Cardiovascular Cardiovascular ChallengesChallenges

NURS 2016NURS 2016

Chapters: 27-32Chapters: 27-32

CV ChallengesCV Challenges

HypertensionHypertension

Coronary Vascular disordersCoronary Vascular disorders

Congestive Heart FailureCongestive Heart Failure

Diet and Blood CholesterolDiet and Blood Cholesterol

Factors include: cholesterol, total and Factors include: cholesterol, total and type of fat, dietary fibre and energytype of fat, dietary fibre and energy

¾ of cholesterol is manufactured in ¾ of cholesterol is manufactured in liverliver

2/3 population: liver manufactures 2/3 population: liver manufactures fluctuate with dietary intakefluctuate with dietary intake

1/3 population: liver production does 1/3 population: liver production does not accommodate dietary intakenot accommodate dietary intake

Factors affecting Heart DiseaseFactors affecting Heart Disease

CholesteralCholesteral LDLLDL HDLHDL TriglyceridesTriglycerides

Goal : Low LDL values, High HDL valuesGoal : Low LDL values, High HDL values Triglycerides <200mg/dLTriglycerides <200mg/dL Low cholesteralLow cholesteral

HypertensionHypertension

BP > 140/90mmHg over a sustained BP > 140/90mmHg over a sustained periodperiod

Approximately 20% adult population Approximately 20% adult population in Canadain Canada

Primary hypertensionPrimary hypertension Secondary hypertensionSecondary hypertension

HypertensionHypertension

SignSign

RiskRisk

DiseaseDisease

Complications of HypertensionComplications of Hypertension

Left ventricular hypertrophyLeft ventricular hypertrophy Myocardial infarctionMyocardial infarction Heart failureHeart failure Transient Ischemic Attacks or Transient Ischemic Attacks or

Cerebral Vascular AccidentCerebral Vascular Accident Renal insufficiencyRenal insufficiency Retinal hemorrhageRetinal hemorrhage

Nursing AssessmentNursing Assessment AnginaAngina Shortness of breathShortness of breath Alterations in speech, vision, or balanceAlterations in speech, vision, or balance HeadachesHeadaches DizzinessDizziness NocturiaNocturia Monitor BPMonitor BP Monitor for symptoms-target organ Monitor for symptoms-target organ

damagedamage Pt. knowledge deficitPt. knowledge deficit

GoalGoal

Decrease BP to normal range without Decrease BP to normal range without causing adverse affects or undo costcausing adverse affects or undo cost

Nursing Intervention/ActionNursing Intervention/Action

Teaching/LearningTeaching/Learning

LifestyleLifestyle

Medication regimeMedication regime

LifestyleLifestyle

Increase aerobic activityIncrease aerobic activity Obtain and maintain optimal body Obtain and maintain optimal body

weightweight Discontinue smokingDiscontinue smoking Decrease intake of saturated fats & Decrease intake of saturated fats &

cholesterolcholesterol Limit intake of alcoholLimit intake of alcohol

LifestyleLifestyle

ElectrolytesElectrolytes Na+: Na+: RNIRNI 500-2400mg (1/4 tsp 500-2400mg (1/4 tsp

salt)salt) K+:K+: RNI RNI 2000mg2000mg Ca+:Ca+:RNIRNI 800mg800mg Mg+:Mg+: RNI 200mgRNI 200mg

Medication RegimeMedication Regime

Monotherapy is bestMonotherapy is best

Minimal/simpleMinimal/simple

Approximately 50% of individuals Approximately 50% of individuals discontinue medication within one yeardiscontinue medication within one year

Encourage regular monitoring (self or Encourage regular monitoring (self or other)other)

Coronary Vascular DisordersCoronary Vascular DisordersRisk FactorsRisk Factors

Non-modifiableNon-modifiable Family hx of CADFamily hx of CAD Increasing ageIncreasing age GenderGender RaceRace

ModifiableModifiable High serum High serum

cholesterolcholesterol Cigarette smokingCigarette smoking HypertensionHypertension DMDM Low estrogenLow estrogen Inactivity & obesityInactivity & obesity StressStress

AnginaAngina

Episodes of pain or pressure in the Episodes of pain or pressure in the anterior chestanterior chest

Insufficient coronary blood resulting Insufficient coronary blood resulting in inadequate supply of Oin inadequate supply of O22

Can be induced byCan be induced by exertion, exposure to cold, eating a exertion, exposure to cold, eating a

heavy meal, stress, emotional situation heavy meal, stress, emotional situation (inc. myocardial work)(inc. myocardial work)

AnginaAngina

Pain:Pain: indigestion (choking, heavy sensation)indigestion (choking, heavy sensation) severe apprehension (impending death)severe apprehension (impending death) retrosternal (deep in chest)retrosternal (deep in chest) poorly localized (neck, arm)poorly localized (neck, arm) tightness (strangling)tightness (strangling) SOBSOB vomitingvomiting

Types of AnginaTypes of Angina

StableStable UnstableUnstable Intractable or RefractoryIntractable or Refractory VariantVariant SilentSilent

AnginaAngina

Goal: Goal: demand demand

supplysupply

Treatment Treatment ApproachesApproaches

PharmacologicalPharmacological

SurgicalSurgical

Pharmacological Pharmacological

NitroglycerinNitroglycerin Beta-adrenergic blocking agentsBeta-adrenergic blocking agents Calcium channel blocking agentsCalcium channel blocking agents Antiplatelet and anticoagulant Antiplatelet and anticoagulant

medicationsmedications Oxygen (2-4 L/m via nasal cannula)Oxygen (2-4 L/m via nasal cannula)

controversialcontroversial

Nursing DxNursing DxAnginaAngina

Altered myocardial tissue perfusion Altered myocardial tissue perfusion secondary to CAD, as evidenced by secondary to CAD, as evidenced by chest pain.chest pain.

Anxiety related to fear of death.Anxiety related to fear of death. Learning need related to underlying Learning need related to underlying

disease. disease. Teaching/learning opportunity Teaching/learning opportunity

related to therapeutic regime.related to therapeutic regime.

GoalsGoals

Immediate and appropriate txmt & Immediate and appropriate txmt & avoidance of complicationsavoidance of complications

Decreased anxietyDecreased anxiety Increase awareness of disease Increase awareness of disease

processprocess Understanding of prescribed care, Understanding of prescribed care,

adherence to self-care programadherence to self-care program

Nursing InterventionNursing InterventionPainPain

Immediate action requiredImmediate action required Patient to D/C all activityPatient to D/C all activity Sit or recline in semi-fowler’s positionSit or recline in semi-fowler’s position Assess pain and vital sign & OAssess pain and vital sign & O2 2

saturationsaturation Administer nitroglycerin (if ordered), Administer nitroglycerin (if ordered),

repeat x 3 if needed repeat x 3 if needed Administer oxygenAdminister oxygen ECGECG

Surgical InterventionSurgical Intervention Percutaneous Transluminal Coronary Percutaneous Transluminal Coronary

Angioplasty (PTCA)Angioplasty (PTCA) Coronary Artery StentCoronary Artery Stent Coronary Artery Bypass GraftCoronary Artery Bypass Graft

Nursing CareNursing CarePost Cardiac SurgeryPost Cardiac Surgery

Neurologic statusNeurologic status

Cardiac statusCardiac status

Respiratory statusRespiratory status

Peripheral vascular Peripheral vascular statusstatus

Fluid & electrolyte Fluid & electrolyte statusstatus

PainPain

Nursing InterventionsNursing InterventionsPost Cardiac SurgeryPost Cardiac Surgery

Restoring Cardiac outputRestoring Cardiac output Promoting Adequate Gas ExchangePromoting Adequate Gas Exchange Maintaining Fld & Elect. BalanceMaintaining Fld & Elect. Balance Reducing symptoms of Sensory OverloadReducing symptoms of Sensory Overload Relieving PainRelieving Pain Maintaining Adequate Tissue PerfusionMaintaining Adequate Tissue Perfusion Maintaining Adequate Renal PerfusionMaintaining Adequate Renal Perfusion Maintaining Adequate Body TemperatureMaintaining Adequate Body Temperature

Myocardial InfarctionMyocardial Infarction

Areas of myocardial Areas of myocardial

cells are cells are permanently permanently

destroyeddestroyed Chest pain not Chest pain not

relieved with relieved with antianginals or restantianginals or rest

Dx based on hx, Dx based on hx, ECG and lab resultsECG and lab results

Diagnostic Lab TestsDiagnostic Lab TestsMIMI

Creatine Kinase (CK-Creatine Kinase (CK-MB)MB)

Increased within Increased within 1hr and peaks at 1hr and peaks at 24h24h

Lactic Lactic DehydrogenaseDehydrogenase

Peaks at 2-3 daysPeaks at 2-3 days

MyoglobinMyoglobin Negative results Negative results

may indicate no MImay indicate no MI

TroponinTroponin An elevated serum An elevated serum

level indicates an level indicates an MIMI

Thrombolytic TherapyThrombolytic Therapy

Used to dissolve or lyse the Used to dissolve or lyse the thrombus in a coronary arterythrombus in a coronary artery

‘‘Door to needle’ time: quicker the Door to needle’ time: quicker the better better 3 hours 3 hours

StreptokinaseStreptokinase TPaTPa RetavaseRetavase

Health PromotionHealth Promotion

NutritionNutrition

ActivityActivity

Symptom recognition and Symptom recognition and managementmanagement

NCP for MINCP for MI

Nursing Care Plan Nursing Care Plan Uncomplicated for MIUncomplicated for MI

Ineffective cardiopulmonary Ineffective cardiopulmonary perfusionperfusion

Potential of effective air exchange Potential of effective air exchange Risk for inadequate tissue perfussionRisk for inadequate tissue perfussion AnxietyAnxiety Knowledge deficit Knowledge deficit

Congestive Heart FailureCongestive Heart Failure

Occurs when the contractility of the Occurs when the contractility of the heart is reduced & the ventricle is heart is reduced & the ventricle is unable to pump as much blood out unable to pump as much blood out during systole as comes in during during systole as comes in during diastolediastole

Inability of the heart to pump Inability of the heart to pump sufficient blood to meet the needs of sufficient blood to meet the needs of the tissues for oxygen and nutrients.the tissues for oxygen and nutrients.

SidednessSidedness

Left SidedLeft Sided Most commonMost common Blood backs up into Blood backs up into

pulmonary veinspulmonary veins Forces fluid shift Forces fluid shift

leading to leading to pulmonary pulmonary congestion and congestion and edemaedema

Right SidedRight Sided Blood backs up into Blood backs up into

venous circulationvenous circulation Peripheral edema, Peripheral edema,

hepato/splenomeghepato/splenomegaly,jugular aly,jugular distentiondistention

Planning & GoalsPlanning & Goals

Manage fluid overloadManage fluid overload Decrease peripheral edemaDecrease peripheral edema Decrease shortness of breathDecrease shortness of breath

Increase activity toleranceIncrease activity tolerance Knowledge of treatment regime and self-Knowledge of treatment regime and self-

carecare Decreasing incidence of anxietyDecreasing incidence of anxiety Able to verbalize ability to make decisions/Able to verbalize ability to make decisions/

influence outcomesinfluence outcomes

Promoting Activity TolerancePromoting Activity Tolerance

20-30 minute physical activity daily20-30 minute physical activity daily Warm up activity (3 minutes)Warm up activity (3 minutes) Avoid temperature extremesAvoid temperature extremes Ensure ability to talk during activityEnsure ability to talk during activity Wait 2 hours pc prior to activityWait 2 hours pc prior to activity Stop activity if pain, SOB or dizzyStop activity if pain, SOB or dizzy Cool down activity (3 minutes)Cool down activity (3 minutes)

Managing Fluid Overload: Low Managing Fluid Overload: Low Sodium DietSodium Diet

500-1500mg sodium per day 500-1500mg sodium per day Most sodium is added in processing Most sodium is added in processing

of foodof food

Review the hand out on Sodium Review the hand out on Sodium contentcontent

For fun, calculate your daily sodium For fun, calculate your daily sodium intakeintake

Other Nsg InterventionsOther Nsg Interventions

Control anxietyControl anxiety Teach self careTeach self care Auscultate lung fields Auscultate lung fields Monitor I & OMonitor I & O Wt ptsWt pts Semi-high fowlersSemi-high fowlers Skin integrity/pos chgsSkin integrity/pos chgs Elastic stockings/leg exercisesElastic stockings/leg exercises