Nursing Care of Patients with Occlusive Cardiovascular Disorders

Artery/Arteriole Walls◦ Thicken◦ Harden◦ Lose Elasticity

Type of Arteriosclerosis Plaque Formation in Arterial Wall Childhood Onset

Non-modifiable Risk Factors◦ Age ◦ Gender◦ Ethnicity◦ Genetic Predisposition for Hyperlipidemia

Modifiable Risk Factors◦ Diabetes Mellitus ◦ Hypertension◦  Smoking◦  Obesity◦  Sedentary Lifestyle◦  Increased Serum Homocysteine

Modifiable Risk Factors (cont’d)◦ Increased Serum Iron Levels◦ Infection◦ Depression ◦ Hyperlipidemia ◦ Elevated Apolipoprotein B ◦ Excessive Alcohol Intake

Diagnostic Tests for Increased CVD◦ Cholesterol

Elevated Increases Risk ◦ Low-density Lipoproteins (LDL)

Increased risk◦ High-density Lipoproteins (HDL)

Protective

Diagnostic Tests (cont’d)◦ Lp(a) Cholesterol

Elevated Increases Risk◦ Apolipoprotein B > Apolipoprotein A

Increased Risk◦ Triglycerides

Increased Risk

Diagnostic Tests (cont’d)◦ C-reactive Protein

Inflammation in C.A. Shows Increased Risk

◦ Elevated Leukocyte Count in Women Increased Risk

Therapeutic Interventions◦ Low-fat Diet◦ Avoid Smoking◦ Exercise◦ Lipid-lowering Agents

Obstruction of Coronary Artery Blood Flow Typically from Atherosclerosis

Contributes to◦ Angina◦ Myocardial Infarction◦ Sudden Death

Modify Risk Factors◦ Low-cholesterol Diet◦ Lipid-lowering Agents

Low Dose Aspirin

Symptom of Ischemia Chest Pain Causes: CAD, Vasospasm, Valvular Heart

Disease, Hypertension, Heart Failure

Stable Angina◦ Arteries Cannot Increase Blood to Heart During

Increased Activity ◦ Usually Stops with Rest/Vasodilator

Variant Angina (Prinzmetal’s Angina)◦ Longer Duration◦ Can Occur at Rest ◦ Often Same Time Each Day◦ Coronary Artery Spasm Cause◦ Serious

Pain◦ Heaviness, Tightness, Viselike, Crushing Pain in

Chest Center◦ In the Morning◦ Radiation

Pale Diaphoretic Dyspneic

Chest Pain, Jaw Pain, Heartburn Atypical Symptoms

◦ Describe Less Severe Pain ◦ Fatigue ◦ Nausea◦ Breathlessness

ECG Exercise ECG (Stress Test) Graded Exercise Testing Stress Echocardiography Chemical Stress Testing Radioisotope Imaging Coronary Angiography

Weight Reduction Low-fat, Low-cholesterol Diet Stress Reduction Medications

Vasodilators◦ Nitroglycerin (NTG)

Calcium Channel Blockers◦ Diltiazem, Amlodipine

Beta blockers◦ Propranolol, Metoprolol, Atenolol

ACEI◦ Captopril, Lisinopril, Ramipril, Enalapril

Statins◦ Atorvastatin, Fluvastatin, Lovastatin, Pravastatin,

Simvastatin, Rosuvastin Antiplatelets

◦ Aspirin, Clopridogrel (Plavix)

Acute Pain Deficient Knowledge

Acute Pain Interventions◦ Oxygen◦ Vital Signs◦ Sublingual NTG◦ Remain with Patient◦ Emotional Support

Caused by Lack of Oxygen to Heart Muscle Conditions

◦ Unstable Angina◦ Myocardial Infarction

Worsening CAD Rest Does Not Relieve Can Occur at Rest Increasing Frequency Risk for Cardiac Damage/Death

Death of Heart Muscle Pathophysiology

◦ Coronary Artery Blockage◦ Decreased Cardiac Blood Supply

Types◦ Non-ST Segment Elevation Myocardial Infarction◦ ST Segment Elevation Myocardial Infarction

Myocardial Ischemia Without Chest Pain

Cardiac Arrest Triggered by Lethal Ventricular Dysrhythmias or Asystole from an Abrupt Occlusion of a Coronary Artery

Crushing, Viselike Pain◦ Radiates to Arm/Shoulder/Neck/Jaw

Shortness of Breath Restlessness Dizziness, Fainting Nausea Sweating

Atypical – Women/Older Adult◦ Absence of Classic Pain◦ Dyspnea◦ Fatigue◦ Anxiety◦ Chest Cramping, Epigastric or Abdominal Pain

Atypical – Women/Older Adult (cont’d)◦ Restlessness◦ Falling

Report Shortness of Breath, Fatigue,Fast/Slow Heartbeats, Chest Discomfort

Silent MI Collateral Circulation

◦“Act in Time to Heart Attack Signs” Call 9-1-1 (or Local Emergency Number) www.nhlbi.nih.gov/actintime/

◦ National Heart Attack Alert Program “60 Minutes to Treatment” www.nhlbi.nih.gov/about/nhaap

Leading Cause of Death African American Women at Higher Risk Higher Mortality Rate, More Complications

Than Men Prodromal Symptoms the Month Before MI

◦ Unusual Fatigue, Sleep Disturbances, Dyspnea

Delay Treatment Less Aggressive Treatment Given

Consider Patient History Serial ECG Cardiac Troponin I or T Myoglobin CK-MB C-reactive Protein Magnesium

“Time is Muscle” Chew One Uncoated Adult Aspirin Call 911 in 5 Minutes for Unrelieved Chest

Pain Do Not Drive Self

Mission: Lifeline ◦ www.americanheart.org/

Door-to-Balloon Time: 90 Minutes◦ www.d2balliance.org/

Oxygen Aspirin Morphine Sulfate Thrombolytics

Vasodilators Nitrates Beta Blockers Antidysrhythmic

PCI◦ Balloon Angioplasty◦ Coronary Artery Stents

Bedrest/Bedside Commode Intra-aortic Balloon Pump Glucose Control Daily Weight Low-sodium Clear Liquids Low-fat, Low-cholesterol, Low-sodium Diet

No Caffeine   Fluid Restriction Weight Loss Smoking Cessation

Fab Four Cardiac Drugs◦ Antiplatelets◦ Statins◦ ACEIs◦ Beta Blockers

Coronary Artery Bypass Graft◦ Coronary Artery Occlusions Bypassed with

Vein/Artery Grafts◦ Increases Blood Flow/Oxygen to Myocardium

Thoracoscope No Cardiopulmonary Bypass Small Incisions Two Coronary Arteries Maximum

Combines Peripheral Cardiopulmonary Bypass (CPB) with Minimally Invasive Heart Access

Acute Pain Decreased Cardiac Output Activity Intolerance Deficient Knowledge

Pain Ineffective Airway Clearance Impaired Gas Exchange Decreased Cardiac Output Risk for Infection Deficient Knowledge

Monitor Vital Signs Report Symptoms Incisional Care

Disease Information Medications Diet Activity Rehabilitation

Optimizes Functioning Begins in Hospital Protocols Specify Activities Outpatient Program After Discharge

Arterial Venous

Arterial Blood Clot Can Become Embolus

Six Ps◦ Pain ◦ Pulselessness◦ Paralysis ◦ Pallor ◦ Paresthesia ◦ Poikilothermia

Therapeutic Interventions◦ Anticoagulants◦ Thrombolytics◦ Thrombectomy ◦ Embolectomy

Pathophysiology◦ Chronic, Progressive Arterial Narrowing◦ Reduced Blood Supply◦ Ischemia Develops

Intermittent Claudication Cool Skin Reddish-purple When Dependent Pale When Elevated Diminished/Absent Pulses

Ankle-brachial Index Doppler Ultrasound MRI Arteriography

Low-fat, Low-cholesterol, Low-calorie Diet Medications

◦ Lipid-lowering Agents◦ Pentoxifylline (Trental) ◦ Thrombolytics

Invasive Therapies◦ Percutaneous Transluminal Angioplasty (PTA)◦ Atherectomy◦ Stents ◦ Aortic-femoral Bypass

Ineffective Tissue Perfusion ◦ Do Not Elevate Legs

Pain Activity Intolerance Deficient Knowledge

Vasoconstriction with Cold/Stress Causing Ischemia

Mainly Affects Hands Phases: Blanching, Pain, Reddening Therapeutic Intervention: Keep Warm, Avoid

Vasoconstriction, Take Vasodilators

Nursing Care: Education

Recurring Inflammation of Small and Medium Arteries and Veins of Hands/Feet

Vasospasms, Ischemia, Gangrene Cause is Unknown Heavy Cigarette Smoking Contributes

Signs and Symptoms◦ Intermittent Claudication ◦ Six Ps◦ Lower Extremities Red or Cyanotic in Dependent Position

Therapeutic Interventions◦ Smoking Cessation◦ Calcium Channel Blockers◦ Skin Assessment

Dilation at Weakened Area of Artery Cause Unknown Abdominal Aorta Most Common

Fusiform Saccular Dissecting

None Early Back/Flank Pain Classic Pulsating Abdominal Mass Rupture

◦ Severe, Sudden Back, Flank, or Abdominal Pain◦ Shock

CT Scan Abdominal Ultrasound Aortography

Control Hypertension Bypass Graft

◦ Open◦ Endovascular

Acute Pain Ineffective Tissue Perfusion

Education◦ Medication◦ Avoid Lifting◦ Reduce Stress

Postoperative Care

Elongated, Tortuous, Dilated Veins Cause is Unknown Hereditary Varicosities

◦ Primary ◦ Secondary

Contributing Factors◦ Prolonged Standing◦ Pregnancy◦ Obesity

Signs and Symptoms◦ Disfigurement of Lower Extremity◦ Dull Pain ◦ Edema◦ Ulceration

Therapeutic Interventions◦ Reduce Contributing Factors◦ Compression Stockings ◦ Injection Sclerotherapy ◦ Radiofrequency Ablation◦ Laser◦ Surgical Intervention

Damaged/Aging Valves Cause Pooling of Blood in Lower Extremities

Chronic

Result of Chronic Venous Insufficiency Leg/Foot: Edema; Brownish Discoloration;

Hardened, Leathery Skin Stasis Ulcers at Ankle Patient’s Quality of Life Affected

Goal: Decrease Edema/Heal Ulcerations Compression Wraps Bedrest with Elevation of Legs Avoid Prolonged Standing/Sitting Walk Skin Ulcers: Unna Boot, Skin Grafts

Acute Pain Impaired Tissue Integrity Ineffective Health Maintenance

Wound Care Emotional Support

Education◦ Elevate Legs◦ Protect Legs from Injury◦ Do Not Cross Legs/Wear Tight Clothing◦ Avoid Heating Devices◦ Apply Compression from Foot Upward

Acute or Chronic Pain Anxiety Deficient Knowledge

Restores Blood Flow and Oxygenation Can Be Surgical Emergency

Bypass: Graft Anastomosed to Artery Above and Below Occlusion

Graft Repair: Diseased Area of Blood Vessel Replaced with Graft

Video-assisted Aortofemoral Bypass

Arteriosclerotic Plaques Dissected Carotid Artery Common

Open Plaque-blocked Arteries Balloon or Laser

Support to the Artery Walls to Keep Them Open

Bleeding and Hemorrhage Re-occlusion Hematoma Neurological Dysfunction Volume Deficit

Neurological Checks Neurovascular Checks Incision Care Fluid Status

Pain Ineffective Airway Clearance Risk for Infection Ineffective Tissue Perfusion Deficient Knowledge

Inflammation/Infection of Lymphatic Channels

Pain, Red Streak, Chills and Fever Antibiotic, Heat, Elevation, Pneumatic

Pressure Devices Monitor Site

Acute Pain Risk for Excess Fluid Volume