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Oxygen Needs Interference with O2 Transport. Case Study.

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Presentation on theme: "Oxygen Needs Interference with O2 Transport. Case Study."— Presentation transcript:

1 Oxygen Needs Interference with O2 Transport

2 Case Study

3 Oxygen Needs Interference with O2 Transport Coronary Artery Disease Coronary Artery Disease  Complications  Dysrhythmias  Pulmonary Embolism  Hypertension  Complication  Congestive Heart Failure  Peripheral Vascular / Arterial Disease

4 Oxygen Needs Interference with O2 Transport  Care of Patients with:  Coronary Artery Disease  Risk Factors  Myocardial Infarction  Alterations in:  Rate & Rhythm (Cardiac Conduction)  Effect on Cardiac Output

5 Content Approach  Anatomy & Physiology Review  Demographics/occurrence  Pathophysiology  Clinical Manifestation  Medical / Surgical Management  Nursing Process (APIE)  Assessment - Nursing Actions - Education

6 Anatomy & Physiology  Right Heart  Left Heart  Systole  Valve Closure:  Diastole  Valve Closure:

7 Cardiac Circulation

8 Myocardium Anterior Posterior

9 Cardiac Cycle 1. Passive Filling – preload 2. Atrial contraction – Aortic & Pulmonic semilunar valves close – S2 3. Isovolumetric ventricular contraction – all valves closed 4. Ejection – ventricular systole – Mitral & Tricuspid valves close – S1 - afterload 5. Isovolumetric ventricular relaxation – all valves closed

10 Cardiac Cycle Phases

11 Heart Sounds & Stethoscope Placement

12 Coronary Arterial System

13 Physiology: Oxygen Supply to the Cardiac Muscle during the Cardiac Cycle  Coronary artery oxygen deficit  during ventricular contraction & ejection (systole)  Coronary artery filling  during ventricular filling (diastole) What is the impact of heart rate on coronary artery filling?

14 Oxygen Supply to the Cardiac Muscle during the Cardiac Cycle  The actual time available for diastole shortens significantly as the heart rate increase % of a MinuteHeart Rate 70% 60 50% % 188  Results: Less time for ventricular filling & coronary artery filling + as HR increases, increased oxygen is needed each minute to eject the same volume of blood. Stroke volume: volume ejected in one heart beat Stroke volume: volume ejected in one heart beat Cardiac Output: volume ejected in one minute Cardiac Output = Stroke Volume x Heart Rate

15 Factors Determining Myocardial Oxygen Needs  Decreased Oxygen Supply:  Noncardiac: Anemia, hypoxemia, pneumonia, asthma, COPD, low blood volume  Cardiac: Arrhythmias/dysrhythmias, congestive heart failure (CHF), coronary artery spasm, coronary artery thrombosis, valve disorders  Increased Oxygen Demand or Consumption:  Noncardiac: anxiety, cocaine use, hypertension, hyperthermia, hyperthyroidism, physical exertion  Cardiac: aortic stenosis, arrhythmias, cardiomyopathy, hypertension, tachycardia

16 CAD - Demographics

17

18 Comparison of death by CV Disease and Breast Cancer – by Women’s Age

19 Coronary Artery Disease (CAD) Pathophysiology  ASHD, IHD, CVHD = CAD  AHA  1.1 mil Americans will have an MI in 2003  460,000 will die  About half of those deaths occur within 1 hour of the start of symptoms and before the person reaches the hospital.  Major cause: Atherosclerosis—focal deposit of cholesterol & lipids

20 CAD – Risk Factors  Unmodifiable  Unmodifiable: Age, Gender, Ethnicity, Genetic predisposition/family history   Modifiable Major: Dyslipidemia--Elevated serum lipids*, hypertension*, cigarette smoking, obesity—visceral/central obesity   Modifiable Contributing: Diabetes Mellitus*, stressful lifestyle * may have genetic predisposition

21 CAD – Risk Factors Metabolic Syndrome: Metabolic Syndrome: –Insulin Resistance –Hyperglycemia >110mg/dL –Hypertension - > 130/85 –Increased triglycerides >110mg/dL –Decrease HDL <40 men; < 50 women –Central Obesity  men: waist > 40” women: waist > 35”

22 Risk Factors One of the Major Modifiable Physical Inactivity

23 Types of Plasma Lipoproteins  HDL –  Contain more protein and less lipid  Carry lipids away from arteries to liver for metabolism  This process prevents lipid accumulation within arterial walls  Higher levels are desirable  LDL –  Contain more lipids than any other lipoproteins  Affinity for arterial walls  Increased levels correlate closely with an increased incidence of atherosclerosis incidence of atherosclerosis  Lower levels are desirable  VLDL  Contain of triglycerides  Correlation with heart disease is uncertain

24 Plasma Lipoproteins

25 Atherosclerosis  Elevated serum lipids  Cholesterol > 200mg/dl  Triglyceride > 200mg/dl  HDL  < 35 mg/dl – major risk  mg/dl – average risk  > 60 mg/dl – negative risk  LDL  < 130 – desirable  130 – 159 mg/dl – borderline risk  > 160 mg/dl – high risk

26 Progressive Atherosclerosis

27 Drug Therapy for Dyslipidemia  Bile Acid Sequestrants (Questran) - Binds with bile salts  Niacin - Inhibits synthesis of VLDL & LDL  Fibric Acid Derivatives (Atromid)– Decrease VLDL  HMG CoA Reductase Inhibitors (Statins - Lipitor, Pravachol, Zocor) – Block synthesis of cholesterol  Cholesterol Absorption Inhibitor (Zetia)– Inhibits intestinal absorption of cholesterol

28 Natural Lipid Lowering Agents  Niacin - < LDL levels  Omega-3 fatty acids – fish/flaxseed oil - HDL levels  Milk thistle – Silymarin - > HDL levels  Fiber - < Cholesterol  Phytosterols - < Cholesterol  Soy - < Cholesterol absorption from GI tract  CoEnzyme Q10 – HMG CoA reductase inhibitors – natural statins

29 Coronary Thrombogenesis

30 During an Acute Coronary Syndrome

31 Angina

32 Clinical Manifestations Angina – Chest Pain  Stable Angina Pectoris – intermittent, same pattern of onset, duration, intensity of symptoms mins.  Silent Ischemia – 80% of patients with ischemia are asymptomatic  Prinzmetal’s Angina – variant – not precipitated by physical activity – may be due to spasm  Nocturnal Angina – occurs at night but not necessarily during sleep or in recumbent position  Angina Decubitis – recumbent position – relieved by standing  Unstable Angina – Unpredictable or may evolve from stable angina – increasing frequency, duration, intensity

33 CAD Clinical Manifestation – Diagnostics  History & Physical Examination  EKG / Echocardiogram / Stress Echocardiogram  Thallium Stress Test (perfusion scanning) cold spots where tissue is inadequately perfused cardiac tissue  CAT scan- calcium score/CT coronary angiogram  MUGA (Multiple gated radioisotope scan) – left ventricular function  MRI of the heart  PET (Positron emission computed tomography) – evaluate coronary artery patency

34 Normal Thallium Stress Test

35 Abnormal Thallium-Stress Test

36 CAD - Clinical Manifestation Invasive Diagnostics  Cardiac Catheterization  Right sided:  Catheter through the femoral vein through the vena cava into right atrium and right ventricle – pulmonary artery – wedge pressure  Left sided:  Catheter through the femoral artery through the aorta into the left atrium and left ventricle / openings of the coronary arteries  Coronary arteriography: Injected dye with video & x-rays

37 CAD - Clinical Manifestation Invasive Diagnostics  Cardiac Catheterization  Potential Complications  Catheter looping/breaking, dysrhythmias, allergic reaction to contrast medium, arterial thrombosis, myocardial infarction, hemorrhage, infection.  Patient Preparation  Informed consent; allergies – shellfish/iodine; NPO x 6 hrs; explanation “flushed/tingling”; supine – absolutely still  Postprocedure Care

38 Right Heart Catherization

39 Left Heart Catheterization

40 Coronary Angiography Coronary Blockage - LAD

41 Cardiac Catheterization Post Procedure Care  Assess:  VS q15 mins. x 2 hrs; q30 min x 2 hrs  Monitor cardiac rate and rhythm  Check site for bleeding  Extremity: Peripheral pulse check, temperature, color, sensation, mobility  Assess for chest pain, dizziness, dyspnea  Nursing Action:  Straight at groin x 24 hours; pressure at site x 30 mins.  Maintain IV KVO for 2 hrs; IV capped x 2 hrs; then d/c  Encourage oral fluids  Patient/Family Education:  Rationale for all nursing actions  No squatting, sitting, lifting for 24 – 48 hours++  Report bleeding, swelling, discoloration, drainage  Change dressing after 24 hours – small dressing to bandaid

42 Clinical Manifestation Myocardial Infarction Lab Diagnostics  Cardiac Protein – Troponin T  More sensitive than CK  Elevates 3 hr – peak hrs; normal 5-14 days  Cardiac Enzyme – Creatine kinase (CK-MB)  Released when cardiac cells die  Elevates 3 hrs – peak hrs; normal 2-3 days  Cardiac Marker - Myoglobin  First to elevate  Lacks cardiac specificity  Normal range within 24 hours

43 Serum Cardiac Markers after MI

44 CAD – Angina Relationship Coronary Artery Disease /\ Stable AnginaAcute coronary syndrome // \ Unstable Angina >Myocardial Infarction ST-elevated MI Non-ST-elevated MI Non-ST-elevated MI

45 CAD & Acute Coronary Syndrome

46 Heart With Muscle Damage and a Blocked Artery

47

48 Myocardial Infarction

49 Myocardial Infarction Acute Coronary Syndrome  Location correlates with coronary circulation involved  Inferior Wall – Right coronary artery  Anterior Wall – Left anterior descending  Lateral, posterior or inferior – left circumflex  Healing Process  Within 24 hours – leukocytes & enzymes  Third day – collateral circulation developing  days – scar tissue is still weak  Vulnerable time – unstable state of healing + increased activity  6 weeks – scar tissue replaces necrotic tissue  Normal myocardial tissue may compensate – ventricular remodeling – can cause late congestive heart failure

50 Coronary Artery Collateral Circulation

51 Angina Medical Management  AAspirin / Antianginal therapy / ACE Inhibitor  B b-Adrenergic blocker / blood pressure  CCigarette smoking / Cholesterol  DDiet / Diabetes  E Education / Exercise

52 Angina- MI Medical Management  B-Adrenergic Blockers – decreases rate, contractility, afterload  Nitrates – peripheral vasodilation decreasing preload and afterload / coronary artery vasodilation  Calcium Channel Blockers – Coronary & peripheral vasodilation, decreases AV conduction and myocardial contractility  Morphine – analgesic – reduces preload & myocardial oxygen consumption  Angiotensin-Converting Enzyme Inhibitors – Vasotec / Capoten - prevents Angiotensin I conversion to Angiotensin II – HTN, CHF

53 Antiplatelet and Anticoagulant Agents in unstable angina and NSTEMI Oral anti-platelet agent Aspirin Initially 300 mg p.o. then mg daily Aspirin Initially 300 mg p.o. then mg daily Clopidogrel (Plavix) Initial loading dose of 300 mg then 75 mg daily Clopidogrel (Plavix) Initial loading dose of 300 mg then 75 mg daily Increased bleeding risk Increased bleeding risk Heparins Heparins Heparin Sodium: Bolus: 60 U/kg IV bolus to a maximum of 4,000 units Heparin Sodium: Bolus: 60 U/kg IV bolus to a maximum of 4,000 units Drip: 12 units/kg/h infusion to a maximum of units/h Drip: 12 units/kg/h infusion to a maximum of units/h Monitor PTT: keep at seconds Monitor PTT: keep at seconds Low-molecular-weight heparin - Enoxaparin 1 mg/kg subcut q12 hr Low-molecular-weight heparin - Enoxaparin 1 mg/kg subcut q12 hr Precautions: Peptic ulceration Aspirin allergy GI bleeding

54 Antiplatelet Drugs used in unstable angina and NSTEMI Intravenous Intravenous –tirofiban (Aggrastat), eptifibatide (Integrilin)  New class, GP IIb/IIIa inhibitors –Abciximab (ReoPro) 0.25 mg/kg IV bolus min before PCI, than 10 μg/min IV - Infusion for 12 h Precautions: Thrombocytopenia Bleeding disorder Surgery < 6 weeks Thrombocytopenia Bleeding disorder Surgery < 6 weeks Abnormal bleed < 30 d Active GI ulceration Abnormal bleed < 30 d Active GI ulceration Puncture of a non-compressible Prior stroke, organic CNS pathology Puncture of a non-compressible Prior stroke, organic CNS pathology Any systolic BP > 180 mmHg during the acute event Any systolic BP > 180 mmHg during the acute event

55 Thrombolytic Drugs Drugs that break down, or lyse, preformed clots Tissue plasminogen activator Tissue plasminogen activator –plasminogen-streptokinase activator complex (APSAC) –streptokinase (Streptase) –alteplase (t-PA, Activase) –reteplase (Retavase)

56 Angina - MI Invasive Medical Management  Percutaneous Coronary Intervention – PCTA – Percutaneous transluminal coronary angioplasty  Balloon-tipped catheter passed through just beyond the lesion – balloon inflated – atherosclerotic plaque is compressed  Reduction in lesion size by >50% in 90% of patients  Used in conjunction with thrombin inhibitors

57 Angina- MI Invasive Medical Management  Stent Placement – may be placed during PCTA – expandable meshlike structures to maintain vessel patency – placed over the angioplasty site to hold the vessel open  * Stents are thrombogenic –  IV antiplatelet agents  ASA/Plavix  Atherectomy – plaque is shaved away from the coronary artery wall  Limited to use in larger portions of vessels  Laser Angioplasty – “cool” laser – no heat

58 Coronary Artery Stent Placement

59 Coronary Atherectomy

60 Angina - MI Invasive Medical Management  Complications  Abrupt closure of angioplasty site  Stent thrombosis / embolization  Hemorrhage / vascular damage  Coronary spasm, Acute MI  Need for emergent coronary artery bypass graft (CABG)

61 Fibrinolytic Contraindications  Absolute Contraindications  Active internal bleeding, active inflammatory bowel disease, active peptic ulcer disease, acute pericarditis, GI/GU bleeding within 6 months, Hx of hemorrhage CVA, Neurosurgical procedure within 2 months, Pregnancy, Suspected aortic dissection, Uncontrolled HTN, >180/110  Relative Contraindications  Bacterial endocarditis, chronic Coumadin Therapy, Diabetic hemorrhagic retinopathy, Poorly controlled HTN

62 Angina - MI Surgical Management Coronary Artery Bypass Graft (CABG) construction of new vessels between the aorta to beyond the obstructed coronary artery (or arteries)  Saphenous vein or internal mammary artery  Palliative treatment for CAD – not a cure  Postoperative care: Care of cardiac patient with chest tubes / sternotomy; pain management; short ventilator support; early ambulation; 4-5 day hospital stay

63 Coronary Artery Bypass

64

65 Complications of MI  Arrhythmias – lethal PVC’s within 4 hours of onset of chest pain  Congestive Heart Failure  Cardiogenic Shock – severe left ventricular failure – intra-aortic balloon pump & vasoactive medications  Papillary Muscle Dysfunction – Mitral valve regurgitation – treat dyspnea, pulmonary edema & decreased CO  Ventricular Aneurysm Pericarditis – 1-3 days post MI; pleural friction rub & fever  Dressler Syndrome – pericarditis with effusion & fever 1- 4 wks post MI; elevated WBC & Sed Rate. Tx-Steroids  Pulmonary Embolism

66 Acute Coronary Syndrome Pair Share Discomfort or a heavy feeling in the chest can signal a heart attack. A. True B. False Discomfort or a heavy feeling in the chest can signal a heart attack. A. True B. False Women do not frequently experience heart attacks. A. True B. False Women do not frequently experience heart attacks. A. True B. False African-American women die of heart attacks at the same rate as white women. A. True B. False African-American women die of heart attacks at the same rate as white women. A. True B. False Some people who are experiencing the symptoms of a heart attack may wait hours or even days before seeking needed medical care. A. True B. False Some people who are experiencing the symptoms of a heart attack may wait hours or even days before seeking needed medical care. A. True B. False Being treated within about an hour of the first symptoms can make a significant difference. A. True B. False Being treated within about an hour of the first symptoms can make a significant difference. A. True B. False

67 Acute Coronary Syndrome Pair Share Many heart attack victims say their heart attack wasn’t what they’d expected. A. True B. False Many heart attack victims say their heart attack wasn’t what they’d expected. A. True B. False A family member, such as a spouse, can persuade a loved one having a heart attack to seek help immediately. A. True B. False A family member, such as a spouse, can persuade a loved one having a heart attack to seek help immediately. A. True B. False Calling for chest pain alone would probably turn out to be a waste of the emergency medical personnel’s time. A. True B. False Calling for chest pain alone would probably turn out to be a waste of the emergency medical personnel’s time. A. True B. False Most heart attacks occur in people over 65. A. True B. False The major issue in delay is how long it takes for emergency medical personnel to find the address and deliver the patient to the hospital. A. True B. False Most heart attacks occur in people over 65. A. True B. False The major issue in delay is how long it takes for emergency medical personnel to find the address and deliver the patient to the hospital. A. True B. False

68 Nursing Diagnoses TOP 4 ?????

69 Nursing Process Nsg Dx: Acute Pain related to Cardiac Ischemia  Assess: Chest pain—intensity, location, duration, precipitating, alleviating factors; Monitor cardiac rate & rhythm; effect of pain medication; peripheral pulses; VS; Pulse Oximetry  Nsg Action: Administer O2 NC; IV access; position of comfort  Patient Education: Rationale for all procedures; pain scale; instruct to report pain

70 Nsg Dx: Ineffective Tissue Perfusion related to Myocardial Injury  Assess: VS & Pulse Oximetry qh; continuous cardiac monitoring; respiratory status if Morphine IV is used; fluid balance – strict I&O peripheral edema; heart & breath sounds  Nsg Action: Rest periods; Administer meds & oxygen as ordered  Patient Education: Rationale for rest; energy conservation

71 Nsg Dx: Anxiety related to perceived or actual threat of death  Assess: verbal & nonverbal queues  Nsg Action: Calm, reassuring approach; encourage verbalization of feelings, fears, perceptions; family involvement;  Patient Education: Relaxation techniques; simple instructions

72 Nsg Dx: Ineffective therapeutic regimen management related to lack of knowledge  Assess: Current knowledge level & readiness to learn; family dynamics  Nsg Action: Assist pt in identifying small successes; Assist pt is identifying lifestyle that needs to be changed; Community referrals— smoking cessation, cardiac rehab, support groups,  Patient Education: Lifestyle changes, Medications—desired effect/side effects; comprehensive discharge plan—continuity with community cardiac rehabilitation

73 Nsg Dx: Activity Intolerance related to fatigue & chest pain Nsg Dx: Activity Intolerance related to fatigue & chest pain  Assess: Monitor patient’s response to medications, activity tolerance as increased; Cardiac rate, rhythm, respiratory effort  Nsg Action: Include family; advance activity as tolerated; supplement oxygen as needed  Patient Education: Teach patient energy conservation – activity/rest – activities that will promote independence and decrease oxygen consumption; Cardiac Rehab: exercise & sexual activity

74 Patient Education: Exercise Guidelines post MI  Type of Exercise – regular, rhythmic & repetitive – using large muscle groups  Intensity – determined by patient’s HR – should not exceed 20 beats per min > resting HR  Duration – Build to mins  Frequency x/week  Warm-up/Cool-down – 5 mins before and after aerobic exercise. Exercise should not be stopped abruptly

75 Cardiac Rehab – Metabolic Equivalents of Energy Expenditure

76 Patient Education: Sexual Activity post MI  Plan of resumption of sexual activity should correspond to activity prior to MI  Physical training improves physical response to coitus  Food & alcohol < prior to sexual activity  Familiar & relaxed surroundings; positions of comfort  Avoid hot or cold showers  Foreplay is desirable – gradual increase in heart rate prior to orgasm  Prophylactic use of nitrates decreases angina  Orogenital sex places no undue strain on the heart  Anal intercourse may cause undue cardiac stress – vasovagal response

77 Emotional & Behavioral Response to Acute MI  Denial – Ignores symptoms; minimizes severity; ignores activity restrictions  Anger – “Why did this happen to me?”  Anxiety & Fear – Fear of death & disability –apprehension, tachycardia, restlessness, hypochondria, projection of feelings  Dependency – reliant on staff; hesitant to leave ICU or hospital  Depression – Mourning period; realizes seriousness of situation  Realistic Acceptance – Focuses on optimum rehabilitation; plans changes compatible with cardiac function


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