1. Coronary Artery Disease By: Julie Tamoney

2. Objectives Understand the signs and symptoms of CAD Recognize who is at risk Discussion of case scenario Understand the purpose of a CABG Identify interventions to reduce sternal wound infections

3. Pathophysiology CAD is the narrowing of the coronary arteries, usually resulting from atherosclerosis Signs and symptoms: Some individuals report pain, burning, or pressure in their chest that starts from exertion, exposure to cold air, or consuming a huge meal Substernal pain can radiate to the arm, neck, or between the shoulder blades

4. Pathophysiology Signs and Symptoms: Patients can also be asymptomatic Atypical pain may start in the jaw, shoulder or elbow Some patients won’t have pain, but may complain about shortness of breath, nausea, vomiting, light headedness, or sweating (Unbound Medicine 2012)

5. Deaths CAD is the leading cause of death and illness in Western societies Accounts for 20% of all deaths (Unbound Medicine 2012)

6. Who’s At Risk? First degree relatives of CAD patients are at higher risk for developing the disease and to develop it at an earlier age (Unbound Medicine 2012) Elevated serum cholesterol levels Elevated blood pressure Cigarette smoking

7. Who’s At Risk? Obesity Lack of physical exercise Stress Diabetics

8. Who’s At Risk? CAD is a major cause of death for women in their late 50s At the age of 80, the risk for CAD is equal for both men and women Of all the deaths related to cardiovascular problems in the elderly, 85% are from CAD (Unbound Medicine 2012)

9. Case Scenario Mrs. Smith, who is 57 years old, complains of jaw and shoulder pain as well as shortness of breath. She smokes 15 cigarettes a day, does not exercise, and is a diabetic. Mrs. Smith is currently under a lot of pressure at work. Her family history indicates her mother had “bad cholesterol”, and died at the age of 48 of CAD.

10. Objective Findings Patient’s blood pressure is 156/90 Heart rate is 87, irregular LDL is 188 HDL is 42 Triglycerides is 474 Total Cholesterol 248

11. CABG Surgeons will perform a CABG to treat patients with severe coronary heart disease This surgery will improve the blood flow to the heart

12. CABG A healthy artery or vein from the body is connected to the blocked coronary artery The grafted vein or artery bypasses the blocked portion of the artery

13. How to Reduce Sternal Wound Infections in CABG Patients Identification of modifiable risk factors is vital for the implementation of practices that decrease the frequencies of infections Preoperative risk factors include: Obesity, diabetes, and smoking

14. Modifiable Risk Factors Intra operative risk factors include: bilateral use of internal mammary arteries and transfusion of 4 or more units of blood Post operative risk factors include prolonged ventilator support

15. Medical and Nursing Interventions Identify and treat all infections remote to the surgical site before surgery Only use clippers to remove hair from the site Encourage patient to stop using tobacco (Dunaway & Goldrick 2007)

16. Medical and Nursing Interventions Administer the initial dose of prophylactic antibiotic IV The first dose of IV prophylactic should be timed so that the bactericidal concentration of the drug in the serum and tissues is reached before the incision is made Utilize continuous insulin infusion to maintain normal blood glucose levels In the postoperative phase, elevated blood glucose levels have been associated with an increased rate of sternal wound infections (Dunaway & Goldrick 2007)

17. Medical and Nursing Interventions Protect closed incisions with sterile dressing for 24- 48 hours Hibiclens antimicrobial scrubs for patient cleansing Wash hands before and after coming in contact with the surgical site Educate the patient and family regarding care and S/S of infection (Dunaway & Goldrick 2007)

18. Interventions Used for Mrs. Smith Mrs. Smith was given prophylactic antibiotic before and after surgery Continuous insulin was infused to maintain normal blood glucose levels Incisions are protected with sterile dressings Hibiclens antimicrobial was used to clean the site Nurses and Doctors washed hands before and after coming into contact with Mrs. Smith

19. Prognosis After applying these interventions, only 2.2% for superficial and 1.5% for deep wound infection have been reported (Hettenbaugh 2006)

20. Prognosis Mrs. Smith’s (post-op day two) sternum is healing without any signs of infection

21. Nursing Diagnosis Altered tissue perfusion related to narrowing of the coronary artery associated with atherosclerosis

22. NCLEX Questions The nurse is giving health teachings to several clients. Which among these clients is at risk for coronary artery diseases? a)The client who works in the department store b)The client who had her menarche at age 12 years old c)The client whose serum cholesterol level is 180 mg/dL d)The client who smokes cigarette

23. NCLEX Questions The client has coronary artery disease (CAD). Which of the following statements when made by the client indicates that he understands the health instructions? A) I need to avoid carbohydrates B) I need to avoid working in cold weather C) I need to avoid exercise D) I need to avoid fruits

24. Answers 1. D. The client who smokes cigarette 2. B. Working in cold weather precipitates coronary artery spasm. This reduces myocardial tissue perfusion and oxygenation. Therefore the client with CAD should avoid working in cold weather.

25. Sternal Wound Infection http://www.youtube.com/watch?v=Dtgvc_sXy oUhttp://www.youtube.com/watch?v=Dtgvc_sXy oU

26. Reference Austin, K., Boyle, D., & Coulen, C. (2005, Oct). Implementing evidence-based practice findings to decrease postoperative sternal wound infections following open heart surgery. Retrieved from http://www.nursingcenter.com/lnc/journalarticle?Article_ID=599757 Dunaway, E., & Goldrick, B. (2007, July). Sternal wound infections: What every nurse should know. Retrieved from http://www.nursingcenter.com/prodev/ce_article.asp?tid=736522 Hettenbaugh, V. (2006, July 22). Best Practice Interventions for the Reduction of Sternal Wound Infections in Coronary Artery Bypass Graft Patients. Retrieved from https:// stti.confex.com/stti/congrs06/techprogram/paper_28871.htm National Institutes of Health. (2012, Feb 23). What is coronary artery bypass grafting. Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/cabg/ Rosenberger, L., Politano, A., & Sawyer, R. (2011, August 03). Surgical infections. Retrieved from http://online.liebertpub.com/doi/abs/10.1089/sur.2010.083 Unbound Medicine. (2000-2012). Nursing Central. http://nursing.unboundmedicine.com/ nursingcentral/ub