NUR 317: Cardiovascular Disorders

• NUR 317 studies Cardiovascular Disorders

Topics covered

• Peripheral Arterial Disease
• Coronary Artery Disease
• Acute Coronary Syndrome (Myocardial Infarction)
• Pericarditis

Arteries

• Carry oxygenated blood and nutrients to tissues
• Have muscular walls to handle pressurized flow
• Heart force ensures flow in one direction

Atherosclerosis

• Characterized by lipid deposits within the arterial
• A progressive disease that begins with endothelial injury
• Advanced Atherosclerosis leads to restriction in distal perfusion
• Causes peripheral artery disease and coronary artery disease (cerebral, mesenteric, and renal artery disease!)
• Injury to the endothelium is caused by Hypertension, Tobacco use, Hyperlipidemia, Hyperhomocysteinemia, Diabetes, Infections, Toxins
• Smoking destroys the vessel wall
• Diabetes Mellitus changes vessel make-up

Peripheral Arterial Disease (PAD)

• Progressive artery narrowing, especially in lower extremities, often due to advanced ATHEROSCLEROSIS
• Can be associated with high mortality, major coronary and stroke events
• Often undiagnosed and undertreated
• Slow progression
• Advanced PAD can include arterial occlusions that can be surgically removed or need amputation
• PAD symptoms depend on blockage site/extent
• Symptoms present when artery 60-75% blocked

PAD Symptoms

• Symptoms occur when the artery becomes 60-75% blocked
• Classic symptom is "Intermittent Claudication," and can be caused by unstable angina due to blocked blood flow to the heart leading to chest pain
• Some patients have no symptoms
• Paresthesia (peripheral neuropathy) with nerve pain/burning
• Hair/toenail and temp changes, edema, pulse deficits, and capillary refill changes on assessment
• Skin changes: elevation pallor/dependent rubor
• Occurs symmetrically

PAD Risk Factors

• Modifiable risk factors: smoking, physical inactivity, obesity, hyperlipidemia, diabetes and hypertension
• Non-modifiable Risk Factors: Prevalence increases with age between 50-70 years, race, genetics

PAD Diagnostic Tests

• Ankle Brachial Index: Non-invasive to measure the ratio of blood pressure in the ankle to the BP of Arm
• Doppler Ultrasound: Non-Invasive to measure of blood flow through the vessels
• Segmental Blood Pressures: Compares pressures to detect blockages
• Angiography: Invasive gold standard using contrast dye that requires caution in pts with renal disease
• MRI: Non-Invasive for detailed artery images

PAD complications

• Critical Limb Ischemia cases present with delayed or non-healing wounds
• Primary Arterial Lesions
• Gangrene with dead tissue and infection
• May require amputation

Revascularization for PAD

• In PAD with a 100% artery occlusion, it depends if revascularization is needed to prevent a distal ischemic wound
• Based on collateral development and new vessel blood flow

PAD treatment

• Improve manages symptoms
• Smoking cessation, weightloss, exercise, healthy diet
• Pharmacological: lipid-lowering drugs, ACE to help with symptoms, low dose aspirin or Plavix to anticoagulate, Intermittent Claudication of Cilostazol and pentoxifylline

Surgical options for PAD

• Revascularization performed to attempt limb preservation
• Bypass surgery involves grafting of new vessels
• Native vein vs. synthetic grafts available
• Angioplasty (endovascular)
• Not every patient is a surgical candidate and conservative management or amputation may be the only option

Postoperative Care

• Post operative Bleeding needs monitoring for Dysrhythmias
• New versus Old
• CMS and temperature needs constant checks
• Assess site for bleeding, hematoma, thrombosis, compartment syndrome
• Pain needs attention and reduction of VTE/PNA
• Out of bed with legs elevated

Goals for PAD care

• Adequate tissue perfusion
• Pain relief
• Increased exercise tolerance
• Maintain intact, healthy skin of LE
• Increase knowledge of disease and treatment plan

Coronary Artery Disease

• Atherosclerosis leads to progressive limitation in distal perfusion
• Chronic and progressive disease caused by atherosclerosis
• Plaque buildup in coronary arteries effects the perfusion on the heart muscle that never fully recovers and can lead to cardiac arrest

CAD Symptoms

• Begin when one of the coronary arteries has 70% or more blockage
• Exercise intolerance from affecting daily activities
• Dyspnea
• Fatigue
• Chest pain - "Angina", often sub-sternal
• Angina is associated with ECG changes

Categories of Angina

• Stable Angina
• Unstable Angina
• Full vessel occlusion

CAD Risks

• Modifiable: smoking, hypertension, hyperlipidemia, diabetes (making CAD 2-4x more likely), physical inactivity, obesity, stress and substance abuse.
• Non-modifiable: Prevalence increases with age, race/gender, genetics

CAD Treatment

• Pharmacological Intervention: Lipid lowering drugs, Low dose aspirin or Plavix (anticoags)
• Non-pharmacological Intervention: Tobacco cessation, dietary modifications, hypertension management, BG control and weight loss through exercise

Prinzmetal's Angina

• Pain is caused by a coronary spasm
• Unrelated to Coronary Artery Disease.
• Coronary spasm is caused by substance exposure and cold weather exposure
• Pain may subside with exercise, nitro or spontaneously
• Treatment: calcium channel blockers, nitrates, stop use of offending substance

Chronic Stable Angina

• O2 Demand is greater than O2 Supply
• Goal must be to Decrease O2 demand, or increase O2 supply
• Pain relief through immediate and appropriate treatment
• Preservation of heart muscle thru rest when experiencing pain
• Effective coping, participation in rehab and reduction of risk factors are key

Chronic Stable Angina Care

• Ask patient to describe pain & rate it
• Treatment with Nitro (should relieve it)
• Assess VS, EKG and heart sounds, assessing for nonverbal pain cues
• Support and reassurance is key

Diagnostics of Angina

• 12-lead ECG
• Labs - troponin -> elevated result indicates a MI
• Chest Xray- Treadmill walk
• Echocardiogram- Ultrasounds to view the structure of the heart
• Exercise stress test or Pharmacological stress test
• Cardiac Catheterization to contrast for clots in coronary arteries
• PCI may be done

Surgical Options

• Thrombolytic Therapy is used to breaks up clots
• CABG: Requires Sternotomy & Cardiopulmonary Bypass
• May use LIMA or a Leg vein as a graft to graft new vessels

CABG Postoperative Nursing Care

• First 24-48 in ICU
• Postop Considerations: Monitor Bleeding (new vs old dyshythmias), pain, reduce chance of VTE/PNA

Acute Coronary Syndrome (ACS)

• Myocardial Infarction (MI)

Pathophysiology

• Ischemia is prolonged and not immediately reversible
• Previously stable atherosclerotic plaque ruptures
• Lodges in the vessel with platelet aggregation and a thrombus forming

Pathophysology of MI

• Can lead to partial of full coronary occlusion
• Irreversible tissue death begins after just 20 minutes
• All CAD prevention/treatment is preventative

Types of MI

• Unstable Angina (NSTEMI): partial occlusion
• Myocardial Infarction (STEMI): full occlusion

Unstable Angina

• Angina is very different from any “normal" chest pain
• Unpredictable and needs emergent treatment
• ECG changes: ST depression/T wave inversion

Myocardial Infarction

• Medical Emergency for full occlusion
• Reperfusion must occur within 90 minutes to limit infarct size
• Tx with PCI vs thrombolytic therapy
• ECG changes: ST Elevation, and pathologic Q waves

Management of MI

• Need to check Collateral Development and new formed blood vessels, as patients withCAD with 100% artery need revascularization

Manifestations of an Acute MI

• Profound chest pain often described as crushing, substernal or epigastric, but can radiate
• Silent MI is possible (no pain)
• Tachycardia/ Hypertension
• Nausea & Vomiting, Fever, SOB
• Eventually, signs/symptoms of decreased CO: Low UOP and Confusion
• Dysfunction in Left Ventricular Dysnnea or right ventricular JVD and edema

Questions for assessment of MI

• Need to ask about any meds/allergies
• Precipitating Events, Quality, region and severity of Pain (0-10 objective grimacing), and Timing
• Time to PCI =90 mins

MI Diagnostics

• ECG needed to compare with previous ECG
• Pattern of ECG changes provides information on which artery is involved
• STEMI = ST elevation is seen in leads facing the infarcted wall
• NSTEMI = ST depression and/or T-wave inversion in leads facing the infarction
• Serum Cardiac Biomarkers: Troponin elevated
• Cardiac Catheterization may be indicated

MI Treatment

• First = quick diagnosis
• Start Treatment with PCI
• If ST elevations are seen directly access cath lab
• Facilities without available cath labs administer Thrombolytic therapy or Medications
• Nutrition is NPO at first followed by a heart healthy diet

Anticipate Nursing MI Care

• 12-lead ECG
• Continuous ECG monitoring
• Upright positioning and Oxygen
• IV access with fast Nitro- dilators and Morphine for pain
• High dose statin to be admin
• Obtain Labs

Nursing Management For Cardiac Catheterization

• Pre cardiac Management Requires assessment of Allergies and Contrast dye in lab and baseline assessments for kidney and liver function Patients must observe: NPO 6-12 hrs prior
• Post Operation: CMS compare, VS for stability to extremity that artery Check for bleeding, hematoma, changes in electrolytes/ labs with new dysrhythmias
• Bedrest must be enforced per bedrest policy Expect: minimal/stable VS
• Cardiac rhythm: stable (without irregular beats)

Complications of MI

• Dysrhythmias is first priority
• Heart failure (acute or chronic) with muscle/pump failure
• Cardiogenic Shock from minimal to no pumping
• Papillary Muscle Dysfunction/ Rupture and LV Aneurism
• Ventricular Septal Wall Rupture
• Pericarditis causing inflammation of the heart

Heart complications from MI

• Papillary muscle rupture: Acute pulmonary edema, cardiogenic shock, with eccentric or Broad Jet of Severe MR. Mobile Mass in LV; prolapsing into LA
• Ventricular septal defect from left to right shunt and high continuous wave Doppler velocity resulting in Asymptomatic to circulatory collapse
• Pseudoaneurysm that Is Asymptomatic, Small neck communication
• To-and-fro blood flow through rupture.
• Free wall rupture that resulti in Circulatory collapse, Pericardial effusion or cardiac tamponade, Electromecanical dissociation

Nursing MI Care focus

• Promoting rest and comfort
• Gradually increasing physical activity – "listen to your body"
• Helps reduce anxiety through teaching additional needed emotional/ spiritual support systems
• Teaching- Risk factors, meds, incisional care,
• Cardiac Rehab and discussion of when to resume sexual activity

Pericarditis

• Inflammation of the pericardial sac containing the heart
• Causes of Pericarditis can include Viral, Bacterial or Fungal infection types
• Non-infectious MI, Cancer with Injury or Trauma and Radiation cause Rheumatoid fever

Manifestations of Pericarditis

• Inflammation of the pericardium.
• Often with fluid accumulation (pericardial effusion)
• Normal volume is 15mL
• Occurs 2-3 days following MI
• Symptoms: Sudden onset: Mild to severe sharp chest with pain
• Increases with inspiration, coughing, laying down and Pain relieved when sitting up relievers pressure
• A pericardial friction rub is hallmark finding* plus Patient will have a fever

Complications and treatment

• Pericarditis: Pericardial Effusion restricting the movement of the heart that requires Ultrasound to measure chamber dimensions and for visuals heart Procedural Treatment: Is pericardiocentesis removing all fluid from pericardium chamber Medical Treatment uses aspirin, NSAIDS and ABx if infectious