Jessica Koch SIM Lab February 1, 2013 Annamarie Zerby Chest Pain Management of the Telemetry Patient 1.

Coronary Artery Disease happens when the arteries that supply blood to the heart muscle become hardened or narrowed. It is due to the buildup of cholesterol and other material, called plaque or atheromas, on the inner walls. This may be stable or unstable depending on the degree of inflammation of and the thickness of the fibrous cap over it. The buildup is called atherosclerosis. The development happens over many years and involves an inflammatory response, which begins with injury to the vascular endothelium. The injury could be from smoking, hypertension, or other factors. The presence of inflammation has multiple effects on the arterial wall, such as attraction of inflammatory cells called monocytes (macrophages). The macrophages ingest lipids becoming foam cells, which are transported to the arterial wall, as well as release biochemical substances that further damage the endothelium and initiate clotting by attracting platelets. As the buildup thickens, less blood can flow through the arteries; and, as a result, the heart muscle does not get the blood or oxygen it needs. It can lead to chest pain (angina) or a heart attack (MI). 2. Risk factors for CAD include modifiable and non-modifiable. Modifiable factors: Hyperlipidemia, smoking & tobacco use, hypertension, diabetes, mellitus, metabolic syndrome, obesity, physical inactivity Non-modifiable factors: family history, increasing age (>45 men, >55 women), gender (men dev earlier), race (^ in African American) Health promotion measures include controlling cholesterol, promoting cessation of tobacco use, managing hypertension, and controlling diabetes mellitus. 3. Classic symptoms of angina include sensation of ingestion or nausea, choking, heaviness, weakness or numbness in upper extremities, dyspnea, or dizziness. Atypical symptoms include fatigue, sweating, lightheadedness or breathing difficulties. These differ in men and women by the fact that men are more likely than women to suffer from typical symptoms. It is possible that coronary disease tend to be more diffuse in women, thus affecting long segments of the artery rather than discrete ones. 4. Stable angina is predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin. Unstable angina (aka preinfarction angina or crescendo angina) has symptoms that increase in frequency and severity; may not be relieved with rest or nitroglycerin. 5. MAKE DRUG CARDS. 6. Post cardiac angiogram nursing and medical management include establishing patient is stable with EKG, vital signs, oxygenation level, urine output, cardiac, respiratory, pulmonary, gastrointestinal, and gentle urinary assessments. Monitor for bleeding or hematoma at catheter access site. Particular attention must be paid to the peripheral vascular assessment of lower

extremities. If patient has a sheath, institution procedures to be implemented. Generally, nurse to monitor vital signs q 15 mins x 4, q 30 mins x 2, q h x 2, then routinely as institution or MD order. Bedrest for 2 to 6 hours. Instruct to report pain or bleeding. Monitor serum creatinine levels for contrast agent-induced neuropathy. Instruct to request help to get out of bed. 7. Interventions and care for the patient with anxiety and chest pain include taking immediate action when pain is reported or the symptoms suggest anginal ischemia. Instruct patient to stop all activity and sit or rest in semi-fowlers position to reduce oxygen requirements to ischemic myocardium. Measure vital signs and observe for signs of respiratory distress. Administer nitroglycerin sublingually and assess the patients response (up to 3 doses). Administer oxygen therapy if respiratory rate is increased or O2 saturation is decreased. If pain is significant or continues after interventions, further evaluate for MI and may need to be transferred to higher-acuity nursing unit. Educate about fear and anxiety. If this is not successful, medication may be necessary. 8. A coronary artery bypass graft surgery preoperative education plan for a patient and family should include information about prescribed medications, including anticoagulants, antihypertensives, and those that control diabetes. The patient is instructed to shower in an antiseptic solution. The nurse will instruct about equipment, tubes, and lines that will be present after surgery and what they are for. Most patients will be intubated for 2-24 hours after surgery, so the patient must understand that this will prevent talking. The nurse will assist with other forms of communication. The nurse will be sure to answer questions about post-op care and procedures. The patient will be instructed about deep breathing and coughing, use of incentive spirometer, and foot exercises. The nurse will discuss importance of early and frequent ambulation. The nurse will also answer any questions of the family regarding where to wait, how long surgery might last and who will discuss surgery results, visiting procedures, and how to support the patient. 9. The basic components of cardiac rehabilitation are exercise, education, counseling, and lifestyle changes. This is to provide comprehensive, multifaceted treatment, education, and secondary prevention in order to aid recovery and prevent recurrence of heart problems. 10. Infusing packed red blood cells (PRBCs) are used for symptomatic anemia, hemorrhage, and to provide cells with oxygen carrying capacity without volume expansion of plasma. One unit of PRBCs (250mL) should increase the Hct about 2-3%.