N3910 W8

Define Coronary Artery Disease (CAD)

Narrowing or obstruction of the coronary arteries as a result of atherosclerosis (buildup of plaque in arterial walls)

What causes CAD?

* injury to artery walls (due to hypertension, diabetes, inflammation, cholesterol)

Plaque impacts ______. What does this lead to?

Impacts perfusion = damage to body systems

What are comorbidities of CAD?

Hypertension, dyslipidemia, diabetes, high BMI

What are modifiable risk factors for CAD?

Lifestyle = stress, alcohol, smoking, depression, sedentary lifestyle

What are Neuro S&S of CAD?

* fatigue
* dizziness
* anxiety
* insomnia

What are Cardiac S&S of CAD?

* chest pain = from tissue/muscle hypoxia
* higher risk of cardiac events = angina, MI

What are GI S&S of CAD?

* indigestion = pain coming from chest/heart

What 3 lab values should a nurse investigate for CAD? Why?

1. Lipid profile
2. HbA1C - measures BG over past 3 months. uncontrolled diabetes = high A1C = increased risks
3. BG

What is good / bad cholesterol?

Good = HDL

Bad = LDL

What are nursing priorities for CAD? what is the highest priority?

1. control cholesterol = highest priority


1. Medication, lifestyle changes
2. manage comorbidities


1. promote BG control
2. promote BP improvement
3. Meds/lifestyle changes
3. health teaching


1. treatment/lifestyle
2. IP

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What is stenosis?

Something building up in vessel wall causing blockage

MI and angina are conditions of _______ ___________.

Myocardial Ischemia = when demand of O2 is not being met by the supply of O2

Define Angina

Ischemia of partial thickness of myocardial muscle

Define MI

Ischemia of full thickness of myocardial muscle

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= heart muscle is not being oxygenated

What is Angina characterized by?

Chest pain brought on by myocardial ischemia

T or F: angina is a chronic episode

False. Acute.

What are the causes of angina?

* stenosis
* vasopasm
* thickening of the heart wall

Define vasospasm

vessels become very restricted (idiopathic conccern)

What is the goal for patients with angina?

relieve pain and reduce risk of disease progression and MI

= relieve pain by getting blood and O2 to the heart

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(perfusion, pain management)

What is MI characterized by?

Death or myocardial cells as a result of prolonged ischemia

MI is an ____________.

Emergency

What are the causes of MI?

Stenosis, plaque lodge (complete blockage)\*\*\*\*

What is the goal for patients with MI?

Restore blood flow by clearing blockage

How do we measure stenosis?

Through echos / contrast dyes via CT scans

Why do people who had strokes use blood thinners?

because there is an increased risk of blood clots forming and blocking vessels

What are the Neuro S&S of MI/Angina? Explain why

* anxiety (impending doom)\*\*\*
* restlessness

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^ because the sympathetic nervous system is activated to get blood to the heart

What are the Cardiac S&S of MI/Angina?

* chest pain (pressure, squeezing, heavy)
* irregular rhythm
* bounding pulse
* pressure in left arm, jaw, shoulders, center of the back

What are the GI S&S of MI/Angina? Explain why

* N/V relating to pain

What are the Respiratory S&S of MI/Angina? Explain why

* SOB
* related to pain = hurts to take a deep breath
* Anxiety
* Crackles
* blood backs up into lungs

What are the Integumentary S&S of MI/Angina? Explain why

* flush
* pale
* diaphoretic

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^ related to pain

What are the 2 types of Angina?

1. stable
2. unstable

What is stable angina? how do you relieve stable angina?

Predictable, occurs with exertion, relieved with rest and nitroglycerine

What is unstable angina? how do you relieve unstable angina?

unpredictable, occurs without exertion and at rest

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not relieved with rest and nitro

What causes unstable angina?

Vasospasms

What are the 2 types of MI?

STEMI (ST elevation) and N-STEMI (Non-ST elevation)

Describe the lab findings for angina.

* negative cardiac biomarkers (troponin)
* negative ECG

Describe the lab findings for NSTEMI

* positive biomarkers
* negative ECG

Describe the lab findings for STEMI

* positive biomarkers
* positive ECG

When a client comes in with symptoms of angina or MI, we get bloodwork and an ECG.

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What would we do first? and whY?

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What is the goal?

Start with an ECG because time is muscle = define whether the client is having an MI or angina. ECG is faster.

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Goal = within 10 minutes of arrival with S&S so we can determine if they have a STEMI.

how would Angina, STEMI, and N-STEMI appear on an ECG?

1. Angina = ST depression
2. NSTEMI = no change on ECG
3. STEMI = ST elevation

If we see Angina (ST depression) on an ECG, what do we do?

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How about if we see normal ST on an ECG?

Wait for bloodwork for both.

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If normal ST is seen despite having symptoms, still have to wait for bloodwork.

What do we do next if we see a STEMI on an ECG?

Don’t need to wait for bloodwork. we can continue with interventions.

What is more common? STEMI or NSTEMI?

STEMI

What are 3 cardiac biomarkers that are investigated in a case of angina/MI?

1. troponin I
2. Creatinine Kinase
3. Myoglobin

What is Troponin I?

A failproof sign. It is elevated with cardiac muscle damage. With elevated troponin, you had MI / are going to.

What are the nursing priorities for angina?

1. pain management and promote perfusion


1. medication (nitro)
2. lifestyle changes
3. cardiac rehabilitation plans
2. minimize risk for complications


1. through medications
3. health teaching


1. treatment/lifestyle
2. anxiety/stress reduction

Apart from physical exertion, what else can exertion refer to?

stress/anxiety since HR increases due to the stress hormones.

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Exertion = mental or physical

How do we manage angina chest pain?

1. stop activity
2. sit semi-fowlers
3. assess pain
4. administer nitro
5. re-assess pain
6. VS and cardiac assessment
7. apply O2 to get O2 to heart muscle
8. re-assessment

What is the dose/frequency for nitro?

1 doses q 5 mins sprayed under tongue (3 times max)

What happens if a patient is still having pain after 3 doses of nitro?

Go to emergency because they either have MI or unstable angina

What do nitrates do? What is the difference between short acting and long acting nitrates?

Nitrates cause vasodilation

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Short acting: 5 mins

Long acting: dilate to a lesser degree but over a longer period of time

Is a client at risk of developing a tolerance to nitrates?

Yes. may need to increase dose / change type

What are the nursing priorities for MI?

1. re-perfusion


1. PCI
2. Clot busters
2. Pain management


1. O2, Morphine, Nitro
3. Health teaching


1. medications, lifestyle changes

What is the first line of treatment for MI?

PCI/angioplasty/Cath-lab

What are clot busters?

very strong blood thinners to break up clots and allow re-perfusion.

Do clot busters work on atherosclerotic plaque?

no.

What do medications for angina target?

* vasodilation
* pain
* reducing risk of clotting/atherosclerosis

What type of medications can be given to patients with angina?

* nitrates
* calcium channel blockers
* beta blockers
* antihyperlipidemics (statins)
* anticoagulants

How does a percutaneous coronary intervention (PCI) / angioplasty work?

1. thread catheter up vessels in arm
2. mesh netting (stent) is put in place
3. balloon inflates to expand the stent
4. stent holds area of vessel open for a long period of time

\-ASE medications:

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1. what is the action?
2. caution?
3. nursing considerations?

Action: dissolve thrombus = not plaque

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Caution: High bleeding risk

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Nursing considerations: IV administration

Medications for acute MI target:

* vasodilation
* clot busting
* pain
* reduce risk of future complications

What medications are given to patients with MI?

* thrombolytics
* nitrates
* morphine
* calcium channel blockers
* beta blockers
* anticoagulants
* antihyperlipidemics (statins)

What does health teaching for post-MI cardiac rehab encompass?

1. knowledge


1. self-management
2. understand risk factors
3. what to do in event of MI/chest pain
2. Monitor


1. stress testing for damage
2. F/U appointments
3. engage with IP
3. Lifestyle
4. Meds

What are complications that can result after an MI?

* dysrhythmias
* pulmonary edema
* MI
* Cardiogenic Shock
* heart failure

What is heart failure?

A chronic condition that involves diseased myocardium (heart not working as it should be)

What is systolic dysfunction?

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What causes it?

Impaired myocardial contraction

* contractility issue

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Results from: ventricles lacking strength

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What is diastolic dysfunction?

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What causes it?

Impaired ventricular filling

* compliance/preload issue

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Results from: ventricles lacking elasticity

is there a cure for heart failure?

no

Heart failure leads to:

decreased Cardiac Output = decreased tissue perfusion

Decreased CO → decreased tissue perfusion.

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What does the body do to compensate?

1. stimulate SNS
2. Activate RAAS


1. vasoconstriction, shunting to vital organs
2. retains fluid (FVO)
3. dilate ventricles, hypertrophy cardiac muscle, increase fibrous tissue

What are 6 causes heart failure?

1. hypertension
2. MI - death of muscle cells
3. COPD
4. Cardiomyopathy
5. Valve issues

How does COPD lead to heart failure?

Due to chronic hypoxia = the heart gets poor perfusion

How do valve issues lead to heart failure?

Heart engages in heart structure changes to solve valve issues

Left sided CHF and RIght sided CHF lead to…

* fatigue = inability to cope with exertion
* organ damage

What characterizes left sided CHF?

Respiratory congestion = blood backs up in lungs

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Left side of heart brings blood from the lungs into that area of the heart

What are respiratory S&S of left sided CHF?

* dyspnea / SOB
* nocturnal dyspnea
* cough
* crackles
* orthopnea
* decreased SpO2

What are cardiac S&S of left sided CHF?

* extra beats / sounds
* palpitations
* dysrhythmias
* increased HR (compensation)
* weak pulses

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Why do we see decreased SpO2 in left sided CHF?

there is no good air exchange since alveoli is swimming in the fluid

What are renal S&S of left sided CHF?

* oliguria
* CKD risk ^

Why do we see oliguria in left sided CHF?

FVO

* holds onto fluid which in theory allows body to perfuse better. because the body thinks poor perfusion is due to low blood volume

What are neuro S&S of left sided CHF?

* dizzy
* confusion
* restlessness

What are GI S&S of left sided CHF?

* altered digestion since it is not a vital organ system, blood is shunted to priority systems

What are integumentary S&S of left sided CHF?

* pale, cool, clammy

What characterizes right sided CHF?

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What would u see?

peripheral and visceral blood backs up into body (not the lungs) = peripheral congestion

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You would see:

* FVO
* peripheral edema
* weight gain

What are cardiac S&S of right sided CHF?

* Jugular vein distension
* unstable BP

What are GI S&S of right sided CHF?

* fluid backs up into liver = liver dysfunction
* Fluid backs up into abdomen = ascites
* Fluid backs up into spleen (splenomegaly

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What signs of liver dysfunction would u see in right sided CHF? Why?

RUQ pain = because that is where the liver is

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Hepatomegaly (enlarged size)

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Jaundice + itching due to not getting rid of wastes

Why would we see when ascites occurs from right sided CHF? explain.

Ascites as abdomen fills with fluid (third spacing)

= nausea, anorexia = because it is painful to have all of the fluid to back up into GI

What is an implication of splenomegaly in right sided CHF?

* reduced RBC because spleen has a big function with RBC production

What is B-Type Natriuretic Peptide (BNP)?

It is a lab value that is associated with heart failure

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Increase = heart failure

T or F: BNP can be elevated from other cardiac conditions

True.

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For example: it can be released in body with muscle dysfunction in heart

* doesn’t always mean MI / etc.

T or F: BNP is more accurate than troponin

False.

Do we use an ECG or ECHO for heart failure? What do we measure then?

Use an ECHO to measure the ejection fraction

What does a decreased ejection fraction indicate?

There is worsening heart failure

What lab/investigation is key to diagnosing heart failure?

ECHO

Why would an ST in ECG be normal after MI?

Because the heart is being re-perfused

What are 3 complications of heart failure?

1. cardiogenic shock
2. pulmonary edema
3. venous disorders

What is pulmonary edema? What is it caused by?

Really severe backup of fluid in the lungs.

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Causes:

* third spacing = different hydrostatic pressures between vessels and areas of lungs cause fluid to go to other spaces (alveoli, etc.)
* pulmonary congestion (L side HF)

In pulmonary edema, what happens to the alveoli?

Fluid backs up into lungs and alveoli = lack of air exchange