

4. I d e n t i f y c l i n i c a l t e s t s a n d

artery disease. 5. State the pathophysiological changes

6. patient education.

7. List characteristics of the adult and elderly learner.

8. Identify principles of teaching/learning that guide the education of the client.

9. will assist the client to meet the goals set.

Name the components of an

coronary artery disease.11.

medications used in the treatment of coronary artery disease.

Identify at least one strategy that will assist the client in managing each

Coronary artery disease (CAD) is the leading cause of death in the United States for both men and woman. Accord-ing to the Centers for Disease Control

die from this lethal disease annually. Re-search has shown that CAD is the most common type of heart disease, and was

recent year. In another study, CAD cost

to reduce the onset of CAD.

of this disease by being knowledgeable of the risk factors associated with the

nurse with the risk factors, particularly

-gies for success will be emphasized.

a major role in research and education for this disease. A consensus panel from the AHA has strongly urged that a multidisciplinary approach - including physician, nurse and dietitian - manage

-

of life, decrease the need for surgical procedures, and reduce the incidence of myocardial infarction.

Current research includes many strat-

disease. Ongoing research includes the effect of community-based health

-tional strategies, effects of lowering cholesterol and triglycerides, gender

nurse should keep abreast of the latest

Coronary artery disease (CAD) is -

of CAD is obstruction to the blood

conditions include atherosclerosis, arte-riosclerosis, arteritis, -coronary artery spasms, coronary thrombosis, coronary embolus and infectious diseases. Hyper-tension plays a major role in -causing the disease, with atherosclerosis and

syndromes leading to CAD. Atherosclerosis, a common arte-

rial disorder characterized by yellowish plaques of cholesterol, lipids and cellular debris in the inner layers of the walls of arteries, results from alteration in the

will recall that the artery is composed of three layers: the intima, the media,

of atherosclerosis is fatty streaks along the intima and media. Research has demonstrated that the lipoproteins (the


risk factors. See Table 1 for factors that contribute to CAD.

regarding the pathophysiology of each

working with the client regarding the elimination or reduction of risk factors.

most of the factors can be eliminated

Hypertension, often called the silent disease, is one of the major contributors to coronary artery disease. In adults, pre-hypertension is when systolic pressure is

I Hypertension is characterized when the

present when the systolic pressure mea-

-sure is the pressure against the walls of the arteries during the contraction of the heart and diastolic is the pressure when

-

the wall of the artery constantly, causing damage and injury to the lining of the ar-

through the lining more easily due to the

increase the wall to lumen ratio of the

time, this stress on the wall of the arteries contributes to fatigue and rupture of the arterial walls and plaques deposited on

Current treatments include angiotensin-

beta blockers, thiazide diuretics, angio-

muscle of the artery.

streaks change to plaques. Low density lipoprotein (LDL) and other substances such as prostaglandins and hormones

-

process is slow, it starts early, pointing out the importance of early risk reduction strategies beginning in childhood.

continuous increase in perfusion pres-sure results in hypertrophy of the smooth

size, shape, and cytoplasm of the en-dothelium, intima, and smooth muscle

and hypertension, continue the damaging process to the coronary artery.

Are there gender differences regard-ing CAD? It is not widely recognized that the most common cause of death in women, as well as men, is coronary artery disease. In the United States half of the deaths are attributed to women.

Because of this, CAD in women has been considered an elderly woman’s problem.

to be fatal. A recent study from the -

of myocardial infarction from coronary artery disease has increased in 35 to 54-year-old women, while decreasing in similarly aged men.

risks are considered major risks, it is the combination of risks that increases

-

cigarette smoking. Some factors cannot

discussion will focus on the factors that

Table 1

Major Risk Factors

Secondary Risk Factors

-

Terms


tension-receptor-blockers (ARBs) and calcium antagonists.

Research is focused on calcium medi-

-ercise are important therapeutic regimes to be utilized with the pharmaceutical treatment.

Although the pathophysiology linking

with hypertension, it is clear that smok-

-

Platelet aggregation and thrombosis are increased in smokers, leading to a decreased diameter of the arterial lumen

Density Lipoproteins (HDLs) are also lowered by smoking.

showed this as a major risk factor. One study showed that smoking cessation

good news is that after a year of smok-ing cessation, the risk of CAD declines

information to share with clients.

In order for fat, as a source of energy, to be utilized by the membranes of the

different types of particles to transport

particles are made up of proteins, phos-

pholipids, and free cholesterol. Plasma

low-density lipoprotein cholesterol -

-

the form of plaque. --

onstrated a direct relationship between total cholesterol and coronary disease

directly associated with an increased in-

-times known as the “good cholesterol”)

indicated to reduce death and disability in middle-aged men.

Up until recently, coronary artery -

shows that HDL-cholesterol is the most common abnormality associated with

suggested that heart attacks did not occur

coronary artery disease remains a risk

the theory that both men and women can

balance. (See Table 3 for blood choles-

Atherosclerosis is correlated with the glucose intolerance associated with

of alterations in carbohydrate and fat

incidence of atherosclerosis is higher among those with diabetes mellitus than

diabetes mellitus are also more likely to

-chrony to increase plaque formation.

-cumulation of fat on the body. When one

weight, and body structure, this creates a problem with -respiration and circula-tion. Abdominally distributed obesity seems to be especially highly correlated with atherosclerosis. Closely associated with -obesity are hypertension, hyper-

Table 2 Categories for Blood Pressure Levels in Adults (measured in millimeters of

mercury, or mmHg)

Category Systolic (top

number) Diastolic (bottom

number)

Normal Less than 120 And Less than 80

Prehypertension 120–139 Or 80–89

High blood pressure

Stage 1 140–159 Or 90–99

Stage 2 160 or higher Or 100 or higher

Table 2


carbohydrate tolerance, sedentary life-

As you can see, reducing weight may -

of the heart requires increased circulation to the coronary arteries. As a result, the

increased work and blocked arteries.

Another factor related to cholesterol and obesity is a diet high in saturated

primarily from animals. It is present in meats, dairy products, coconut oil, palm oil, chocolate, nondairy whipped toppings and coffee creamer. Saturated

-glycerides in the blood are not an in-dependent risk factor in CAD, there is an indirect association of triglycerides with atherosclerosis. It is thought that a diet high in saturated fats, sugar, and

-erides. Again, obesity is an interacting

triglycerides consumed in the diet, and include those manufactured by the body

Effects of immobility are well known to the nurse caring for the sick person.

and gastrointestinal systems are especial-ly affected. If these same consequences

-ing risk factors for CAD, the problems are enhanced greatly. Obese, smoking,

will increase blood pressure and throm-

considered when determining the use of these drugs, especially for women

-tis. Women who smoke are at higher

risk when taking oral contracep-

been reduced in the current for-m u l a t i o n s o f these products; therefore, the risk

reduced slightly.

Stress and per-sonality factors,

-siderable public and professional attention for the past twenty years.

studies showed a higher incidence

of death due to myocardial infarction

studies showed a lower rate than in

-

urgency. Because the characteristics are

may play a greater role for clients at risk for CAD. Stress results in the release of endogenous catecholamines that con-tribute to the workload of the heart and

rushed, stressed person may also not be

stressed people tend to smoke and are

this subject, order course #478 “Anger Kills.”

Coronary artery disease is often -

Male clients usually suffer from chest

clients generally complain of nausea, neck pain and shortness of breath. As the disease progresses and plaque con-tinues to accumulate in the coronary arteries, the hallmark symptoms of chest pain, shortness of breath and weakness

pain, also known as angina, is described as a feeling of tightness or pressure and is sometimes accompanied with lightheadedness. At times, this pain can be felt in the stomach, arms and back. When assessing a client with angina, the following categories are often used as a standard:

angina and is usually short in duration. Stable angina follows a regular frequen-cy or pattern, and occurs when the heart is working harder than normal. Most

pain that occurs behind the breastbone or

begins slowly and becomes increasingly worse for a brief couple of minutes be-

Table 3 Recommendations of the Adult Treatment Panel- National Cholesterol Education Program

Total Cholesterol Level Category Less than 200 mg/dL Desirable

200-239 mg/dL Borderline High 240 mg/dL and above High

LDL Cholesterol

Level LDL-Cholesterol

Category Less than 100 mg/dL Optimal

100-129 mg/dL Near optimal/above optimal 130-159 mg/dL Borderline high 160-189 mg/dL High 190 mg/dL and

above Very high


pressure, tightness or crushing pain. It may spread to the back, neck, arms, jaw and shoulders.

doesn't follow a pattern. Because un-stable angina is not precipitated by

strong indicator of a future heart attack.

of the body that occurs during stable angina, but can also be accompanied by shortness of breath and sweating.

occurs when the client is resting. It usually happens between midnight and

felt under the chest bone and is described as pressure, tightness and crushing. In some cases, the pain may spread to the shoulders, arms, neck or jaw. While the

type of angina.

Research has shown that no single test can diagnose coronary artery disease;

are often used to measure precipitating factors of the disease. Clients, who are

stress testing, electrocardiogram, echo-cardiography, coronary arteriography,

and a host of laboratory tests.

measure the threshold whereby coronary

supply to the heart. Stress tests also re-

of breath, as well as changes in blood

During this test, electrodes from an

and blood pressure is monitored, while

-tached to the skin to measure the rhythm

-

accomplishes this task by measuring the timing and strength of electrical signals as they pass through certain sections of the heart.

which measures the thickness and size of

-

well the heart's chambers are working.

rays and dye to show the inside of the

into the bloodstream through a catheter,

arteriography is the most reliable test to

disease.

tracer in injected into the bloodstream

special cameras to get a reading on the

or damage to the heart.

CAD patients, physicians note weight,

signs and often inquire about lifestyle

pressure are usually good candidates for coronary artery disease.

sugars, total cholesterol, hemoglobin,

protein in the body. Laboratory tests

heart cell damage from the presence of certain cardiac markers.

-

the chronically ill, and the disabled, as

client population.

of health promotion as seen in the me-dia, schools and community programs.

information, this is not true for many.

challenged by the different, and some-

-port of a study just completed that refutes information reported earlier. Studies on the effect of cholesterol and sodium in

these reports are from a small study and

damage may already be done as the client

need to keep aware of the new reports and help the client with sorting through

good source of information for the nurse.Although client education is the best

-

-

-tion about community-based programs. With these resources, the nurse may plan accordingly.


Utilizing the nursing process, the framework will include: assessment of need for education; assessment of

-tion of the program; and documentation

Probably the assessment of readiness is

great programs in the world will not be

1. awareness of risk factors and/or diagnosis

3. 4. 5. physical condition 6. psychological state7.

-

success of the educational plan.

Working with the adult learner is usually characterized by focusing on

Adults want to know why they need to learn something new and often will enjoy

come to the situation with a great deal

some amount of pride, many preoccupa-tions (i.e., work, family, worries), and a desire to learn things they can use now.

nurse who sees herself as a facilitator, and utilizes the participant as a co-teacher and co-learner, will be the most

by the client to make lifestyle changes, the adult will become a more eager par-

risk factors will be discussed later in this study.

Working with the elderly client may

is important to take into account the changes of aging that will affect the learning of your client. Some of the physiological changes will impact the ability to participate in classes. Older clients will fatigue more easily than

will help compensate for this. Because of the decrease of lean muscle mass, and increase in subcutaneous fat with ag-ing, sitting in uncomfortable chairs will

be more comfortable in padded chairs with armrests.

If you are working with the older cli-

take into consideration the changes in

of aging. Slowing heart rate, decreased

output are normal changes of aging. Decreased function also occurs in the

strength, and speed. As a result, endur-ance will be affected. Although many

this needs to be taken into consideration. If the client is too fatigued after these

lost and the client discouraged about continuing the program.

Other considerations regarding the

changes include loss of the lens’ abil-ity to accommodate as it becomes less elastic, larger, and more dense. Loss

serious problem, and loss of peripheral

large print and good color contrasts. Check the lighting in your classroom

the outside windows may help reduce glare, and incandescent lighting is bet-

client’s ability to interact with others in the group, as they may not be aware of

the sounds in the middle and lower ranges are lost as well. Word sounds are distorted, especially if there is back-ground noise. Clients with presbycusis

will need more time to process the in-formation. It is important for the nurse to speak slowly and distinctly and face the client directly. Speaking with a lower pitch will also help your client.

It is important to take a holistic ap-proach to assessing changes associated with the aging of your client. In addition to assessing the physiological changes

sociological and cultural dimensions -

short-term memory. With this problem -

may impact their ability to learn more

important concept is the attitude of both the client and the nurse. It is easy to get

pace and teaching strategy are used, this problem is not insurmountable. Using written -materials, lists, and calendars for appointments are all good ways to

is interest. Most of us remember what

increase with age, and this should be emphasized.

Cultural aspects will impact strategies used by the nurse. It is important to as-

other aspects of lifestyles. Attempting

tradition will probably be unsuccessful

plan. Working with, and not to, the client is the key word.

guide you when planning, implement-

the learning process. It is multifaceted and sometimes complicated.

Learning can be categorized into three

body of knowledge that the learner is


psychomotor includes the skills or ac-tions the person takes with new knowl-

the teaching session to be clear that the person has internalized the information, has accepted it, and has followed it with a change.

used as the nurse and the client establish

-

the effect on attitudes and action will not be known.

As you work with the client, you

-

-egies she is teaching will be the most

will gain the ability to use them, too.Social learning theory is a model

Social learning theory emphasizes the

“person’s assessment of his or her abil-

action to attain a designated type of per-

1. factors:information and persuasion

3. 4. successful performance of the

5. physiological feedbackInformation and persuasion from the

health care professional that the person -

the person focus on the most important aspects of the learning that needs to take

the client. Cardiac rehabilitation classes

for persons participating in the classes.

-

cardiac risk classes will look to the others

Unfortunately, many look to past fail-ures at losing weight or quitting smoking

nurse will need to focus on different ways that the client can succeed with

-

different plan.-

crete laboratory work to encourage a patient. As the person sees changes in

will be enhanced.-

grams noted in clinical research and the

programs are:

results

realistic goals contracting

modeling prompting feedback

rewardssocial support

Each of these components will be dis-cussed later in this study with strategies for risk management.

Hans Selye, known as the father of stress, once stated that if you can laugh

sense of humor will help the nurse and -

-

It is known that a habit begins with small thread but forms a cable impos-sible to break. A person will not work on breaking that cable unless they can see

following her assessment of the client, -

needs to seek to understand what the

open-ended questions. Ask the patient to describe the goals or anticipated outcomes of the lifestyle changes. After these goals are elicited, the nurse will need to show personal interest in the client and continue to offer encourage-

nurse can be a great support in helping the person to put the failure behind them

-tion is the warmth and good feelings that the client gets from the nurse. If the client

a resource, these feelings will continue.

commitment from the client to pursue the

“Why not?” – just to get them thinking about this commitment. As the old habits are replaced by the new healthy habits, the person will begin to feel better and

must come from within. Some strategies to share with the client include: medita-

self-talk, and a sense of humor.

thoughts. Meditation can take the form of just sitting comfortably in a quiet place,

minutes. It is a time to clear the mind and try to dispel any worrisome thoughts.

statements such as, “I’ll worry about that later.” - and channel these thoughts into a

reading Scripture or meditation materi-


Since many of your clients are probably -

a three-week trial.

technique that may help the person with

after successfully meeting his goals.

grease dripping from the fried chicken he had planned to eat.

Encourage the person to use language. “I am healthy, I enjoy my life, I want to

person to speak to himself. Again, a sense of humor will be the

strongest asset you and your client will

well the power of laughter in restoring one’s health.

programs include both educational and

-

professionals in a team approach to gain control of the health problems that lead

the physician, nurse, dietitian, psycholo-

practitioner who specializes in choles-terol management is often utilized. A structured program is usually necessary to accomplish these changes.

Because coronary artery disease is known as the silent killer, proper screening measures to help identify and

-ciation publishes the online Heart Risk

regarding their risk of coronary artery

user to input the following factors ap-plicable to them:

Age

WeightHeightWaist circumference

After the user inputs the appropriate -

tors, the program generates a risk assess-ment score that measures their likelihood

Heart Study scoring system. See Table 4.

by the National Cholesterol Education

established by the National Heart, Lung and Blood Institute to help physicians

for heart disease outcomes (myocar-dial infarction and coronary death) in

-

calculation are age, total cholesterol, HDL cholesterol, systolic blood pres-sure, treatment for hypertension, and cigarette smoking.

following characteristics that play a con-tributing role in coronary artery disease:

L a rg e w a i s t c i r c u m f e r e n c e (abdominal obesity)Raised blood pressure A b n o r m a l b l o o d f a t s ( h i g h triglycerides and/or low HDL cholesterol)High fasting blood glucose

-line tool is designed for users, who are

heart disease or diabetes. Prior to using the tool, users must know their blood pressure, cholesterol and blood sugar

-

scoring is more accurate if the users input their own numbers. In addition to

help educate clients regarding their risk

Please see Table 4.

-agement program begins with a careful

risk assessment is done, which includes modifiable and non-modifiable risks.

with the client’s needs in mind, focus-

-able assessment tools, such as the Heart

http://

hp2010.nhlbihin.net/atpIII/calcula-

tor.asp?usertype=prof for an online tool. Once the assessment is completed, a multidisciplinary approach is used.

educator, usually is the coordinator for

discussed, including a strategy for each. Some strategies may be used for all risks,

than one risk factor, a combination of strategies will be used.

Education for this person will in-clude important ways to control blood

blood pressure checked often, and be encouraged to keep the records to create

member, or someone at the local grocery store or community center, take their

same place, same time of day and in a reclining position.

An important factor in the regulation of hypertension is to make sure the client pays attention to their sodium intake. Recent USDA dietary guidelines

per day. Special populations, to include those with high blood pressure, should


4 Healthy Hearts, Healthy Homes

Are You at Risk for Heart Disease?

Look at the list of risk factors below. Check all the risk factors you have. If you are not sure,

ask your doctor.

Risk factors that you can do something about:

Being overweight Not sure Lack of physical activity High blood cholesterol Not sure High blood pressure Not sure Diabetes Not sure Cigarette smoking

Risk factors that you cannot change:Age ■

45 years or older for men55 years or older for women

Family history ■Father or brother with heart disease before age 55Mother or sister with heart disease before age 65

"e more risk factors you have, the greater your chances of developing heart disease.


Serum Cholesterol HDL

140 2 1 0 0 0 0 0 0 160 3 2 1 0 0 0 0 0 180 4 3 2 1 0 0 0 0 200 4 3 2 2 0 0 0 0 220 5 4 3 2 1 0 0 0 240 5 4 3 3 1 0 0 0 260 5 4 4 3 2 1 0 0 280 5 5 4 4 3 2 1 0 300 6 5 4 4 3 2 1 0 340 6 5 5 4 3 2 1 0 400 6 6 5 5 4 3 2 2

Patients should be counseled that the scale does not

heredity, or the contribution of other medical condi-tions such as diabetes to heart disease. Risk is probably

55 or physically inactive; risk is probably lower than the score indicates for those under 45. Clients should also

Nurses can help their clients develop increased -

crease the risk of developing heart disease by having them calculate their own level of risk. The American Heart Association’s RISKO scale, which is based on

data collected in the long-term Framingham Heart Study, is a popular tool for this purpose. It has been most useful for education of healthy individuals who are currently free of heart disease but may be at risk of developing heart disease in the next few years.

be reminded that the score is not a permanent indicator of risk and can likely be lowered through a program of exercise and weight loss, or through use of medication. More information is available from the:

American Heart Association1-800-AHA-USA1 or

www.americanheart.org

Weight A B C D 4' 8"


milligrams per day.

them to read nutritional labels on pack-aged food and by decreasing the amount of salt added to the diet. Omitting highly salty foods, and refraining from adding more salt after the food is prepared, will help. Note the amounts of sodium in Table 5.

Canned tuna fish illustrates a sig-

milligrams in water packed tuna. It is noted that meat high in fat is often high in sodium.

medication, the nurse will teach about -

untoward reactions. When most clients don’t “feel” any different with hyper-tension, they are prone to skip dosages or stop taking the medication without

nurse needs to stress the importance of taking the drug as prescribed, and report any undesirable side effects or untoward effects before stopping or altering the

includes:a list of the drugs (including non-prescription drugs)the reason for taking the drugdosage and timing of the drugspecial instructions (i.e. “take with food or milk”)side effectstreating side effects (i.e. call Dr. if

to take this list of medications to the physician(s), or nurse practitioner(s), who are prescribing the medications. In addition, the nurse case manager or

the patient understands the monitoring of

included the American Heart Association

based programs for education often use

his own copy as a workbook.

-ful program to reduce blood pressure

to remind the person to check nutrition -

chart, will help the person be successful. Many place their calendar or notes on their refrigerator. If the nurse is the one monitoring the blood pressure, a phone call to the client may be the prompt.

Addiction to cigarettes is both physical

cessation class may be the nurse’s best option for the client. In this class the

action steps to curb the addiction.

help. If one chooses to break the habit,

education part includes: the physical urge to smoke; feelings of being de-

to think “cigarette” at certain times of the day.

Physical symptoms may include light-headedness, sleepiness or headaches for

client may be encouraged to time the

they last about a minute, then get shorter.

because he used the cigarette as a time

-fortunately, many substitute high calorie food as a reward. Encourage the use of

small meals with three snacks planned

three hours.

particular times when one used to smoke.

successful smoking cessation program, taking a walk during a coffee break may accomplish two goals. Encourage the client to remember that he is in control,

and that he can change his habits. Oth-ers close to the client can help by not smoking, and by making the home or

If the person is using the nicotine patch or gum, the nurse will need to educate the person about the use and abuse of this drug. Unfortunately many smokers become -dependent on the patch or gum. Caution the client to use the medication only when he has quit

it with cigarettes.-

components: 1. a realistic and specific goal, (i.e.

“I promise that I will remain a

a plan if there is a relapse3. signatures of the client and a witness.

accountable and will reinforce the goal.

abstinent clients who relapse justify

that since they already failed in the at-tempt to quit, they might as well keep on

the lapse from a good habit to a bad habit.

person is taught to identify the situations or feelings that lead to the lapse and learn and practice skills to cope with the situa-

need to be conducted by professionals trained in this special technique.

factor is a change in diet. If a person with -

duce body weight, a planned nutritional program, directed by a dietitian, may be

help with this plan.

cholesterol in the diet is essential. Ap-

should be encouraged to eat less than


If your client has diabetes a careful assessment will need to be done to

the condition, and are working with a health care professional for management. Unfortunately, many diabetics increase

been able to comply with the regimen of

addition, many non-insulin dependent

client. Information that the client must

knowledge about the diseasedietary managementmedication administration

methods for monitoring blood sugar

schools” that include education for lon-ger periods. If your community has one, this would be a good referral. A new diabetic will need to deal with this prior

-

“buddy system” with another diabetic

need to caution the support people not to

has gained on dietary changes for reduc-ing cholesterol will be utilized with a

-cant reduction of weight in most obese

reduce both fat and sugar to accomplish the goal.

Unfortunately, many prepared prod-

choosing a diet plan. Most obese clients

and often do well in groups that help

-ries needed to sustain a one to two-pound

will need to be cautioned about fad or crash diets that cause fast weight loss, as usually the weight returns easily.

to determine the number of calories needed to sustain weight loss. In June,

-riculture Center for Nutrition Policy

published food pyramid with “MyPlate.” It is designed to remind Americans to

main difference in this illustration is that there is no section for sweets, fats and oils. See Table 6.

How does a person know how many calories to eat to safely reduce weight?

---

program helps users plan and analyze

and calculate how many calories they can consume along with what physical

maintain a healthy weight. Adhering to these personalized guidelines are an ef-

the health risks that often accompany obesity. Go to https://www.choosemy-plate.gov/SuperTracker/myplan.aspx

-

a nutritionist to help with selecting and

-gest eating three small meals and three

is sometimes associated with lowering

Strategies that help with weight loss include social support, rewards, and

--

ing to reach and maintain goals. Many

Since cholesterol comes from saturated fat, the person should be encouraged to read nutrition labels on prepared foods. Nutrition labels include both saturated

of the fat calories come from saturated fat. Note: Use Tables 5 and 6 as teach-ing tools.

Since not all food, such as meat, has a nutrition label the following tips may help: 1.

size of a deck of cards).

before cooking. 3. Steam, boil, broil or bake. 4. Limit egg yolks to three per week,

including use in cooking. 5.

heart, kidney, or brains. 6. Use skim milk products including ice

milk and fat-free yogurt. 7. Use cholesterol-free oils such as

8. Choose margarine that has twice as much polyunsaturated fat as saturated fat.

Encourage the client and family mem--

tions for reducing fat in the recipes. If your client does not do the shopping and/or cooking, be sure that the person who does is in the teaching sessions. Success-ful programs include family members, or

Eating out may present a problem for -

include asking for salad dressing “on the side” to control the amount, or using a

eat bread without butter or margarine. Once a person has become accustomed to low-fat cooking, high-fat foods may not taste as good as he remembers.

for reducing cholesterol in the diet. Lab

be a great reward for the client. Another -

tions about results. As you set goals to-gether for dietary changes, plan to check blood cholesterol in three months so the

changes in a concrete way.


Nutrition Facts

Calories

% Daily value* ....................................... 5%

Saturated Fat 0 g. ............................ 0%

0 mg. .............................

300 mg. .................................13%

13 g. ................ 4%

Dietary Fiber 3g. ..............................12%

Sugars 3g

*Percentage Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calo-rie needs: Calories: 2,000 2,500Total Fat Less than 65g 80g Sat Fat Less than 20g 25gCholesterol Less than 300mg 300mgSodium Less than 2,400mg 2,400mgTotal Carbohydrate 300g 375g Dietary Fiber 25g 30g

Calories per gram:

2.

5.

9.

Similar food products have similar serving size. This makes it easier to compare foods. Serving sizes are based on amounts people actually eat.

Indicates the number of servings in the package.

The total number of calories in each serving of food.

Total % of fat should be kept below 30% each day. A product that advertises low fat should have less than 3 grams per serving. A product that advertises fat free should have less than 1/2 gram fat.

Amount of fat from animals, coconut oil, etc. Eat less of products that have more than 20% of fat that is saturated.

The amount of cholesterol in grams is recorded. Eat less than 300mg each day. A product that advertises low cholesterol has less than 24mg cholesterol and 2 grams of saturated fat.

Total amount of sodium each day is suggested at 2500mg.

With less fat in the diet, you should increase your calories in this area.

Recommended for a healthy diet. Fruits, vegetables, whole grain foods, beans, and peas are good sources.

This amount should be less than 50% of the total carbohydrate amount. If it is the same as the total carbohydrate, it is concentrated sugar.

Reduce fat by eating lean meat,

yogurt and cheese. Use vegetable proteins like beans, grain, and cereals.

The labels are required to only show Vitamins A and C and the minerals calcium and iron. Aim for 100% of daily requirement.

Recommended daily amounts of critical dietary nutrients for a 2000-2500 calorie diet. If your diet is reduced for weight loss, the amounts will need to be reduced. For fat, saturated fat, cholesterol, and sodium, choose foods with a low % daily value.

and minerals, your daily value goal is to reach 100% of each.

Some labels tell the approximate number of calories in a gram of fat, carbohydrate and protein.

Serving Size 1/2 cup (114g)Servings Per Container 4

Amount Per Serving

Source: FDA of the Dept. of Health and Human Services

Nutrition Facts and Explanation


the person to follow through with this reward. Initially, the client needs to set

attainable and not something that they -

important in setting a goal of sensible weight for the person’s height and age. After the client has maintained that goal for a while they can always reset it.

in saturated fat. Knowledge regarding the use of polyunsaturated fat can be the

-curred because the person depends upon beef as his primary source of protein. By

the person may be able to attain this goal.

saturated fat include: 1.

Make stews or soups that contain

3. 4. nonstick spray; 5. Don’t force yourself to eat all the

meat in a restaurant; take some home

high in saturated fat, but may not know that dairy products, coconut and coco-nut oil, palm oil, chocolate, nondairy whipped toppings, and coffee creamer are also high in saturated fat. Again, remind the client to read nutrition labels (Table 5) and if the ingredients contain lard or animal fat, these are high in

and reinforcement. It will be important

that he will not be confused on reading

be useful for your client.

usually has a diet high in saturated fats, -

apply to this risk. If one will reduce sugar and concentrated sweets, the triglyceride

to read nutrition labels (Table 5) and

compare, because many contain more

are better than simple sugars, as it takes -

hydrates. Also, caution the client to read

whole container.

the client will need social support and

news is, if the obese client is successful

should drop, too.

people. Not only do they feel better, but it also helps with the other risk factors.

-

is trying to lose weight, or stop smoking,

outlet with others, which will reinforce

will guide the health care professional

If the person is obese and sedentary, a professional who specializes in cardiac

-ticipate in a class with others with the same goal, he will often be more suc-

-age a warm-up time with stretching of

-

a sedentary person, walking is usually

cautioned to challenge himself, but not

encouraged to build up to more strenuous

-

for the person to continue. -

-ing increased strain on the circulatory system.

-

a week”). In addition, the contract will

lab reports of lowered cholesterol and higher HDL’s.

-tions be communicated to the client.

-

-


about a change.

As the client begins the program, he

stress. He may be encouraged to take a

a role in helping the client determine the stressors and plan goals accordingly. Some of the education that the nurse

effects of anger and hostility; helping the

helping the client refocus to change from old habits to new heart healthy habits.

-

the nursing process they are skilled in the

helps the client identify the problems in -

tions, and then identify a plan to imple-ment these solutions, the client then

as he implements it. Anger and hostility

If lifestyle changes and complemen-tary treatments are not enough to combat coronary artery disease, medication may be necessary. Drugs are used to treat high

-els and certain contributing diseases such

coronary artery disease utilizes a combi-nation of drugs to include Beta Blockers, Statins, Ace Inhibitors and Antiplatelet Agents, Calcium Channel Blockers and Nitrates.

block the effects of the epinephrine hormone by slowing the heart rate and reducing blood pressure. Beta blockers

are supposed to lower the potential for myocardial infarctions and lessen the

type of medication include but are not limited to the following:

Nadolol (Corgard)Propranolol (Inderal)Acebutolol (Sectral)Metoprolol (Lopressor)

other lifestyle changes fail to lower the body's cholesterol. Some well-known

limited to:

(ACE) inhibitors lower blood pressure -

blood pressure. By blocking the protein,

this class of medication include but are not limited to the following:

Captopril (Capoten)Benazepril (Lotensin)

Perindopril (Aceon)

Antiplatelet therapy is widely used to reduce the incidence of myocardial infarction. Antiplatelet agents include the following:

Aspirin

Dipyridamole (Persantine)

Calcium channel blockers help to -

of medication can lower the blood pres-sure and decrease the heart’s workload.

blockers are frequently used to lessen

not limited to:Diltiazem (Cardizem)

Nisoldipine (Sular)

When angina presents itself in coro-nary artery disease patients, nitrates

tablets, capsules, patches and ointments. Nitrates, such as nitroglycerin, dilate

to the heart, which ultimately helps ease the heart’s work-load.

certain minerals are not always created -

istration requires pharmaceutical com-

drug to the market; this is not the case for dietary supplements. Before counseling your patients regarding the risks and ben-

sure they consult their physician and do their own due diligence concerning the supplement manufacturer.

Vitamin B3 (nicotinic acid or nia-

cin)

-

In relation to CAD, current research has shown that niacin, when taken with

help to reduce plaque accumulation in the arteries. In addition, niacin therapy often increases HDL-cholesterol (the


Vegetables

Very your veggies.

Any vegetable or 100% vegetable juice counts as a member of the vegetable group.

Fill half your plate with fruits and vegetables.

FruitsFocus on fruits. Whole fruit is pref-erable to juice but any fruit counts: fresh, frozen, canned, 100% juice or dried.

Fill half your plate with fruits and veg-etables.

GrainsMake at least half your grains whole.

more whole grain foods.

Whole wheat, oatmeal and brown rice are all good.

ProteinGo lean with pro-tein

Keep portion to 1/4 of the plate.

Nuts, beans/peas, seeds, poultry, lean meat, seafood, soy and eggs are in this group.

Dairy Get your calcium-rich foods.

Remember to buy skim or 1% milk.

Go easy on cheese.

Skim yogurt is a good choice, too.

ChooseMyPlate.gov


“good” kind).

that plaque buildup in the arteries was significantly reduced, when patients were treated with a combination of

concluded that high-risk CAD patients,

from a regression of atherosclerosis.

physician because of possible side ef-fects.

CoQ10 (coenzyme Q10): Basic nutri-

like compound that occurs naturally in our bodies. We obtain some from food, but most is manufactured within the body from raw materials. It is an es-sential component of one of the most fundamental biochemical processes in

energy for later use. Increasing amounts

in -tissues that use a lot of energy: spe-

immune system. Studies in Japan show

lowers high blood pressure.

-

food item, there will be better health.”

esteem by so many cultures through so

contemporary research.

the primary nutritional constituents of

acid, also known as LA or Omega 6, and linolenic acid, a.k.a. LNA or Omega

meaning we need them but are unable to manufacture them; therefore, they must be supplied by the diet. A fundamental

-

the body, metabolic processes increase

results in an increase of the fat burning

and fat utilization processes. Increasing

“bad” fats, including artery-clogging LDL cholesterol.

Nurses play a big part in managing the risks for coronary artery disease. As

-tion. A familiarity with the signs and symptoms of CAD is essential in your

-ally, patients suffering from CAD may

procedures and medications. By staying informed about current tests for CAD and understanding the pharmaceutical treatments, you will be better suited to

study of goal setting, contracting, re-

share with the client will reinforce the

that often lead to coronary artery disease.

Centers for Disease Control and

National Heart, Lung, and Blood

American Heart Association, http://www.heart.org

National Cholesterol Education Program: Online CAD/Heart Attack

nhlbihin.net/atpiii/calculator.asp

United States Department of Agriculture,

pressure, rich meals, desserts, high waist measure,

nutritionwill bring bad news from your physician.

reduce the fat,

tableand when you shop, read the food label.

Plan for the future and increase your chancesof attending your kids' graduations and dances.

Source: National Heart, Lung, and Blood Institute


AdditivesBaking: Chocolate 1 oz. 143 0 *8.4 5.6 0.3 1 Powder 1 tsp. 3 0 0 0 0 *290 Soda 1/4 tsp. 0 0 0 0 0 *345 Table salt 1 tsp. 0 0 0 0 0 *2,196

DairyCheese: Cheddar 1 oz. 114 *30 *6.0 2.7 .03 184 Light- % butterfat 1 oz. 40 1.5 0.2 0.1 0 *414 Fat Hardened 1 cup 269 *59 *8.9 4.1 0.5 *116Milk: Whole 1 cup 150 *33 *5.1 2.4 0.3 115 Skim 1 cup 86 4 0.3 0.1 trace 115Milkshake Chocolate 11 oz. *369 *33 *5.2 2.4 0.3 *346Yogurt 2% fat 1 cup 244 *10 1.9 0.7 0.1 121Frozen Skim-nonfat 1 cup 125 *0 0.3 0.1 0 175

Vegetable & FruitsAvocado 1 Tlbs. 25 0 *0.5 1.1 0.3 1Peas: Green/can 1 cup 150 0 0 0.4 0.7 *401Coconut: Shredded 1 cup 277 0 *25.0 1.7 0.5 18Potato: Baked 1 whole 145 0 0 0 0.2 6

GrainsBread: White enriched 1 slice 68 0 0.2 0.4 0.2 *127 Whole wheat 1 slice 61 0 0.1 0.3 0.2 *132 White-low sodium 1 slice 76 0 0.2 0.4 0.2 3Cereals: Grape Nuts 1 cup *430 0 0 0 0.7 *814 Oatmeal (cooked) 1 cup 132 0 0.4 0.8 1.0 2 Puffed Rice 1 cup 60 0 0 0 0.1 0 Raisin Bran 1 cup *144 0 0.1 0.1 0.4 *212Rice: Cooked 1 cup 221 0 0.1 0.1 0.1 5

Oils Canola 1 Tbs. 120 0 1.0 9 4 0 Coconut 1 Tbs. 120 0 *11.7 0.8 0.2 0 Corn 1 Tbs. 120 0 1.7 3.4 7.9 0 Olive 1 Tbs. 119 0 1.9 *9.8 1.2 0 Palm Kernel 1 Tbs. 120 0 *11.1 1.6 0.2 0

Margarine/Corn oil 1 Tbs. 102 0 *2.0 *5.5 *3.4 138 Butter 1 Tbs. 100 30 7 0 0 2

Mounoun- Polyun- Serving Cholesterol Saturated saturated saturated Size Calories (mg) Fat-grams Fat-grams (mg) Sodium

Most fruits and vegetables are low in cholesterol, low fat, low sodium unless canned or cooked with add-ed salt or fats - the methods of preparation need to be considered as carefully as the foods themselves.

continued on next page


ProteinsBeef: Weiner 30% fat 1 184 *27 *6.8 8.2 0.7 *506 Lean 3 oz. 177 77 3.7 3.4 0.2 23 Liver 1 oz. 40 *86 0.4 0.2 0.2 39Fish: Can Tuna: Oil Pack 1 cup *295 *104 *3.6 2.8 2.9 *1,280 Water Pack 3 oz. 167 55 1.7 1.4 1.4 69 Filet 3 oz. 115 43 .08 .07 0.18 23Pork: Bacon 2 slices 86 *11 *2.7 3.4 0.8 *153 Ham 7-10% fat 1 oz. 56 *25 0.9 1.1 0.2 *273 Knockworst 1 link *165 *42 *6.8 8.8 1.8 *748 Lean 3 oz. 187 80 3.2 4.2 1.1 23Poultry: Light Meat 3 oz. 163 76 1.3 1.7 1.1 23without Dark Meat 3 oz. 203 82 2.7 3.7 2.4 23skinVariety: Egg-white 1 16 0 0 0 0 50 Egg-whole 1 79 *274 *1.7 2.2 0.7 69 Peanut butter 2 Tbs. 190 0 3.0 7.4 4.6 *196 Pinto beans 1 cup 218 0 0.3 0.1 0.6 6

Sauces Mayonnaise 1 Tbs. 101 *9 2.0 2.4 5.5 84 Soy sauce 1 Tbs. 12 0 0 0 0.2 *1,319 Tomato Catsup 1 Tbs. 12 0 0 0 trace *203

Shortening Animal 1 Tbs. 111 10 *6.3 5.5 0.8 0 Vegetable 1 Tbs. 111 0 *3.3 5.8 3.5 0

SnacksBeverage: Coca Cola 12 oz. *144 0 0 0 0 *30 Sprite 12 oz. *143 0 0 0 0 *63Chocolate: Candy Bar 7 kisses 147 5 *5.1 3.3 0.2 27 Covered raisins 1 cup *808 *19 *18.1 11.8 0.7 *122Cookies: Vanilla wafer 1 wafer 19 1 0.2 0.3 0.2 *10 Graham cracker 2 whole 58 1 0.4 0.8 0.4 *72Crackers: Saltine (singles) 4 whole 48 1 0.3 0.6 0.3 *123Doughnut: Yeast (plain) 1 whole 176 *12 *2.8 5.6 2.5 *99Olives: Green 10 whole 45 0 0.5 3.7 0.3 *926Pickles: Dill 1 whole 15 0 0 0 0.3 *1,928 Sweet (3x1") 1 whole 51 0 0 0 0.1 *500Popcorn: no salt 1 cup 23 0 0 0.1 0.2 traceChips: Potato 10 chips 114 0 *2.0 1.7 4.0 *200 Pretzels (twisted) 10 whole 117 0 0.3 0.8 0.2 *504

SoupsInstant: Bouillon 1 cube or 1 tsp. 5 0 0.1 0 0 *960Canned: Chicken Noodle 1 cup 67 6 0.6 1.0 0.5 *979prepared Cream of Celery 1 cup 86 *7 1.4 1.2 2.4 *955W/equal Cream of Mushroom 1 cup 132 6 *2.5 1.8 4.4 *955volume Vegetable Beef 1 cup 89 6 0.8 0.9 1.6 *1,046water Vegetarian vegetable 1 cup 80 2 0.5 0.6 0.9 *838

Mounoun- Polyun- Serving Cholesterol Saturated saturated saturated Size Calories (mg) Fat-grams Fat-grams (mg) Sodium


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