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MODULE V | CARE OF PATIENTS WITH CARDIOVASCULAR DISORDERS
ANATOMY OF THE HEART
▪ WHO : Leading cause of morbidity & mortality worldwide ▪ Leading Cause of heart diseases in the PH is RF then HPN, followed by Atherosclerosis. ▪ Associated with stroke. ▪ Globalization, urbanization, aging population, poverty, and stress ▪ Technology increase survival rate - Requires continuous clinical care - increasing cost of care. RISK FACTORS: NON-MODIFIABLE ✓ Family history ✓ Race ✓ Sex ✓ Age ✓
RISK FACTORS: MODIFIABLE
✓ Diet ✓ Inactivity ✓ Diabetes ✓ Stress ✓ Smoking ✓ Hypertension CARDIOVASCULAR ASSESSMENT HISTORY a) Emergent vs. stable patient - Triage b) Common presenting symptoms - Chest pain, fatigue, dyspnea, cough, weight gain c) Symptom analysis - Typical vs. Atypical symptoms d) Medication history – Medication Reconciliation Process (National Patient Safety Goals, JCAHO, 2008) e) Chronic medical conditions MEDICATION RECONCILIAION PROCESS
MODULE V | CARE OF PATIENTS WITH CARDIOVASCULAR DISORDERS
SBAR APPROACH
→Provides a framework of communication between the interdisciplinary team about a patient’s condition. ▪ Situation ▪ Background ▪ Assessment ▪ Recommendation A General appearance B Skin color & temperature C Cardiac sounds D Pulses E Urine output F Level of consciousness COMPLICATIONS ▪ Heart failure ▪ Dysrhythmias ▪ Renal failure ▪ Cerebrovascular accident ▪ Retinopathy ▪ Hypertensive crisis LABORATORY & DIAGNOSTICS CARDIAC ENZYMES ✓ CK-MB ✓ Troponin I BIOPHYSICAL MARKERS ✓ Type B Natriuretic Peptide (BNP) ✓ NT-pro-BNP ✓ Erythrocyte Sedimentation Rate (ESR) ✓ C-Reactive Protein (CRP) ✓ Homocysteine
CBC
✓ Hemoglobin & hematocrit (H & H) BASIC METABOLIC PANEL (BMP) ✓ Sodium ✓ Potassium ✓ magnesium LIPID PROFILE ✓ Total cholesterol ✓ LDL ✓ VLDL ✓ HDL ✓ LDL:HDL ratio GLYCOSYLATED HEMOGLOBIN (HBA1C) COAGULATION STUDIES CARDIAC STRESS TEST ✓ Physical o Pharmacological ✓ Mental / Psychological ECHOCARDIOGRAPHY CARDIAC CATHETERIZATION SCANS ✓ PET NURSING RESPONSIBILITIES
- Diagnosis of coronary vascular disease, cardiac functional capacity; determines effectiveness of medications.
- Explain procedure: physical, pharmacological, mental.
MODULE V | CARE OF PATIENTS WITH CARDIOVASCULAR DISORDERS
CARDIOVERSION
✓ Synchronized with QRS ✓ Scheduled ✓ Sedation ✓ Anticoagulation DEFIBRILLATION →Emergency management for ventricular tachycardia or ventricular fibrillation PERCUTANEOUS CORONARY INTERVENTIONS PTCA → Percutaneous Transluminal Coronary Angioplasty (PTCA) NURSING RESPONSIBILITIES
- Coagulation studies
- Assessment of access site for bleeding / clotting ▪ Vascular closure devices (Angio- Seal, VasoSeal)
- Positioning of affected extremity
- Sheath removal ▪ Atropine sulfate
- Analgesia and sedation
CORONARY ARTERY BYPASS GRAFTING
→CABG
PACEMAKER
INTRA-AORTIC BALLOON PUMP (IABP)
MODULE V | CARE OF PATIENTS WITH CARDIOVASCULAR DISORDERS
HEART TRANSPLANTATION
CARDIOVASCULAR PHARMACOLOGY
ANTI-HYPERTENSIVES
✓ Diuretics ✓ Vasodilators ✓ Beta-adrenergic blockers ✓ Calcium channel blockers ✓ ACE inhibitors ✓ Angiotensin receptor blockers ANTI-DYSRHYTHMICS ✓ Sodium-channel blockers ✓ Calcium channel blockers ✓ Beta-adrenergic blockers CARDIAC GLYCOSIDES ✓ Digoxin ✓ Lanoxin PROPHYLACTIC ANTICOAGULANTS ✓ Heparin ✓ Lovenox VASOPRESSORS
CARDIAC REHABILITATION
PHASE I
→ Low-level activities and initial patient and family education. → Signs and symptoms, medications, rest- activity balance, follow-up appointments PHASE II → Supervised out-patient activities →ECG-monitored exercises, lifestyle modification, adherence to treatment plan PHASE III → Self-directed phase →Maintenance of CV stability and long- term conditioning NATIONAL PATIENT SAFETY GOALS RELATED TO CARDIOVASCULAR CARE, JCAHO (2008) ▪ Goal : Improve the safety of using medications. Requirement : Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. ▪ Goal : Accurately and completely reconcile medications across the continuum of care ▪ Goal : Improve recognition and response to changes in a patient’s condition. Requirement : The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.
MODULE V | CARE OF PATIENTS WITH CARDIOVASCULAR DISORDERS
PATHOPHYSIOLOGY OF ATHEROSCLEROSIS
ANALYSIS OF SERUM LIPIDS
→Total cholesterol, triglycerides, LDL, HDL LDL
- High cholesterol content
- Transports cholesterol liver cells
- Dangerous component HDL
- “good”
- Low cholesterol content
- Transports cholesterol cells – liver ETIOLOGY
- Age
- Gender
- Genetic factors
- Obesity, diet high in cholesterol, animal fats
- Cigarette smoking
- Sedentary lifestyle
- Diabetes mellitus
- Poorly controlled hypertension
- Combo of BC pills and smoking DIAGNOSTIC TESTS
- Serum lipid levels
- Exercise stress test
- Radioisotope TREATMENT
- Decrease cholesterol and LDL
- Decrease sodium ion intake
- Control primary disorders
- Quit smoking
- Physical activity
- Oral anticoagulant
- Surgical intervention ▪ Percutaneous transluminal coronary angioplasty (PTCA) ▪ Cardiac catheterization ▪ Laser beam technology ▪ Coronary artery bypass grafting ANGINA PECTORIS →Temporary imbalance between the coronary arteries’ ability to supply oxygen and cardiac muscles demand for oxygen. TYPES STABLE ANGINA →Usually associated with a stable plaque UNSTABLE ANGINA →Usually associated with a ruptured plaque VARIANT ANGINA PRINZMETAL’S ANGINA) →May occur in the absence CAD; due to a major coronary spasm SILENT ISCHEMIA →Associated with DM FACTORS
- Upon physical exertion
- Extremes of temperature
- Consumption of a heavy meal
- Stress
- Sexual activity
- Stimulants SIGNS & SYMPTOMS ✓ Retrosternal pain ✓ SOB ✓ Pallor ✓ Dizziness ✓ Nausea and vomiting ✓ ST segment depression
MODULE V | CARE OF PATIENTS WITH CARDIOVASCULAR DISORDERS
CARDIAC CATHETERIZATION
→To confirm suspected heart disease →Determines patency of coronary blood vessels, pulmonary artery pressure INDICATIONS
- For unstable angina
- Uncontrolled heart failure
- To assess if cardiac surgery is necessary NURSING RESPONSIBILITIES PRE-PROCEDURE
- Ensure signed informed consent
- Review results of coagulation studies
- NPO
- Skin preparation
- Assess hypersensitivity to iodine
- Ensure an IV access POST-PROCEDURE
- Assess access site for bleeding
- Keep extremity site straight. No flexion.
- Bed rest for 4-6 hours
- Patient is usually attached to a cardiac monitor
- Monitor urine output MANAGEMENT
- O2 administration
- Drug therapy
- Nitrates
- Beta blockers
- Calcium channel blockers
- Anti platelet and anti-coagulant medications ▪ *Aspirin, Clopidogrel, Heparin
MYOCARDIAL INFARCTION
→When myocardial tissue is severely deprived of oxygen → CAUSE - Atherosclerosis → RISK FACTORS - Non modifiable/Modifiable HOW IS INFARCTION DEVELOPED?
- Thrombus may build up.
- Part of the thrombus may break away.
- Vasospasm may occur WARNING SIGNS
- Feeling of pressure, heaviness or burning in the chest
- SOB
- Sweating
- Weakness and fatigue
- Nausea and indigestion
- Substernal chest pain
- Pallor
- Diaphoresis
- Hypotension
- Low grade fever
MODULE V | CARE OF PATIENTS WITH CARDIOVASCULAR DISORDERS
PERCUTANEOUS CORONARY INTERVENTIONS a. Percutaneus transluminal coronary angioplasty - Insertion of a balloon tipped catheter to open blocked coronary vessels CHECK FOR
- Bleeding
- Dysrhythmia
- Hypokalemia
- Hypotension
- Acute closure of vessel b. Coronary artery stent - Insertion of a metal mesh that provides structural support to a vessel at risk of acute closure. NURSING RESPONSIBILITIES
- Monitor for signs of bleeding
- Sheath removal ▪ Vascular closure devices (Angio-Seal, VasoSeal) ▪ Check for blood studies.
- Positioning of affected extremity
- Analgesia and sedation
- IV bolus of Atropine maybe given
- Application of pressure dressings c. Coronary Artery Bypass Graft - blood vessel is grafted to the occluded coronary artery so that blood can flow beyond the occlusion. INDICATION
- Angina with more than 50% occlusion of the left coronary artery
- Unstable angina with 2 or 3 vessel disease
- Ischemia with HF
- Acute MI CARDIOPULMONARY BYPASS
- Cannulation of the inferior and superior vena cavae
- To provide oxygenation, circulation, and hypothermia during induced cardiac arrest POST OPERATIVE
- Transported to a post open heart surgery unit
- On mechanical ventilation for 6- 24 hours Complications
- Fluid and electrolyte imbalance
- Hypotension
- Hypothermia
- Impaired cerebral tissue perfusion
