Management & Nursing Care of Patient with Coronary Artery ...nurfac.mans.edu.eg/files/المحاضرات الدراسية... · PPT file · Web viewManagement & Nursing Care of Patient

Management & Nursing CareManagement & Nursing Care of Patient with Coronary Artery of Patient with Coronary Artery

DiseasesDiseases

Dr. Walaa NasrDr. Walaa NasrLecturer of Adult NursingLecturer of Adult Nursing

Second yearSecond year

OutlinesOutlines Anatomic& physiologic Anatomic& physiologic

overview of cardiovascular overview of cardiovascular systemsystem

Coronary atherosclerosisCoronary atherosclerosis AnginaAngina Myocardial infarctionMyocardial infarction Congestive heart failureCongestive heart failure

Anatomic& physiologic overview of Anatomic& physiologic overview of cardiovascular systemcardiovascular system

IntroductionIntroduction

Vascular system( the blood Vascular system( the blood vessels)vessels)

Blood circulationBlood circulation

IntroductionIntroduction

The The cardiovascular/circulatory cardiovascular/circulatory system system transportstransports food, food, hormones, metabolic wastes, hormones, metabolic wastes, and gases (oxygen, carbon and gases (oxygen, carbon dioxide) to and from cells. dioxide) to and from cells.

Components of the circulatory systemComponents of the circulatory system BloodBlood:: consisting of liquid plasma and cellsconsisting of liquid plasma and cells

Blood vesselsBlood vessels: : (vascular system): the (vascular system): the "channels" (arteries, veins, capillaries) which "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. carry blood to/from all tissues. ArteriesArteries carry carry blood away from the heart. blood away from the heart. VeinsVeins return return blood to the heart. blood to the heart. CapillariesCapillaries are thin-walled are thin-walled blood vessels in which gas/ nutrient/ waste blood vessels in which gas/ nutrient/ waste exchange occurs.exchange occurs.

HHearteart: : a muscular pump to move the blooda muscular pump to move the blood

Vascular System - the Blood Vascular System - the Blood VesselsVessels

Arteries, veins, and Arteries, veins, and capillaries comprise capillaries comprise the the vascular systemvascular system. . Arteries and veins Arteries and veins run parallel run parallel throughout the body throughout the body with a web-like with a web-like network of capillaries network of capillaries connectingconnecting them. them.

Blood circulationBlood circulation

Coronary AtherosclerosisCoronary Atherosclerosis Diseases of the coronary Diseases of the coronary

arteries is almost always arteries is almost always due to due to plaqueplaque and its and its complications , complications , particularly thrombosis.particularly thrombosis.

AtherosclerosisAtherosclerosis is a is a progressive inflammatory progressive inflammatory disorder of arterial wall disorder of arterial wall that is characterized by that is characterized by focal lipid rich deposits of focal lipid rich deposits of atheroma that remain atheroma that remain clinically clinically silentsilent until they until they become large enough to become large enough to impair tissue perfusionimpair tissue perfusion

Risk factors for developing Risk factors for developing atherosclerosisatherosclerosis

Age and sexAge and sex Family history for ( hypertension, Family history for ( hypertension,

hyperlipidemia, diabetes mellitus)hyperlipidemia, diabetes mellitus) SmokingSmoking HypertensionHypertension HypercholesterolemiaHypercholesterolemia DMDM Haemostatic factors, platelets activation and Haemostatic factors, platelets activation and

high levels of fibrinogen are associated with high levels of fibrinogen are associated with an increased risk of coronary thrombosisan increased risk of coronary thrombosis

Physical activityPhysical activity ObesityObesity AlcoholAlcohol Personality typePersonality type

Coronary heart disease: clinical Coronary heart disease: clinical manifestations and pathologymanifestations and pathology

Clinical problemClinical problem

Stable anginaStable angina

Unstable anginaUnstable angina

Myocardial Myocardial infarctioninfarction

Heart failureHeart failure

ArrhythmiaArrhythmia

Sudden deathSudden death

PathologyPathology Ischemia due to Ischemia due to fixed fixed atheromatous atheromatous

stenosis of one or more coronary stenosis of one or more coronary arteriesarteries

Ischemia caused by Ischemia caused by dynamicdynamic obstruction obstruction of a coronary artery due to plaque of a coronary artery due to plaque rupture or erosion with imposed rupture or erosion with imposed thrombosisthrombosis

Myocardial necrosis caused by acute Myocardial necrosis caused by acute occlusionocclusion of a coronary artery due to of a coronary artery due to plaque rupture or erosion with imposed plaque rupture or erosion with imposed thrombosis thrombosis

Myocardial dysfunction due to Myocardial dysfunction due to ischemiaischemia or infarctionor infarction

Altered Altered conductionconduction due to ischemia or due to ischemia or infarctioninfarction

Prevention of atherosclerosisPrevention of atherosclerosis primary preventionprimary prevention (control of risk factors) (control of risk factors) Do not smokeDo not smoke

Take regular exercise ( minimum of 20 min Take regular exercise ( minimum of 20 min 3 times a week)3 times a week)

Maintain ideal body weightMaintain ideal body weight

Eat a mixed diet rich in fresh fruit and Eat a mixed diet rich in fresh fruit and vegetablesvegetables

Aim to get no more than 10% of Aim to get no more than 10% of energy intake from saturated fatenergy intake from saturated fat

Primary preventionPrimary prevention in patients in patients without evidence of coronary without evidence of coronary disease but with high serum disease but with high serum cholesterol concentration, cholesterol concentration, cholesterol- lowering with statin cholesterol- lowering with statin prevent coronary events e.g. prevent coronary events e.g. (angina, MI)(angina, MI)

Secondary preventionSecondary prevention in in patients with established patients with established coronary disease (MI or coronary disease (MI or angina), statin therapy is angina), statin therapy is safely.safely.

AnginaAngina Out linesOut lines DefinitionDefinition Causes and pathophysiologyCauses and pathophysiology Precipitating factorsPrecipitating factors Clinical manifestationClinical manifestation TypesTypes Diagnostic evaluationDiagnostic evaluation ManagementManagement Nursing processNursing process

DefinitionDefinition It is a clinical syndrome, It is a clinical syndrome, characterized by characterized by paroxysmparoxysm of chest pain, or of chest pain, or a felling of pressure in the a felling of pressure in the anterior chestanterior chest. It may . It may occur whenever there is occur whenever there is an imbalance between an imbalance between myocardial oxygen supply myocardial oxygen supply and demand.and demand.

Causes and PathophysiologyCauses and Pathophysiology The cause is considered to The cause is considered to

be be insufficientinsufficient coronary coronary blood flow, resulting blood flow, resulting inadequateinadequate O2 supply of O2 supply of the myocardium. Angina is the myocardium. Angina is usually usually causedcaused by by atherosclerotic plaque.atherosclerotic plaque.

Precipitating factorsPrecipitating factors Common factorCommon factor Physical exertion can precipitate an attack Physical exertion can precipitate an attack

by increase myocardial O2 demands.by increase myocardial O2 demands.

Exposure to cold can cause Exposure to cold can cause vasoconstriction and increased B.P with vasoconstriction and increased B.P with increased demands.increased demands.

Eating heavy meal which the blood flow to Eating heavy meal which the blood flow to the mesenteric area places a heavier the mesenteric area places a heavier demands on the heart.demands on the heart.

Stress and emotional provoking Stress and emotional provoking situation cause the release of situation cause the release of adrenaline and B.P may accelerate adrenaline and B.P may accelerate the heart ratethe heart rate

Precipitating factors (cont…)Precipitating factors (cont…)

Uncommon factorUncommon factor

Lying flat (angina decubitus)Lying flat (angina decubitus)

Vivid dreams ( nocturnal Vivid dreams ( nocturnal angina)angina)

Clinical manifestationsClinical manifestations

The pain is usually felt The pain is usually felt deepdeep in in the chest behind the sternum. the chest behind the sternum. Although the pain frequently is Although the pain frequently is localized, it may localized, it may radiateradiate to the to the neck, jaw, shoulders, and inner neck, jaw, shoulders, and inner aspects of the upper extremitiesaspects of the upper extremities

Patient often experience a Patient often experience a tightness tightness or strangling sensationor strangling sensation

Clinical manifestations Clinical manifestations (cont…)(cont…)

Feeling of Feeling of weakness or numbnessweakness or numbness in in the arms, wrists, and hands may be the arms, wrists, and hands may be accompanied by painaccompanied by pain

Patient also has a sense of Patient also has a sense of impending deathimpending death and an and an apprehensionapprehension

Types of anginaTypes of angina Stable angina (classic angina)Stable angina (classic angina) It may occur whenever there is an It may occur whenever there is an

imbalanceimbalance between myocardial between myocardial oxygen supply and demand. Stable oxygen supply and demand. Stable angina is angina is characterizedcharacterized by central by central chest pain, discomfort or chest pain, discomfort or breathlessness that is breathlessness that is precipitated precipitated by exertion or other forms of stress, by exertion or other forms of stress, and is promptly and is promptly relievedrelieved by rest.by rest.

Types of angina (Cont…)Types of angina (Cont…) Unstable angina (Acute coronary Unstable angina (Acute coronary

syndrome)syndrome) Unstable angina is Unstable angina is characterizedcharacterized by by

new-onset or rapidly worsening new-onset or rapidly worsening angina, angina on angina, angina on minimal exertionminimal exertion or angina or angina at restat rest. It is most . It is most dangerous and does not follow a dangerous and does not follow a pattern, do not pattern, do not go awaygo away with rest or with rest or medicine. the common features of medicine. the common features of unstable angina are breathlessness, unstable angina are breathlessness, nausea&vomiting nausea&vomiting

Types of angina (Cont…)Types of angina (Cont…)The pain occurs in the The pain occurs in the same sites as angina but same sites as angina but is usually more is usually more severesevere and lasts and lasts longerlonger; it is ; it is often described as a often described as a tightness, heavinesstightness, heaviness or or constriction in the chest.constriction in the chest.

Diagnostic evaluationDiagnostic evaluation Patient's historyPatient's history

Cigarette smokingCigarette smoking HypertensionHypertension HyperlipidemiaHyperlipidemia Family history of coronary artery Family history of coronary artery

diseasedisease Male genderMale gender ObesityObesity Diabetes mellitusDiabetes mellitus Lack of regular exerciseLack of regular exercise Type A personalityType A personality

Diagnostic evaluation Diagnostic evaluation (Cont…)(Cont…)

The clinical manifestations of painThe clinical manifestations of pain ChestChest discomfort which may be discomfort which may be

described as : heavy pressure, burning described as : heavy pressure, burning sensation, or squeezing or tightness.sensation, or squeezing or tightness.

ThisThis discomfort radiates to the discomfort radiates to the shoulders, arms, neck or jaw.shoulders, arms, neck or jaw.

May beMay be sudden in onset and relieved in sudden in onset and relieved in minutes by rest and /or vasodilators.minutes by rest and /or vasodilators.

May beMay be precipitated by exercise or precipitated by exercise or possibly associated with nausea and / possibly associated with nausea and / or belching.or belching.


Objective indicators of anginaObjective indicators of angina Mental status:Mental status: fearful and apprehension fearful and apprehension

during acute attackduring acute attack Vital signs:Vital signs: normal between anginal normal between anginal

episodes, hypertension and tachycardia episodes, hypertension and tachycardia during an acute attackduring an acute attack

Lungs:Lungs: clear to percussion and clear to percussion and auscultation, possibility of lung auscultation, possibility of lung cripitation during an acute attack.cripitation during an acute attack.

Heart:Heart: irregular rhythm during an acute irregular rhythm during an acute attack attack


Diagnostic testsDiagnostic tests

Resting ECGResting ECG, is often normal, even , is often normal, even in patients with severe coronary in patients with severe coronary artery disease.artery disease.

Exercise ECGExercise ECG, is usually performed , is usually performed using a standard treadmill while using a standard treadmill while monitoring the patient's ECG, BP monitoring the patient's ECG, BP and general condition.and general condition.

Coronary arteriographyCoronary arteriography, this , this provides detailed anatomical provides detailed anatomical information about the extent and information about the extent and nature of coronary artery nature of coronary artery disease, and is usually disease, and is usually performed with a view to performed with a view to coronary artery bypass graft coronary artery bypass graft (CABG) surgery or percutaneous (CABG) surgery or percutaneous coronary intervention( PCI). coronary intervention( PCI).

Management of angina Management of angina pectorispectoris

General measuresGeneral measures

AA careful assessment of the likely extent careful assessment of the likely extent and severity of arterial diseaseand severity of arterial disease

TheThe identification and control of risk identification and control of risk factors such as smoking, hypertension factors such as smoking, hypertension and hyperlipidemiaand hyperlipidemia

TheThe use of measures to control use of measures to control symptomssymptoms

TheThe identification of high-risk patients identification of high-risk patients for treatment to improve life expectancyfor treatment to improve life expectancy

Management of angina pectoris Management of angina pectoris (Cont…)(Cont…)

Advice to patients with stable anginaAdvice to patients with stable angina

Do not smokeDo not smoke

Aim for ideal body weightAim for ideal body weight

Take regular exerciseTake regular exercise

Avoid vigorous exercise after a heavy Avoid vigorous exercise after a heavy meal or in very cold weathermeal or in very cold weather

Take sublingual nitrate before Take sublingual nitrate before undertaking exertion that may induce undertaking exertion that may induce anginaangina


Antiplatelet therapyAntiplatelet therapy

Low-dose (75mg) aspirin Low-dose (75mg) aspirin reducesreduces the risk of adverse events such the risk of adverse events such as MI and should be prescribed as MI and should be prescribed for all patients with coronary for all patients with coronary artery disease indefinitely.artery disease indefinitely.


Anti-anginal drug treatmentAnti-anginal drug treatment Five groups of drug are used to help Five groups of drug are used to help

relieve or prevent the symptoms of relieve or prevent the symptoms of angina: nitrates, β-blockers, calcium angina: nitrates, β-blockers, calcium antagonists and potassium channel antagonists and potassium channel activators.activators.

NitrateNitrate These drugs act directly on vascular These drugs act directly on vascular

smooth muscle to produce venous smooth muscle to produce venous and arteriolar dilatation.and arteriolar dilatation.


Beta - blockersBeta - blockers These lower myocardial oxygen demand These lower myocardial oxygen demand

by reducing heart rate, BP and myocardial by reducing heart rate, BP and myocardial contractility.contractility.

Calcium channel antagonistCalcium channel antagonist These drugs lower myocardial oxygen These drugs lower myocardial oxygen

demand by reducing heart rate, BP and demand by reducing heart rate, BP and myocardial contractility.myocardial contractility.

Potassium channel activatorPotassium channel activator These have arterial and venous dilating These have arterial and venous dilating

properties but do not exhibit the tolerance properties but do not exhibit the tolerance seen with nitrates. seen with nitrates.


Invasive treatmentInvasive treatment 1.1. Percutaneous coronary intervention (PCI)Percutaneous coronary intervention (PCI)

(angioplasty with stent)(angioplasty with stent)

Is Is a non-surgical procedure that uses a catheter a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small structure (a thin flexible tube) to place a small structure called a stent to open up blood vessels in the called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup. heart that have been narrowed by plaque buildup.

A A catheter is inserted into the blood vessels catheter is inserted into the blood vessels either in the groin or in the arm. Using a special either in the groin or in the arm. Using a special type of X-ray called fluoroscopy, the catheter is type of X-ray called fluoroscopy, the catheter is threaded through the blood vessels into the heart threaded through the blood vessels into the heart where the coronary artery is narrowedwhere the coronary artery is narrowed. .


When the tip is in place, a When the tip is in place, a balloon tip covered with a balloon tip covered with a stent is stent is inflatedinflated. The balloon . The balloon tip tip compressescompresses the plaque the plaque and and expandsexpands the stent. Once the stent. Once the plaque is compressed the plaque is compressed and the stent is in place, the and the stent is in place, the balloon is balloon is deflateddeflated and and withdrawn withdrawn


2. Coronary artery bypass grafting (CABG) 2. Coronary artery bypass grafting (CABG) (Revascularization)(Revascularization)

Coronary artery bypass grafts (CABG) Coronary artery bypass grafts (CABG) deliverdeliver a new source of blood to regions of a new source of blood to regions of the heart served by blocked arteries. the heart served by blocked arteries. Surgeons use segments of the patient's Surgeons use segments of the patient's ownown veins and arteries to go veins and arteries to go aroundaround, or , or bypass these blockages. If left untreated, bypass these blockages. If left untreated, severely blocked arteries may lead to severely blocked arteries may lead to heart attack or death. Coronary bypass heart attack or death. Coronary bypass operations are performed half a million operations are performed half a million times a year with an overall success rate times a year with an overall success rate of almost of almost 9898 percent. percent.

Nursing processNursing process AssessmentAssessment The nurse should observe & ask the The nurse should observe & ask the

patient about:patient about: When do attack tend to occur?When do attack tend to occur? How does the patient describe the pain?How does the patient describe the pain? Is the onset of pain gradual or suddenIs the onset of pain gradual or sudden How long does it last?How long does it last? Is the pain is steady?Is the pain is steady? Is the discomfort accompanied by other symptoms?Is the discomfort accompanied by other symptoms? How many minutes after taking the nitroglycerin How many minutes after taking the nitroglycerin

does the pain last?does the pain last? Full historyFull history Physical examination & clinical Physical examination & clinical

manifestationmanifestation Interpretation of the finding of the Interpretation of the finding of the

diagnostic testsdiagnostic tests

Nursing process (cont…)Nursing process (cont…) Nursing diagnosisNursing diagnosisNursing diagnosis may include the following:Nursing diagnosis may include the following: ChestChest pain related to decreased O2 supply to pain related to decreased O2 supply to

the heart muscle secondary to arterial stenosisthe heart muscle secondary to arterial stenosis AnxietyAnxiety related to fear of death related to fear of death HealthHealth maintenance altered related to maintenance altered related to

knowledge deficit about nature of the diseases knowledge deficit about nature of the diseases and ways to avoid and ways to avoid

High High risk for complications ( myocardial risk for complications ( myocardial infarction) related to non adherence to the infarction) related to non adherence to the therapeutic regimen & non acceptance of therapeutic regimen & non acceptance of necessary life- style changesnecessary life- style changes

Nursing process (cont…)Nursing process (cont…) Patient's goals: ( patient will)Patient's goals: ( patient will)

ReportReport pain free or pain is decreased pain free or pain is decreased

ReportReport anxiety level is decreased anxiety level is decreased

UnderstandUnderstand nature of the disease & capable to nature of the disease & capable to avoid complicationsavoid complications

AdhereAdhere to the therapeutic regimen to the therapeutic regimen

AcceptAccept the necessary of life-style changes the necessary of life-style changes

Nursing process (cont…)Nursing process (cont…) Nursing interventionNursing intervention

Prevention of painPrevention of pain

Control of painControl of pain

Reduction of anxietyReduction of anxiety

Understanding of illness & ways to avoid Understanding of illness & ways to avoid complicationscomplications

Adherence to the self care programAdherence to the self care program

Goal :Goal : to improve the quality of life and to improve the quality of life and promotion of healthpromotion of health

Expected outcomes:Expected outcomes:

Patient prevents an episode of anginal Patient prevents an episode of anginal painpain

Patient cope with an attack of anginal painPatient cope with an attack of anginal pain

health teaching of patient with anginahealth teaching of patient with angina

health teaching of patient with health teaching of patient with angina ( Cont...)angina ( Cont...)

patient prevents an episode of anginal painpatient prevents an episode of anginal pain UsesUses moderation in all activities of life moderation in all activities of life

ParticipatesParticipates in normal daily program of activities in normal daily program of activities that don't produce chest discomfort, shortness of that don't produce chest discomfort, shortness of breath& fatiguebreath& fatigue

AvoidAvoid exercises requiring sudden bursts of activity exercises requiring sudden bursts of activity

RefrainsRefrains from engaging in physical exercise for 2 from engaging in physical exercise for 2 hours after mealshours after meals

Avoid Avoid activities that require heavy effortactivities that require heavy effort

AlternatesAlternates activities with periods of rest activities with periods of rest


AvoidAvoid situations that are emotionally stressful situations that are emotionally stressful

Maintain Maintain proper weightproper weight

AvoidAvoid excessive caffeine intake which can increase the excessive caffeine intake which can increase the heart rate& produce anginaheart rate& produce angina

StopStop smoking, since smoking increase the heart rate, smoking, since smoking increase the heart rate, blood pressure&blood carbon monoxide levelsblood pressure&blood carbon monoxide levels

AvoidAvoid cold weather if possible cold weather if possible

Walk Walk more slowly in cold weathermore slowly in cold weather

AvoidAvoid walking against the wind walking against the wind


patient cope with an attack of patient cope with an attack of anginal painanginal pain

CarriesCarries nitroglycerin at all times nitroglycerin at all times PlacesPlaces nitroglycerin under the tongue nitroglycerin under the tongue

( sublingually) at first sign chest ( sublingually) at first sign chest discomfort. It relieves pain within 3 discomfort. It relieves pain within 3 minutes.minutes.

Doesn't Doesn't swallow saliva until the tablet swallow saliva until the tablet has dissolvedhas dissolved

Stops Stops activities and be in rest until all activities and be in rest until all pain subsidespain subsides


Keep Keep the upright position to potential the effect of the upright position to potential the effect of nitroglycerinnitroglycerin

UsuallyUsually another nitroglycerin tablet may be taken in 3-5 another nitroglycerin tablet may be taken in 3-5 minutes if pain persistminutes if pain persist

IfIf the anginal discomfort is un relived or if it reoccurs after the anginal discomfort is un relived or if it reoccurs after short interval, the patient must go to the nearest emergency short interval, the patient must go to the nearest emergency facilityfacility

TakesTakes nitroglycerin prophylactically to avoid pain known to nitroglycerin prophylactically to avoid pain known to occur with certain activities (stair- climbing- sexual occur with certain activities (stair- climbing- sexual intercourse)intercourse)

BeBe alert for the side effects of nitroglycerin, headache, alert for the side effects of nitroglycerin, headache, flushing& dizziness.flushing& dizziness.

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Management & Nursing Care of Patient with Coronary Artery ...nurfac.mans.edu.eg/files/المحاضرات الدراسية... · PPT file · Web viewManagement & Nursing Care of Patient