Cardiac Management PDF

Nursing Management of the Patient with Cardiac Disorders BUC 2024-2025  OBJECTIVES On completion of this lecture, the learner will be able to: - Describe the anatomy and physiology of cardiac system. - Describe the investigation, and diagnostic procedur...

Nursing Management of the Patient with Cardiac Disorders BUC 2024-2025  OBJECTIVES On completion of this lecture, the learner will be able to: - Describe the anatomy and physiology of cardiac system. - Describe the investigation, and diagnostic procedure of angina pectoris, myocardial infarction and congestive heart failure. - List the etiology and risk factors of angina pectoris, myocardial infarction and congestive heart failure. - Classify the clinical manifestation of angina pectoris, myocardial infarction and congestive heart failure. - Explain the medical management of angina pectoris, myocardial infarction and congestive heart failure. - Explain the nursing intervention and health teaching for angina pectoris, myocardial infarction and congestive heart failure.  OUTLINES - Anatomic and physiologic overview of cardiac system. - Assessment of cardiac system. - Common problems: - Coronary atherosclerosis. - Angina. - Myocardial infarction. - Congestive heart disease.  INTRODUCTION - The circulatory system is responsible for transporting blood throughout the body. - It is responsible for delivering oxygen and nutrients to cells of the body, and for removing carbon dioxide and other waste products. - The circulatory system includes the heart, arteries, arterioles, capillaries, venules and veins. - Problems or failure of any of these system can lead to serious health concerns. Anatomy and Physiology of the heart https://youtu.be/WuBeB7CI6Tc Clinical manifestation of cardiac dysfunction  NURSING HISTORY - History of present illness. - Past medical history (medical, surgical, allergies, medication). - Family history. - Personal and social history: - Diet history: 24 hr. sample diet. - Socioeconomic status. - Cigarette smoking. - Physical Activity (sedentary lifestyle). - Obesity – associated with HTN, hyperlipidemia, and diabetes and all contribute to cardiovascular disease. - Type A personality.  Common or Concerning Symptoms Subjective Data / Health History Chest pain. Dyspnea. Syncope (Fainting)- dizziness. Palpitation. Edema, weight gain. Clubbing fingers. Fatigue. Cyanosis, Nocturia. Respiratory problems. Common or Concerning Symptoms: Chest Pain - Chest pain: or discomfort, a symptom of cardiac disease, can result from ischemic heart disease, pericarditis and aortic dissection. - Chest pain of cardiac origin is most often caused by myocardial ischemia, a condition in which the oxygen supply is inadequate to meet the metabolic need of cardiac muscle. - If the ischemia is temporary and does not result in the death of myocardial tissue, it is called angina pectoris. - If ischemia is sufficient severe or prolonged to kill myocardial cells, a myocardial infarction (heart attack) has occurred. Common or Concerning Symptoms: Chest Pain S Site Where exactly is the pain? O Onset. What were they doing when the pain started? C Character What does the pain feel like? R Radiation Does the pain go anywhere else? A Associated symptoms e.g. Nausea / Vomiting. T Time / duration How long have they had the pain? E Exacerbating / relieving Does anything make the pain better or worse? factors S Severity Obtain an initial pain score. Common or Concerning Symptoms: Chest Pain  Different causes of chest pain Causes Character, location Duration Precipitating events Relieving measures and radiation Angina pectoris Substernal or 5-15 min Usually related to: - Rest. retrosternal pain - Exertion. - Nitroglycerin. spreading across chest - Emotion. - Oxygen. may radiate to inside - Eating. of arm, neck or jaw. - Cold. Levine’s sign  Different causes of chest pain Causes Character, location Duration Precipitating events Relieving measures and radiation Myocardial Substernal pain or >15 Occurs spontaneously - Morphine sulfate. infarction pain over precordium, but may be sequel to - Successful may spread widely unstable angina. reperfusion of throughout chest, pain blocked coronary in shoulders and artery. hands may be present.  Different causes of chest pain Causes Character, location and Duration Precipitating Relieving radiation events measures Pericarditis Sharp, severe substernal Intermittent Sudden onset, pain Sitting upright, pain or pain to the left of increase with analgesia, anti- sternum may be felt in inspiration, inflammatory epigastrium and may be swallowing, medications. referred to neck, arms and coughing and back. rotation of trunk.  Different causes of chest pain Causes Character, location Duration Precipitating events Relieving measures and radiation Pleuritic pain Pain arises from 30+ min. - Often occurs - Rest, time. inferior portion of spontaneously. - Treatment of pleura, may be - Pain occurs or underlying cause, referred to costal increases with bronchodilators. margins or upper inspiration. abdomen. Different causes of chest pain  Common or Concerning Symptoms: Dyspnea - Dyspnea: shortness of breath or breathlessness is the feeling associated with impaired breathing. - Refers to the sensation of difficult or uncomfortable breathing. - Subjective experiencing. - Dyspnea occurs in many forms including: - Dyspnea on exertion (DOE). - Positional dyspnea. - Paroxysmal nocturnal dyspnea. - Orthopnea.  Assessment: Dyspnea Types Definition Dyspnea on exertion Is shortness of breath caused by physical exertion and relieved (DOE): by rest. It is a common early symptom of heart failure. Positional dyspnea: Is shortness of breath that develops when a person turns from a supine to a side lying position; especially when turning onto the left side. Paroxysmal nocturnal Is a form of shortness of breath that occurs suddenly, at night. dyspnea: Orthopnea: Is shortness of breath that develops any time the patient lies flat.  Assessment: Dyspnea Index Grade Definition Grade 0 No breathlessness except with strenuous exercises. Grade I Dyspnea on running or on doing more than (Minimal Dyspnea) ordinary effort. 3 Floors ladder or 300 meters Grade II On doing ordinary effort. 2 Floors ladder or 200 meters Grade III On doing less than ordinary effort. (Considerable Dyspnea) one Floor ladder or 100 meters Grade IV Dyspnea at rest.  Assessment: Palpitation - Palpitation: A sensation in which a person is aware of an irregular, hard, or rapid heartbeat. - Palpitations that occur with mild exercises can indicate heart failure, anemia or hyperthyroidism. - Pathologic palpitations also may be caused by non- cardiac factors, such as large amounts of caffeine, alcohol or nicotine, heavy meals, lack of sleep, or stress, fatigue.  Assessment: Weakness, Fatigue, Syncope - Fatigue can be produced by low cardiac output (CO) due to right- or left-sided heart failure. The heart can't provide sufficient blood to meet the increased metabolic needs of cells. - As heart disease advances, fatigue is precipitated by less effort. - Fatigue- is usually worse in evening. - Patients with chronic decreased cardiac output have difficulty performing activities of daily living. - Syncope (fainting): is a transient loss of consciousness, caused by decrease in perfusion to brain; characterized by rapid onset, short duration, and spontaneous recovery, due to global hypo perfusion to the brain that result from hypotension.  Assessment: Edema - Edema: is an abnormal accumulation of serous fluid in soft tissues. - It can be caused by inadequate venous return to the heart because of venous obstruction from external pressure on the veins, incompetent valves, and or the effects of gravity (non-pitting edema). - Weight gain- a sudden increase in weight of 1 kg can be result of accumulation of fluid (1L) in interstitial spaces, known as edema.  Assessment: Edema - Edema is called “pitting edema” when the skin in the edematous area maintains an indentation for 5 to 30 seconds after being pressed with a finger. - It is best palpated over a bony prominence. - Pitting edema does not disappear when the body part is elevated. - Edema may be generalized or localized. - In the ambulatory cardiac patient, edema is usually bilateral and dependent. - It appears in the hands, feet, and ankles from the effect of gravity. - In the bedridden patients, edema occurs in the sacral area and posterior thighs. Assessment: Edema  Dent Depth and Duration Grade Definition +1 2mm or less: slight pitting, no visible distortion, disappears rapidly. +2 2- 4mm indent: somewhat deeper pit, no detectable distortion, disappears in 10-25 seconds. +3 4-6mm: pit is noticeably deep. May last more than a minute. Dependent extremity looks swollen and fuller. +4 6-8mm: pit is very deep. Lasts for 2-5 minutes. Dependent extremity is grossly distorted.  Common or Concerning Symptoms: Clubbing Finger - Clubbing is an abnormality of the nail base. - Clubbing develops in stages and occurs with pulmonary disease as well as cardiovascular disease. - It is thought to result from a diminished oxygen supply to the tissues.  Common or Concerning Symptoms: Altered renal function - With a decreased cardiac output, there is decreased perfusion of the kidneys via the renal arteries. - Activation of the renin-angiotensin aldosterone system is a response to decreased renal blood flow. - The result is increased blood pressure and retention of sodium and water. - With prolonged renal vasoconstriction, the kidney lose their ability to filter, excrete and reabsorb necessary particles. Common or Concerning Symptoms: Altered GIT function - Hepatomegally occurs with impaired venous return to the heart secondary to right-sided heart failure. - This causes abdominal pressure, pain, tenderness, a feeling of fullness, anorexia, nausea and vomiting. - Severe vasoconstriction causes detrimental changes in the pancreas. - Pancreatic injury leads to pancreatitis, pancreatic hemorrhage and peritonitis, which may be life – threatening. Common or Concerning Symptoms: Altered Neurologic function - With cardiac failure and decrease in circulating oxygen, the brain may not receive the necessary amount of oxygen for normal functioning. - This oxygen deficit alters the level of consciousness. - Restlessness is usually the first signs of decreased circulation of oxygen to the brain. - Periods of disorientation and confusion are common.  Respiratory problems with heart disorder Manifestation Definition Crackles: Are first noted at the bases (because of gravity’s effect on fluid accumulation and decreased ventilation of basilar tissue), but they may progress to all portions of the lung fields. Cough: Common in patients with pulmonary congestion from heart failure. Hemoptysis: Pink, frothy sputum is indicative of acute pulmonary edema. Tachypnea: Rapid, shallow breathing. Cheyne-Stokes A pattern of rapid respirations alternating with apnea. respirations: Wheezes: Compression of the small airways by interstitial pulmonary edema may cause wheezing.  Health History - Past history: Hypertension, Nutrition. Congenital or acquired defects; Rheumatic fever; Smoking. Heart surgery or cardiac balloon interventions. Alcohol. - Family cardiac history. - Life-style and health Exercise. practice “Personal habits” (cardiac risk factors as nutrition, smoking…etc.). Drugs. Slide 19-31  Capillary Refilling - Capillary refilling is tested by pressing firmly on a fingernail until it turns white, and estimating the time required for blood to return after pressure is released. - In a normal person with good cardiac output and digital perfusion, capillary refilling should take less than 3 seconds. - A time of more than 3 seconds is considered a sign of sluggish digital circulation, and a time of 5 seconds is regarded as abnormal.  DIADNOSTIC EVALUATION Angiocardiogram and arteriogram: - It is an x-ray study of the heart and major vessels performed after injection of a radiopaque dye into a vessel to determine structural abnormalities and calcifications within vascular system. - Keep the patient on bed rest until he is fully awake. - Instruct the patient not to bend the leg or flex the hip for up to 8 hours if the femoral site was used. - Closely observe the insertion site for bleeding, monitor vital signs to check for internal hemorrhage  DIADNOSTIC EVALUATION Cardiac MRI: - Cardiac magnetic resonance imaging (MRI) is one of the latest and most exciting noninvasive technologies in heart imaging. - The test can be performed at rest or during cardiac stress, and may provide useful diagnostic information regarding the presence of coronary artery disease or the extent of heart muscle damage.  DIADNOSTIC EVALUATION Electrocardiogram “ECG”:. - This test records the electrical activity of the heart using small patches that are attached to the skin. - The test is used as a baseline to evaluate abnormal heart rhythms (arrhythmias) and detect heart muscle damage after a cardiac event.  DIADNOSTIC EVALUATION Exercise Stress Test: - This test provides information on how well the heart responds to physical stress. - The patient usually walks on a treadmill or rides a stationary bike as the level of difficulty is increased. - During the procedure, the patient's breathing, heart rate and blood pressure are monitored. - This test is used to detect coronary artery disease or to determine safe levels of exercise following a heart attack or heart surgery. - Advise patient to abstain from eating, smoking, and consuming caffeine for 2 hours before the test.  DIADNOSTIC EVALUATION Diagnostic Cardiac Catheterization: - This test, also called an angiogram, is performed when it is thought that the patient has significant narrowing in the coronary arteries or abnormalities.  DIADNOSTIC EVALUATION Echocardiography (Ultrasound Cardiography): - Echocardiography is used to visualize and assess cardiac function, structure, and hemodynamic abnormalities. - It is the most commonly used noninvasive cardiac imaging tool. - Clinical usefulness includes demonstration of valvular and other structural deformities, detection of pericardial effusion, evaluation of prosthetic valve function, and cardiomegaly (heart enlargement), clots.  DIADNOSTIC EVALUATION Holter Monitor: - With this test, a small battery-powered monitor is connected to electrodes on the chest. - The monitor records all of the heart's activity in a 24- to 48-hour period. - This test provides information about the regularity of heartbeats, how long the heartbeats last, and is generally used to determine the cause of palpitations.  LABORATORY TESTS - Blood Chemistry (Na, K, Cl- Lipid profile, cholesterol level, blood urea nitrogen and glucose level). - Coagulation profile. - Fasting Lipid Profile Test: A simple blood test, this test requires patients to abstain from eating 8-12 hours prior to having their blood drawn. - The test provides information on total cholesterol, type of cholesterol and ratios, and triglyceride levels to develop a profile of the patient's baseline risk of heart disease.  LABORATORY TESTS - C-reactive Protein Test: This simple blood test detects the amount of C-reactive protein (CRP) in the blood. - CRP is released into the blood in response to the inflammation of blood vessels that accompanies coronary heart disease. - CRP levels may be an even better predictor of heart attack or stroke risk than cholesterol levels.  LABORATORY TESTS Cardiac Enzymes - Myocardial cells produce certain proteins and enzymes associated with cellular functions. - When cell death occurs, these cellular enzymes are released into the blood stream. - Certain enzymes (CPK, LDH, SGOT) are released from the heart muscle cells when it is injured ("heart attack"). - CPK (Creatine Phosphokinase) and troponin. - Often the cardiac enzymes will not be abnormally elevated until 24 hours after the onset of the chest pain. - CPK is present in all muscle tissue (skeletal, cardiac, and smooth muscle), but the CPK-MB (CK-MB) fraction is released specifically from injured heart muscle. - An abnormal elevation in the TOTAL CPK and the CPK-MB is diagnostic for a heart attack.  LABORATORY TESTS - Troponin: Myocardial muscle protein released into circulation after injury. - These are highly specific indicators of MI. - Troponin rises quickly like CK but will continue to stay elevated for 2 weeks. Enzyme Initial rise Peak Back to normal Troponin I < 4 hrs. 14-24 hrs. 3-5 days CPK-MB 3-12 hrs. 12-24 hrs. 2-3 days Myoglobin < 2 hrs. 6-9 hrs. 1 days AST Raises after CPK 48 hrs. 4-5 days LDH 24-48 hrs. 2-3 days 5-10 day  RISK FACTORS FOR CARDIAC DISEASE Controllable / modifiable: - Hyperlipidemia. Uncontrollable / non- - High blood pressure. modifiable: - Diabetes mellitus. - Obesity. - Ethnic background. - Cigarette smoking. - Family history. - Oral contraceptive. - Sedentary lifestyle. - Age. - Type A personality. describes Type A individuals - Sex. as outgoing, ambitious, rigidly organized, highly status- conscious, impatient, anxious, proactive, and concerned - Diabetes mellitus. with time management. People with Type A personalities are often high-achieving workaholics - High blood - Emotional stress. pressure. - Multiple role expectations.  ATHEROSCLEROSIS - Atherosclerosis is a process characterized by endothelial dysfunction, vascular inflammation, and the buildup of lipids, cholesterol, calcium and cellular debris within the intima of the vessel wall. - This buildup results in plaque formation “Atheroma”, vascular remodeling, acute and chronic luminal obstruction, abnormalities of blood flow and diminished oxygen supply to target organs. - Arteriosclerosis: or hardening (sclerosis) of the arteries (arterio), is a general term for several diseases in which the wall of an artery becomes thicker and less elastic.  Coronary Atherosclerosis - Diseases of the coronary arteries is almost always due to plaque “Atheroma” and its complications, particularly thrombosis. - Atherosclerosis is a progressive inflammatory disorder of arterial wall that is characterized by focal lipid rich deposits of atheroma that remain clinically silent until they become large enough to impair tissue perfusion.  Risk factors for developing atherosclerosis Age and sex “Male gender”. Family history for (hypertension, hyperlipidemia, diabetes mellitus). Smoking. Hypertension / Diabetes. Hypercholesterolemia. Lack of regular exercise ‘sedentary lifestyle’. Obesity. Alcohol. Personality type “Type A personality”.  Clinical Manifestation - "Ischemia " refers to an insufficient amount of blood. - The coronary arteries are the only source of blood for the heart muscle. - If this coronary arteries are blocked, the blood supply will reduce. - Ischemic heart disease (IHD): caused by coronary atherosclerotic plaque formation which leads to imbalance between O2 supply and demand - results in myocardial ischemia. - Chest pain: cardinal symptom of myocardial ischemia caused by coronary artery disease (CAD). 48  Prevention of Atherosclerosis Primary prevention (control of risk factors). - Do not smoke. - Take regular exercise (minimum of 20 min 3 times a week). - Maintain ideal body weight. - Eat a mixed diet rich in fresh fruit and vegetables. - Control DM and managing hypertension.  ANGINA PECTORIS - Definition: disease marked by brief sudden attacks of chest pain or discomfort caused by deficient oxygenation of the heart muscles usually due to impaired blood flow to the heart. - Incidence: - Angina due to ischemic heart disease affects approximately 112 million people (1.6% of the population). - Slightly more common in men than women (1.7% to 1.5%). - The prevalence of angina rises with increasing age.  ANGINA PECTORIS - Angina pectoris, the primary symptoms of ischemic heart disease, is caused by transient episodes of myocardial ischemia. - It is a characteristic sudden, severe, crushing chest pain that may radiate to the neck, jaw, back and arms. - It is not a disease in itself but is a clinical syndrome, characterized by paroxysm of chest pain, or a felling of pressure in the anterior chest. - Angina Pectoris: It is an acute pain in the chest - uncomfortable sensation in the chest or neighboring anatomic structures- caused by myocardial ischemia.  Pathophysiology Due to any cause. Increase O2 demand in body. Increase heart workload. Heart needs more blood supply. Then coronary artery dilate and supply more blood to heart. But due to any factors, blood supply defected. Heart needs more blood demands. Decreases O2 level in heart and develop condition of ischemia. Starts angina (pain) in pectoris (chest muscles).  Precipitating factors Physical exertion. Exposure to cold weather. Eating heavy meal. Stress and emotional provoking situation.  Clinical Manifestations - The clinical manifestations of pain: - Chest discomfort which may be described as: heavy pressure, burning sensation, or squeezing or tightness. - This discomfort radiates to the shoulders, arms, neck or jaw. - May be sudden in onset and relieved in minutes by rest and /or vasodilators. - May be precipitated by exercise. - Low cardiac output. - Decreased pulse rate; blood pressure may be elevated or decreased. - Diaphoresis. - ECG changes. - Dysrhythmias.  Clinical manifestations - Respiratory: - Dyspnea or shortness of breath. - Chest heaviness. - Fatigue. - Pulmonary edema. - Gastrointestinal: Nausea and vomiting. - Skin: cool, clammy, diaphoretic, pale appearance on skin. - Genitourinary: decreased urinary output indicate cardiogenic shock.  Diagnostic Evaluation History collection. Physical examination. Laboratory test “CPK-MB; Troponin I” Stress test. Chest x-ray. ECG. Echocardiogram. Cardiac catheterization “angiogram”  Types of Angina Pectoris Chronic stable angina (Classic angina). Unstable angina (Acute coronary syndrome). Variant angina. Silent angina  Types of Angina Pectoris Types Description Chronic -Stable angina is characterized by central chest pain, discomfort or breathlessness. Stable - It is precipitated by a large meal, exposure to cold, emotional stress, or any other factor that increases the angina: workload of the heart. -It is promptly relieved by rest or nitroglycerine tablets. Unstable -Unstable angina is characterized by new-onset or rapidly worsening angina, angina on minimal angina: exertion or angina at rest. -It is most dangerous and does not follow a pattern, do not go away with rest or medicine. -The common features of unstable angina are breathlessness, nausea and vomiting. -The pain occurs in the same sites as angina but is usually more severe and lasts longer. -It is often described as a tightness, heaviness or constriction in the chest. -High frequency of myocardial infarction if not treated. Variant - Typical anginal discomfort usually at rest. angina: - Develops due to coronary artery spasm rather than increase myocardial oxygen demand. Silent - Asymptomatic episodes of myocardial ischemia. angina: - Detected by electrocardiogram and laboratory studies.  Complications - Heart attacks. - Heart failure. - Abnormal heart rhythm “arrhythmia”. Management of Angina Pectoris  Management of Angina Pectoris - Anticoagulants “heparin”. - Thrombolytic drugs “streptokinase”. - Antiplatelet therapy: Low-dose (75mg) aspirin reduces the risk of adverse events such as MI and should be prescribed for all patients with coronary artery disease indefinitely. - Opiate analgesic to reduce pain “morphine suphate.  Management of Angina Pectoris Invasive treatment: 1. Percutaneous coronary intervention (PCI) (angioplasty with stent):  Management of Angina Pectoris 2. Coronary artery bypass grafting (CABG) (Revascularization): - Surgeons use segments of the patient's own veins and arteries to go around, or bypass these blockages. - If left untreated, severely blocked arteries may lead to heart attack or death.  Secondary Prevention - Cessation of smoking. - Control of high blood pressure; blood lipids; diabetes mellitus. - Eating a healthy diet “Diet low in saturated fat, cholesterol, sodium, alcohol” and maintaining a healthy weight. - Reducing stress level. - Physical exercise (at least 30 minutes of moderate intensity exercise most days). - Avoid vigorous exercise after a heavy meal or in very cold weather. - Take sublingual nitrate before undertaking exertion that may induce angina. - Low-dose aspirin daily for those at high risk.  Nursing process: Critical Assessment Assessment: - Primary assessment ABCD and immediate management: - Patients in sudden cardiac arrest will be unresponsive, apneic, pulseless – immediately begin CPR. - Monitor: - Check pulse, blood pressure, skin condition, capillary refill, level of responsiveness, - Assess skin for color, temperature, diaphoresis. - Listen to breath sounds. - Reassess patient and vital signs (Every 3-5 mins if patient is unstable). - Initial investigation. - Secondary assessment: The nurse should observe and ask the patient about: - When do attack tend to occur? - How does the patient describe the pain? - Is the onset of pain gradual or sudden? - How long does it last? - Is the pain is steady? - Is the discomfort accompanied by other symptoms? - How many minutes after taking the nitroglycerin does the pain last? - Full history. - Physical examination and clinical manifestation. - Interpretation of the finding of the diagnostic tests.  Nursing process Nursing diagnosis may include the following: - Impaired gas exchange related to decreased blood flow. - Chest pain related to decreased O2 supply to the heart muscle secondary to arterial stenosis. - Impaired physical mobility related to weakness. - Imbalance nutrition less than body requirement. - Disturbed sleep pattern related to hospitalization - Anxiety related to fear of death. - Health maintenance altered related to knowledge deficit about nature of the diseases and ways to avoid. - High risk for complications (myocardial infarction) related to non adherence to the therapeutic regimen and non acceptance of necessary life- style changes.  Nursing process Nursing intervention: - Prevention of pain. - Control of pain. - Reduction of anxiety. - Understanding of illness and ways to avoid complications. - Adherence to the self care program.  Health teaching of patient with angina pectoris Patient prevents an episode of anginal pain: - Uses moderation in all activities of life. - Participates in normal daily program of activities that don't produce chest discomfort, shortness of breath and fatigue. - Alternates activities with periods of rest. - Avoid exercises requiring sudden bursts of activity or heavy effort. - Refrains from engaging in physical exercise for 2 hours after meals. - Maintain proper weight. - Avoid excessive caffeine intake. - Stop smoking. - Avoid situations that are emotionally stressful or cold weather if possible. - Avoid walking against the wind; Walk more slowly in cold weather.  Health teaching of patient with angina pectoris Patient cop / control with an attack of anginal pain: - Carries nitroglycerin at all times. - Places nitroglycerin under the tongue (sublingually) at first sign chest discomfort. It relieves pain within 3 minutes. - Doesn't swallow saliva until the tablet has dissolved. - Stops activities and be in rest until all pain subsides. - Keep the upright position to potential the effect of nitroglycerin. - Usually another nitroglycerin tablet may be taken in 3-5 minutes if pain persist. - If the anginal discomfort is unrelieved (after 3 tablets of nitroglycerin) or if it reoccurs after short interval, the patient must go to the nearest emergency facility. - Takes nitroglycerin prophylactically to avoid pain known to occur with certain activities (stair- climbing- sexual intercourse). - Be alert for the side effects of nitroglycerin: headache, flushing and dizziness.  Health teaching of patient with angina pectoris Instruct patient on administration of transdermal nitroglycerin patches. - It is usually worn for 12 to 14 hours a day and removed for 10 to 12 hours. Apply the patch to an area on the upper body that is clean, dry and hairless. Avoid injured, irritated, calloused, or scarred areas. Use a different site each day to prevent skin irritation. - Remove previous patch; fold in half so that medication does not touch fingertips and will not be accessible in trash. - Wipe area with tissue to remove any residual medication. - Rotate administration sites. - Instruct patient not to remove patch for swimming or bathing. - If patch loosens and part of it becomes nonadherent, A new patch should be applied.  Myocardial Infarction - Acute myocardial infarction (MI) is a clinical syndrome that results from occlusion of a coronary artery, with resultant death of cardiac myocytes in the region supplied by that artery. - MI is death of myocardial tissue as a result of insufficient oxygen; subsequently, necrosis or “death” to the myocardial tissue occurs.  Myocardial Infarction Factors that can cause myocardial oxygen insufficiency fall into two categories: - Increase the myocardial need for oxygen beyond what the circulation can supply; include acute stress as a heavy exertion, an abrupt increase in blood pressure. - Decrease the flow of oxygenated blood to the myocardial tissues; include occlusion of a coronary artery by a thrombus, coronary artery spasm, embolus lodging in the coronary artery, and sudden dramatic drop in blood pressure during anesthesia.  Clinical Manifestation - Sudden, acute chest pain: which is described as crushing, heavy “like an elephant sitting on my chest”; persistent and increases in severity. - It is prolonged and unrelieved by rest or nitroglycerin. - Patient are frequently pale, diaphoretic, short of breath and dizzy or light headed. - A feeling of impending death /doom is common. - Nausea and vomiting, indigestion, or heartburn.  Complications of M.I - Infarction leading to inability of the heart to function properly leading to Heart Failure. - Cardiogenic shock. - Ventricular aneurysm and rupture. - Embolism formation. - Arrhythmias → Myocardial Infarctions can lead to Ventricular Fibrillation (shockable).  Routine Medical Management Initial Management: - M - Morphine - O – Oxygen. - N – Nitrates. - A – Antiplateletes.  Routine Medical Management Treatment of MI falls into two broad categories: - First: Strategies designed to re-establish blood flow and increase oxygen and nutrients such as: - Thrombolytic therapy. - Angioplasty. - Coronary bypass surgery. - Second: Strategies that reduce demand for oxygen and nutrients such as : - ß-adrenergic blockers. - Calcium channel blocker. - Nitrates “IV nitroglycerin”. - Anticoagulants therapy: as aspirin, warfarin. - Lipid-lowering drugs. - Stool softeners.  Nursing Assessment 1. A complete physical assessment is performed to identify the presence of chest, epigastric, jaw, back, or arm discomfort which is then rated on a subjective scale of 1 to 10 in intensity. 2. The patient is questioned regarding nausea, vomiting, diaphoresis, dizziness, weakness, palpitations and SOB. 3. Gather information about all facets of the patient’s activities, especially those that precede and precipitate attacks of MI. 4. Assess the risk factors in the patient’s history and modifications possible to reduce risk. 5. If chest discomfort is present at the time of the interview, further collection of data is delayed until pain and dysrhythmias are resolved.  Nursing Diagnosis - Pain related to myocardial ischemia. - Altered tissue perfusion: related to imbalance between myocardial oxygen supply and demand. - Anxiety related to fear of death and knowledge deficit. - Activity intolerance related to imbalance between myocardial oxygen supply and demand.  Nursing Interventions 1. Encourage the patient to remain on bed rest. 2. The nurse must teach the patient the link between symptoms and activity and the need to avoid activities known to cause angina. 3. Administer cardiac medication as prescribed. 4. Be alert for adverse side effects, particularly their effect on blood pressure. Teach the patient the symptoms to be aware of and what measures to take. 5. Administer oxygen therapy as prescribed. 6. Evaluate vital signs hourly. 7. Patients with unstable angina are at high risk for myocardial infarction (MI) and sudden death. The nurse watches for development of heart failure and dysrhythmias. 8. Maintain patent IV for administration of fluids and vasodilators and anticoagulant therapy.  Nursing Interventions 9. Prepare for possible emergency heart catheterization or CABG. 10. The nurse should try to alleviate the patient’s and the family’s anxiety and assist them in understanding the need for this life-saving procedure. 11. The nurse describes the postoperative course, emphasizing the close monitoring and use of sophisticated equipment. The patient is encourage to tell the nurse about any discomfort post-operative. 12. Encourage the patient and family members to verbalize their fears and concerns. 13. Teach the patient the nature of the illness and the facts needed to reorganize living habits. 14. Teach the patient about the importance of avoiding the Valsalva maneuver (bearing down when going to bath room). This maneuver increases intra-thoracic pressure that decreases venous return to the right side of the heart which is associated with hypotension and bradycardia.  Congestive Heart Failure - Heart failure is the most common reason for hospitalization of people older than age 65 years. - The severity of Heart failure is frequently classified according to the patient’s symptoms. - The term congestive heart failure (CHF) means the patient has a fluid overload condition (congestion in the pulmonary circulation – Left side HF).  Definition - Congestive Heart Failure (CHF): is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. - The underlying mechanism of cardiac failure involves impairment of the contractile properties of the heart, which leads to lower than normal cardiac output.  Definition - The term congestive heart failure is most commonly used when referring to left sided and right sided failure. - The heart pumps blood inadequately, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and other changes that may further weaken the heart.  Etiology of CHF The most common causes are: - Past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle's normal work. - Cardiovascular disease: - Coronary artery disease (arteriosclerosis). - Valvular heart disease. - Infection / Inflammation of heart muscle. - Abnormal heart rhythms (atrial fibrillation). - Congenital heart defects. - Hypertension. - High cholesterol level; obesity, diabetes mellitus. - Advancing age. - Severe lung disease (pulmonary hypertension).  Etiology of CHF Other less common cause that tend to be associated with high output states: - Severe anemia. - Overactive thyroid gland (hyperthyroidism). - Underactive thyroid gland (hypothyroidism). - Kidney failure. Clinical Manifestations  Types and Clinical manifestations Left heart failure (pulmonary congestion): Right heart failure (peripheral congestion: - Weakness, Fatigue. - Jugular venous distention (Kussmauls's - Diaphoresis. signs). - Oliguria. - Dependent pitting edema. - Weight gain. - Tachypnea. - Weight gain. - Crackles / rales at bases. - Anorexia and nausea. - Cough. - Fatigue. - Hemoptysis. - Breathlessness. - Shortness of breath (SOB) / Dyspnea: - Hepatomegaly. - Dyspnea on Exertional (DOE). - Orthopnea. - Splenomegaly. - Paroxysmal nocturnal dyspnea. - Ascites. - Mental status changes. - Abdominal distension. - Capillary refill ˃ 3 sec. - Right hypochondrial discomfort. - Extra heart sounds. - Extra heart sounds. Types and Clinical manifestations  Diagnostic evaluation - Patient history. - Physical examination. - Diagnostic studies. - Blood tests. - Chest x-ray. - Electrocardiography, ECG. - Radionuclide. - Magnetic resonance (MRI). - Computed tomography imaging (CT). - Cardiac catheterization with angiography. - A biopsy of heart muscle is needed.  Treatment I. lifestyle change – General measures: 1. Maintain desired weight and body mass index (BMI). 2. Diet: - Large meals should be avoided. - Salt restriction, in severe heart failure. - Fluid restriction is necessary. 3.Smoking and alcoholism should be stopped. 4.Physical activity: - Bed rest. - Daily leg exercises / Supportive stockings as prophylactic against DVT. - Low level endurance exercises.  Treatment II. Treatment of the cause: - Surgical measures correcting valvular lesions or congenital malformations. - Medical measures for treating hypertension or infective endocarditis when present. III. Treatment of precipitating factors of HF: - Myocardial ischemia or infarction. - Arrhythmia. - Pulmonary embolism. - Pregnancy. - Anemia.  Treatment IV. Pharmacological treatment of HF: 1. Measures to reduce cardiac work (vasodilator therapy): - Angiotensin converting enzymes inhibitors (ACEIs) as captopril. - Venodilators as short and long acting nitrates. - Arteriolar vasodilators as hydralazine “anti-hypertension”. - Side effects: Postural hypotension (drop in blood pressure that occurs upon standing), headache, peripheral edema, tachycardia possible.  Treatment IV. Pharmacological treatment of HF: 2. Measures to control excessive retention of salt and water as: - Diuretics: - Potassium sparing loop / Loop diuretic as furosemide; powerful diuretics; leading to the loss of large volumes of sodium and fluids. - Thiazide diuretics (e.g., hydrochlorothiazide) - act on distal convoluted tubules of kidney to decrease active sodium reabsorption and increase fluid excretion. - Aldosterone receptor blockers (Spironolactone).  Treatment IV. Pharmacological treatment of HF: 3. Measures to improve the contractile performance of the heart as: - Cardiac glycosides (digitalis - digoxin). - Positive inotropic drugs (drugs that make muscle contract more forcefully) (Dopamine). 4. Beta blockers therapy in chronic HF “lower blood pressure”. 5. Anticoagulants (Heparin). 6. Antiarrhythmic agents. 7. Opioids (Morphine) to relieve anxiety. 8. Oxygen for pulmonary edema is required.  Treatment V. Non pharmacological management of heart failure (surgical intervention) - Coronary artery bypass grafting (revascularization). - Percutaneous coronary intervention (Angioplasty). - Valve replacement. - Biventricular pacemaker. - Heart transplantation. NURSING PROCESS  Assessment Patients Health History: - Obtain history of symptoms, limits of activity, response to rest, and history of response to drug therapy. - The nurse explores sleep disturbances, particularly sleep suddenly interrupted by shortness of breath. - The nurse also asks about the number of pillows needed for sleep (an indication of orthopnea), activities of daily living, and the activities that cause shortness of breath. - The nurse helps patients to identify things that they have lost because of the diagnosis, their emotional response to that loss, and successful coping skills that they have used previously. - Family and significant others are often included in these discussions  Assessment Physical Examination : - Assess peripheral arterial pulses; note quality, character; assess heart rhythm and rate and BP. - Assess edema. - Inspect and palpate precordium for lateral displacement of PMI. - Obtain hemodynamic measurements as indicated and note change from baseline. - Assess weight and ask about baseline weight. - Note results of serum electrolyte levels and other laboratory tests.  Nursing Diagnosis - Decreased Cardiac Output related to impaired contractility and increased preload and afterload. - Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures. - Excess Fluid Volume related to sodium and water retention. - Activity Intolerance related to oxygen supply and demand imbalance.  NURSING INTERVENTION - Maintain the patient in high fowler's position. - Promoting rest and activity. - Frequently monitor vital signs. - Change position frequently. - Monitor intake and output. - Restrict fluids as ordered. - Daily weight.  NURSING INTERVENTION - Providing skin care “edematous skin” - Promoting elimination to avoid straining at defecation. - Teach the patient and family and provide emotional support (life style change). - Explain the side effect of diuretic medications for additional actions (side effects of diuretics include electrolyte imbalance, symptomatic hypotension). - Use aseptic procedures when caring for invasive lines.  NURSING INTERVENTION: Digoxin Monitor for Digoxin toxicity: clinical symptoms include the following: - Anorexia, nausea, and vomiting (early effects of digitalis toxicity). - Abdominal pain. - Visual disturbances: halos, photophobia, red-green or yellow-green vision. - Fatigue, depression, malaise. - Headache, disorientation, confusion. - Gynecomastia and psychosis. - Changes in heart rhythm - ECG changes indicating heart block (SA or AV block).  NURSING INTERVENTION: Digoxin Nursing intervention: - Before administering digoxin, it is standard nursing practice to assess apical heart rate. - Withhold dose if pulse rate is