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DISORDERS
• Transient hypoxia:
Angina Pectoris
• Hypoxia with decrease function:
Myocardial Ischemia
• Death and necrosis of myocardium:
Myocardial Infarction
Risk Factors for developing
atherosclerosis
Non Modifiable
• Increasing Age
• Gender
• Hereditary
• Increasing age
• > 45 yo (M)
• > 55 yo (F)
• Gender
• Affects men more than
women before they
have menopause
• Early Menopause- 3X
increase risk of
developing CAD
• Hereditary
• Family history of first degree relative
with CVD at 55 yo or younger (M),
65 yo or younger (F)
• Family history of HPN,
hypercholesterolemia, DM
Risk Factors for developing
atherosclerosis
Modifiable
• Cigarette Smoking
• Hypertension
• Hypercholesterolemia
• DM
• Physical inactivity
• Obesity
• Metabolic Syndrome
• Inflammatory response
• Homocysteine
Pathophysiology
1. Response to Injury Theory
Injurious Stimuli (HPN, Hypercholesterolemia, Smoking)
Endothelial damage
Plague disruption
Thrombus formation
Definition
• It is a clinical syndrome, characterized
by paroxysm of chest pain, or a felling of
pressure in the anterior chest. It may
occur whenever there is an imbalance
between myocardial oxygen supply and
demand.
Causes and Pathophysiology
• Uncommon factor
Zone of hypoxic
injury
Zone of Ischemic
Clinical Manifestation
• Pain
- crushing, severe, prolonged, unrelieved
by rest or nitroglycerine, radiating to one or
both arms, neck, back
• Signs of shock - hypotension, cold
diaphoresis, peripheral cyanosis,
tachy/brady, thready pulse
• Women often present with a “triad”
of symptoms, including
indigestion or abdominal fullness,
chronic fatigue despite adequate
rest, and inability to catch one’s
breath.
Nursing Assessment
• Thorough and focused health hx and PE
• goal: presence of CAD risk factors, angina,
previous infarctions
• focused assessment
chest pain
general appearance
determination of frequent VS
cont monitoring of cardiac and pulse
ongoing eval of mental status, heart, lungs,
abd, extremities
Diagnostic Exam: ECG
• Unstable angina: The patient has clinical
manifestations of coronary ischemia, but ECG
and cardiac biomarkers show no evidence of
acute MI.
• STEMI: The patient has ECG evidence of acute
MI with characteristic changes in two contiguous
leads on a 12-lead ECG. In this type of MI, there
is significant damage to the myocardium.
• NSTEMI: The patient has elevated cardiac
biomarkers
• but no definite ECG evidence of acute MI.
Laboratory Test
• Creatine Kinase • Myoglobin
(CK-MB) • Myoglobin is a heme
• Elevated CKMB protein that helps transport
indicator of acute MI oxygen. Its found in cardiac
& skeletal muscle
• The level begins to
• The myoglobin level starts
increase within a few to increase within 1 to 3
hours and peaks hours and peaks within 12
within 24 hours of an hours after the onset of
MI. symptoms.
Laboratory test
• Troponin (I, T)
• a protein found in the myocardium, regulates
the myocardial contractile process.
• An increase in the level of troponin in the serum
can be detected within a few hours during acute
MI. It remains elevated for a long period, often
as long as 3 weeks, and it therefore can be
used to detect recent myocardial damage.
Medical Managements
• Goal: to minimize myocardial damage,
preserve myocardial function, and prevent
complication
• Pharmacology therapy: (Nitroglycerin,
Morphine, ACE Inhibitor, Thrombolytic
Agent).
• Procedures: (PCI, Cardiac rehabilitation)
Medical managements
First line & initial treatments
• Semi folwer’s position
• O2 (2-4 lpm)
• IV access
• obtain 12-lead EKG
• VS and pulse oximetry
• labs (serum cardiac markers)
• ECG monitoring
• conduct hx and PE
• reduce pain
• administer meds
Nursing Managements
• Goals
• Recognize and treat cardiac ischemia
• Admin thrombolytic therapy as ordered, or
prepare client for PTCA and observe for
complications
• Recognize and treat potentially life
threatening dysrhythmias
• Goals
• Monitor for complications of reduced CO
• Maintain a therapeutic critical care
• Identify the psychosocial impact of AMI on
• client and family
• Educate the client in lifestyle changes and
• rehabilitation
Nursing Diagnosis
• Acute Pain
• Ineffective Tissue perfusion (Cardiopulmonary)
• Activity Intolerance
• Ineffective Coping
Acute Pain
• related to imbalance between
myocardial oxygen supply and
demand
Intervention
• (Cardiopulmonary) related to
interruption of blood flow
• Goal : to restore perfusion to the injured
area to reduce the size of the infarct and
improve left ventricular function
Ineffective Tissue Perfusion
• 1. Thrombolytic therapy
• 2. Glycoprotein IIB/IIIA Inhibitors
• 3. Antiplatelets
• Aspirin
• Clopidogrel
• 4. Beta blockers
• 5. ACE Inhibitors
Ineffective Tissue Perfusion
1. Thrombolytic therapy
- Tissue plasminogen activator,
streptokinase, reteplase
- Indicated for patients who have chest pain
of greater than 30 minutes, unrelieved by
nitroglycerin and transmural MI (Q wave
MI)
Thrombolitic therapy
• dissolves thrombus and promote
reperfusion
• the golden period is 30 minutes from
onset of pain till thrombolytic therapy
within 30 minutes or PTCA within 1 hour
• Watch out for signs of bleeding and
hypersensitivity reaction ( Streptokinase )
• IV infusion
Ineffective Tissue
Perfusion
2. Glycoprotein IIB/IIIA Inhibitors
- targets the platelet component of the
thrombus to prevent fibrinogen from
attaching to activated platelets at
the site of the thrombus
- Examples: Abciximab, Eptifibatide,
Tirofiban
- Administered through IV
Aspirin
• Swallow the tablets with a full glass of water.
• Taken as regular (not enteric-coated) lowdose
aspirin.
• Swallow the extended-release tablets whole with a full
glass of water. Do not break, crush, or chew them.
• Chewable aspirin tablets may be chewed, crushed, or
swallowed whole.
• Drink a full glass of water, immediately after taking
these tablets.
Nrg Considerations: Aspirin and Plavix
teach: may bleed more easily or for a longer time
than usual while you are taking if having surgery,
including dental surgery, tell doctor or dentist that
taking clopidogrel. Be careful not to cut or hurt aspi
or Plavix
Activity Intolerance
• related to imbalance between
oxygen supply and demand
Actvity Intolerance
1. Bed rest with commode privilege for only 24-48
hours unless with complications.
2. Explain that the purpose of CCU confinement is
for continuous monitoring and safety during the
early recovery period.
3. Administer diazepam as ordered
4. Provide psychosocial support to the patient and
his family. Calmness and competency are
extremely reassuring.
Program of Physical activity
1. Increase activities gradually after the first 24-48
hours
2. Early mobilization after an MI. May be allowed to sit
on a chair for increasing periods of time and begins
ambulation on the 4th or 5th day
3. Monitor V/S before activities.
4. An exercise session is terminated if any one of the
following occurs:cyanosis, cold sweats, faintness,
extreme fatigue, severe dyspnea, pallor, chest pain,
PR > 100, dysrhythmias, Bp > 160/90