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1

CAD modifiable risk factors

smoking, sedentary lifestyle, atherogenic diet, oral contraceptives (women), hormone replacement therapy (women only), obesity, HTN, stress, anxiety, high cholesterol, hyperlipidemia, diabetes mellitus,

2

CAD non-modifiable risk factors

genetics, race, age (men at or older than 45 and women at or greater than 55), sex

3

CAD Assessment

fatigue, dyspnea, chest pain radiating to shoulder and jaw for men, back pain and N/V more common in women, angina

4

What usually causes CAD?

accumulation of atherosclerotic plaques in the coronary artery is the usual cause

5

CAD Patient Education

-take sublingual nitro if chest pain occurs, can take up to 3 doses 5 minutes apart. make sure to stay seated b/c orthostatic hypotension
-nutrition: low fat, low cholesterol, high fiber, low calorie diet, Eat lean meats, no red meats, brown rice.
-exercise
-remove fat from meat, steamed veggies
-decrease alcohol intake, moderation; 2 drinks for men and one for women
-decrease saturated fat
-surgery
-angioplasty with contrast and Coronary artery bypass grafting (CABG)
-smoking cessation

6

CAD labs and diagnostics:

-History and physical to see what other diseases they may have
-Probably has hyperlipidemia so cholesterol levels are going to be high. Normal levels: HDL greater than 60, LDL less than 100, Cholesterol less than 200
-Cardiac catherization: need to know if PT has allergy to iodine or shellfish b/c dye. If they are, give diphenhydramine before
-echocardiography stress test

7

CAD Treatment/Nursing Interventions:

-monitor kidneys after cardiac catherization for excretion of dye
-Statins (#1 for cholesterol): atorvostatin, take at night; rhabdomyalysis, muscle cramps/weakness, monitor liver function
-nitrates: vasodilators, so orthostatic hypotension, headache is common side effect. Nitrate patches long term
-monitor HR and BP with beta blockers
-calcium channel blockers
-antiplatelets for stent placement

8

CAD Complications

Chest pain (angina), MI, HF, abnormal heart rhythm (arrhythmia)

9

Angina general/normal S/S

-crushing, severe, pressure, heaviness, squeezing feeling
-dyspnea, pallor, tachycardia, anxiety, and fear

10

Angina Types: Stable

-relieved when you lay down
-brought on by activity, exposure to cold, or stress
-sit down!!! especially if taking a nitro for relief

11

Angina Types: Unstable

-At risk for Acute MI
-increasing frequency, severity, and duration; pain is unpredictable, occurs with decreasing levels of activity or stress, and may occur at rest

12

Angina Types: Variant

-may occur at night or any other time- may not even have a blockage
-spasmic
-may result from hyperactive sns responses, altered calcium flow, or reduced prostaglandins

13

Angina S/S women

present w/atypical symptoms such as indigestion, N/V, fatigue, and upper back pain

14

DVT risk factors

-Virchows triad- for VTE. 1) venous stasis, 2) endothelial damage, 3) hyper coagulability of blood
-inheriting a blood clotting disorder
-immobility
-injury or surgery; hip surgery, total knee replacement, open prostate surgery
-pregnancy
-obesity
-smoking
-HF
-active cancer

15

DVT assessment:

-can be asymptomatic
-calf or groin pain, tenderness, sudden onset edema
-warmth, edema, induration, hardness
-increased circumference of right and left calf/thigh over time
-SOB/chest pain indicate embolus moved to lungs (can indicate a PE)

16

DVT Patient Education

-bed rest
-elevate extremity higher than heart level
-warm moist compress (NOT UNDER HEEL)
-do NOT massage limb
-thigh high compression or anti-embolism stockings

17

DVT Pharm Interventions: anticoags

Anticoagulants: Unfractioned Heparin, low-molecular weight heparin, Warfarin

Low Molecular weight Heparin: give SQ and is based on PT weight. Take heparin in hospital and start warfarin a few days prior to DC and PT will go home on Warfarin.

Warfarin: therapeutic effect takes 3-4 days to develop, so administration of med while the PT still on heparin.
-Monitor PT and INR.
-ensure Vitamin K (antidote for warfarin) is available in case of excessive bleeding
-instruct PT about food sources of vitamin K (green leafy veggies) and to avoid fluctuations in the amount and frequency of consumption
-Get to therapeutic level

18

DVT Pharm Interventions: thrombolytic therapy

-dissolves clots that have already developed
-to be effective, therapy must be started within 5 days after the development of the clot
-Abciximab and eptifibatide can be effective in dissolving a clot or preventing new clots during the first 24 hours.
-monitor for bleeding
-PT should be instructed about bleeding precautions that should be taken (use electric instead of bladed razor and brush teeth with a soft toothbrush)

19

DVT Treatment/Nursing Intervention

-unfractioned Heparin: monitor PTT, antidote is protamine sulfate
-low molecular weight Heparin (enoxaparin)
-Warfarin: monitor PT/INR, vitamin K antidote, takes 3-5 days to develop therapeutic effect

20

DVT Complications S/S

-Ulcer formation: form over medial malleolus
-PE: sudden onset dyspnea, chest pain, restless, apprehension, cough, feel impending doom****, hemoptysis (throw up blood), increased HR, crackles, increased RR, diaphoresis, decreased O2 saturation

21

Left Sided Heart Failure Risk Factors

-HTN
-Coronary artery disease, angina, MI
-Valvular Disease (mitral and aortic)

22

Left sided heart failure expected findings

-dyspnea, orthopnea (SOB while lying down), nocturnal dyspnea
-fatigue
-displaced apical pulse (hypertrophy)
-S3 heart sound (gallop)
-pulmonary congestion (dyspnea, cough, bibasilar crackles)
-frothy sputum (can be blood-tinged)
-AMS
-manifestations of organ failure, such as oliguria (decreased urine output)
-MORE FLUID IN LUNGS

23

Right sided HF

-left sided heart (ventricular) failure
-right ventricular MI
-pulmonary problems (COPD, pulmonary fibrosis)

24

Right Sided HF Expected Findings

-JVD
-ascending dependent edema (legs, ankles, sacrum)
-abdominal distention, ascites
-fatigue, weakness
-nausea and anorexia
-polyuria at rest (nocturnal)
-liver enlargement (hepatomegaly)and tenderness
-weight gain
-MORE FLUID IN BODY

25

HF lab tests

Human B-type natriuretic peptides (hBNP): clients who have dyspnea, elevated hBNP confirms a diagnosis of heart failure rather than a problem originating in the respiratory system
-Less than 100 pg/mL indicates NO HF
-100 to 300 pg/mL suggests HF is present
-Greater than 300 pg/mL indicates MILD HF
-Greater than 600 pg/mL indicates MODERATE HF
-Greater than 900 pg/mL indicates SEVERE HF

26

HF Medications: Diuretics

Diuretics: Loop diuretics (furosemide and bumetanide), thiazide diuretics (hydrochlorothiazide), potassium-sparing diuretics (spironolactone)
-Teach PT taking loop or thiazide diuretics to ingest foods and drinks that are high in K+ to counter the effects hypokalemia

27

HF Meds: after load reducing agents

Afterload-reducing agents: help the heart pump more easily by altering the resistance to contraction
-Angiotensin converting enzyme (ACE) inhibitors: enalapril and captopril
-Angiotensin receptor II blockers: losartan
-Calcium channel blockers: ditalizem and nifedipine
-Phosphodiesterase-3 inhibitors: milrinone

28

HF Meds: Inotropic agents

-such as digoxin, dopamine, dobutamine, and milrinone are used to increase contractility and thereby improve cardiac output

-Digoxin- take the apical heart rate for 1 minute and hold med if apical pulse is less than 60/min and notify provider. Take digoxin at the same time each day. Do not take digoxin at the same time as antacids, separate the two medications by at least 2 hours.

29

HF Meds: beta blockers

-Carvedilol and metoprolol
-Monitor BP, HR
-check orthostatic blood pressure readings
-do not give if HR less than 60

30

HF Meds: Vasodilators

Nitroglycerin and isosorbide mononitrate
-given to treat angina and help control Bp
-can cause orthostatic hypotension
-headache is a common side effect of this medication

31

HF Meds: Anticoags

warfarin, monitor bleeding times: PT, aPTT, INR, and CBC
-contraindications: active bleeding, PUD, history of cerebrovascular accident and recent trauma

32

HF Med categories general

-diuretics, afterload-reducing agents, inotropic agents, beta blockers, vasodilators, anticoagulants

33

HF Nutrition

small frequent meals, promote low sodium, and low saturated fat food choices

34

HF Nursing Care

-monitor daily weights, and I&O's
-assess for SOB and dyspnea on exertion
-administer oxygen as prescribed
-Position PT in high fowler's to maximize ventilation
-assess for S/S med toxicity (esp. digoxin)
-encourage energy conservation by assisting with care and ADLs
-maintain dietary restrictions as prescribed (restricted fluid intake, restricted sodium intake)

35

HF Diagnostic Procedures

Transesophageal echocardiography (TEE)

36

HF Complicatoins

acute PE, cariogenic shock, pericardial tamponade

37

HF Health Promotion and Disease Prevention

-maintain an exercise routine to remain physically active, and consult with the provider before starting any exercise regimen
-consume a diet low in sodium, along with fluid restrictions, and consult with the provider regarding diet specifications
-refrain from smoking
-follow medication regimen, and follow up with the provider as needed

38

HTN Health Promotion and disease prevention

-maintain BMI of less than 30
-PT with diabetes mellitus should keep blood glucose within a recommended reference range
-use stress management technique during times of stress
-limit caffeine and alcohol intake
-NO SMOKING. Nicotine patches or engaging in a smoking cessation class are potential strategies
-engage in exercise that provides aerobic benefits least 3 times a week
-limit sodium and fat intake

39

HTN Risk Factors: Essential HTN

-positive family history
-excessive sodium intake
-sedentary lifestyle
-obesity
-high alcohol consumption
-African American
-Smoking
-Hyperlipidemia
-stress
-age greater than 60 or postmenopausal

40

HTN Risk Factors: Secondary HTN

-kidney disease
-cushing's disease (excessive glucocorticoid secretion)
-primary aldosteronism (causes HTN and hypokalemia)
-Pheochormocytoma (excessive catecholamine release)
-brain tumors, encephalitis
-Medications such as estrogen, steroids, and sympathomimetics
-pregnancy

41

HTN expected findings

-headaches, particularly in the AM
-facial flushing
-dizziness
-fainting
-retinal changes, visual disturbances (pupils smaller)
-nocturia

42

Levels of HTN

Prehypertension: systolic 120 to 139 mm Hg; 80 to 89 mm Hg
Stage I hypertension: systolic 140 to 159 mm Hg; diastolic 90 to 99 mm Hg
Stage II HTN: systolic greater than or equal to 160 mm Hg; diastolic greater than or equal to 100 mm Hg