Medical-Surgical Nursing: Concepts & Practice 3rd edition Chapter 20 Care of Patients with Coronary Artery Disease and Cardiac Surgery Copyright © 2017, Elsevier Inc. All rights reserved.

Coronary Artery Disease Etiology Cultural considerations Pathophysiology Coronary insufficiency Cardiac reserve and older adults Signs and symptoms Acute coronary syndrome Diagnosis Treatment Complementary and alternative therapies

Progression of Atherosclerosis See Figure 20-1 on p. 452. From Lewis SL, Heitkemper MM, Dirksen SR, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 8, St. Louis, 2011, Mosby.

Signs and Symptoms of Coronary Artery Disease Chest discomfort, including feeling of tightness, aching, burning Chest pain (angina pectoris) radiating to the arm, jaw, or back Dyspnea (shortness of breath) Palpitations or tachycardia Nausea and vomiting See Box 20-1 on p.452.

Nursing Management Aspirin to prevent MI Lower fat and cholesterol in the diet

Angina Pectoris Signs and symptoms Diagnosis Treatment Stable or exertional angina Variant or vasospastic angina Unstable angina Diagnosis Treatment Nursing management There are three types of angina: Stable or exertional angina: triggered by physical activity or stress and related to atherosclerosis. The goal of therapy is to reduce intensity and frequency of attacks. Variant or vasospastic angina: caused by coronary artery spasms which restrict the blood flow to the myocardium. The goal of treatment is to reduce the number and severity of attacks. Unstable angina: usually caused by occlusion of coronary arteries. Angina pain occurs even at rest; may not respond well to drug therapy; may require immediate surgery.

Stenosis of the Left Anterior Descending Coronary Artery See Figure 20-2 on p. 454. From Chabner DA: The language of medicine, ed. 6, Philadelphia, 2001, Saunders.

Acute Myocardial Infarction Etiology and pathophysiology Signs and symptoms Diagnosis Electrocardiography Cardiac enzymes Cardiac catheterization and angiography Treatment MONA

Tests Performed to Determine Myocardial Infarction Troponin I (TnI) Troponin T (TnT) Creatine phosphokinase CK-MB   Myoglobin See Table 20-2 on p. 458

The Joint Commission Core Measures for Myocardial Infarction Aspirin administered within 24 hours of arrival at the hospital or within 24 hours before arrival Beta blocker started within 24 hours of arrival Thrombolytic agent administered within 30 minutes of hospital arrival Aspirin therapy at discharge See Box 20-2 on p. 454.

The Joint Commission Core Measures for Myocardial Infarction (Cont.) Beta-blocker therapy continued at discharge Angiotensin-converting enzyme (ACE) inhibitor therapy at discharge for left ventricular ejection fraction less than 40% Patients with a history of cigarette use within past year given smoking cessation advice or counseling during hospitalization

Treatment Oxygen Sublingual nitroglycerin Morphine sulfate Thrombolytic agents Pacemaker Acute care Critical care Intermediate care Rehabilitation

Acute Coronary Syndrome: Nursing Management Pain relief Rest Medications and side effects Frequent cardiovascular assessment Weight and intake and output Vascular access Activity Decreasing anxiety Rehabilitation

Signs and Symptoms of Complications after Myocardial Infarction Dysrhythmia Heart failure Cardiogenic shock Papillary muscle dysfunction Ventricular aneurysm Pericarditis Dressler syndrome See Table 20-3 on p. 460.

Emotional and Behavioral Responses to Acute Myocardial Infarction Denial Anger Anxiety and fear Dependency Depression Realistic acceptance See Box 20-3 on p. 462.

Cardiogenic Shock Signs and symptoms Decreased cardiac output Confusion; restlessness; diaphoresis; rapid, thready pulse; increased respiratory rate; cold, clammy skin; and diminishing urinary output to less than 20 mL/hr Decreased cardiac output

Intra-aortic Balloon Pump (IABP) Uses a balloon catheter positioned in the aorta that inflates during diastole and deflates during systole, effectively decreasing the workload of the heart and increasing blood flow through the coronary arteries

Surgical and Nonsurgical Treatment Options Percutaneous transluminal coronary angioplasty (PTCA) Proton pump inhibitors Transmyocardial laser revascularization Cardiac surgery Coronary artery bypass surgery Heart transplant

Nursing Care of the Patient Having Cardiac Surgery Preoperative care Diagnostic tests and examinations Teaching Psychological preparation

Nursing Care of the Patient Having Cardiac Surgery (Cont.) Postoperative care Early postoperative period and critical care Frequent assessment of respiratory and cardiac status Care of invasive lines and chest tubes Wound assessment and care Fluid and electrolyte balance Pain management Assessment of emotional status

Cardiac Rehabilitation Home recovery period Dressler syndrome Depression Preventing infection to the surgical sites and managing wounds Monitoring for complications

Community Care Restore and maintain optimal physiologic function. Improve psychological outlook. Maintain ability to work and social well-being.