MED SURG CHAPTER 31

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MED SURG CHAPTER 31

• CARING FOR CLIENTS WITH DISORDERS OF CORONARY
  PERIPHERAL BLOOD VESSELS

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STATISTICS

• Cardiovascular disease is the leading cause of
  death in the US
• Occlusive disorders of the coronary arteries and
  resulting complications are largely responsible
• The most common causes of occlusive vascular
  diseases are atherosclerosis, arteriosclerosis,
  clot formation and vascular spasm

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ARTERIOSCLEROSIS ATHEROSCLEROSIS

• Arteriosclerosis during the natural aging
  process loss of elasticity or hardening of the
  arteries
• Atherosclerosis the lumen of the artery fills
  with fatty deposits or plaque fig 31-1
• Hyperlipidemia triggers atherosclerotic changes

• Factors contributing to hyperlipidemia
• gender
• heredity
• diet
• diseases such as metabolic syndrome
• inactivity

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ATHEROSCLEROSIS

• Current research now shows that development of
  atherosclerosis may be linked to prior infection
  with Chlamydia pneumoniae a respiratory infection
• A relationship between body fat production of
  inflammatory thrombotic or clot forming
  proteins
• Presence of multiple risk factors contribute to
  development of arteriovascular disease

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CORONARY ARTERY DISEASE (CAD)

• Arteriosclerotic atherosclerotic changes in the
  coronary arteries that supply the heart
• Causes multiple factors Box 31-1
• S/S depend on severity range from mild fatigue
  to severe chest pain or angina see table 31-1
• DX Lipid panels, exercise stress testing, EKG
  changes

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CORONARY ARTERY DISEASE (CAD)

• Treatment-lifestyle changes, meds NTG, beta
  blockers, calcium channel blockers, ace
  inhibitors, antilipimic agents
• Noninvasive Enhanced External Counterpulsation
  or EECP fig 31-5
• Invasive PTCA, stents, CABG, TMR
• Nursing client education, med administration
  assessments

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Percutaneous Transluminal Coronary Angioplasty
(PTCA)

• Also known as balloon angioplasty
• Fig 31-6
• Complications may include arterial rupture, MI
  abrupt reclosure
• See discharge instructions

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Coronary Stent

• During PTCA a small metal coil with meshlike
  openings is placed in the coronary artery
• See fig 31-7
• The stent stays in place. Restenosis usually
  does occur
• New stents coated with an antiinflammatory/antibio
  tic substance are available

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Atherectomy

• Removal of the fatty plaque from the artery wall
• Done by
• inserting a cardiac catheter with a cutting
  tool at the tip, see fig 31-8
• performing laser angioplasty

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Coronary Artery Bypass Graft CABG

• Used to revascularize the myocardium
• A 10 12 inch midsternal incision is made
• Heart is stopped during the procedure blood
  routed through a heart-lung machine
• Use either a healthy leg vein or chest artery to
  reroute the oxygenated blood to an area below the
  obstruction in the diseased coronary artery
• Recovery time is several weeks, but results last
  longer than the PCTA or stents

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Transmyocardial RevascularizationTMR

• A laser procedure used for those who do not
  respond to meds are not candidates for CABG
• Performed through an incision in the chest wall.
  A laser is aimed at the beating heart it
  creates channels in the heart tissues which seep
  blood. The heart muscle absorbs the oxygenated
  blood from them instead of the coronary arteries

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Myocardial Infarction (MI)

• Infarct an area of tissue that dies from
  inadequate oxygenation
• This occurs in the heart when there is a
  prolonged total occlusion of coronary arterial
  blood flow
• The location of the infarct depends on the area
  where the blood supply to the myocardium is
  interrupted by the respective occluded coronary
  artery - fig 31-9
• Transmural or Qwave MI extends through the full
  thickness of the myocardium
• NON Q wave MI or subendocardial infarction only
  goes thru partial thickness of the wall of the
  myocardium

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Myocardial Infarction (MI)

• Cause most common is coronary thrombosis
• Complications
• dysrhythmias
• cardiogenic shock
• ventricular rupture
• ventricular aneurysm
• arterial embolism
• venous thrombosis
• pulmonary embolism
• pericarditis
• mitral insufficiency

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MYOCARDIAL INFARCTION

• S/S vary but typically include sudden, severe
  cxp, may radiate to jaw, left arm, shoulder,
  teeth, or throat. Rest or use of NTG does not
  help
• If dx within 6 hours of onset of symptoms may
  give thrombolytic drugs to stop the process

• Dx series of serum enzymes that are elevated
  table 31-3, EKG changes usually within 2-12 hrs

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Myocardial Infarction

• Treatment
• thrombolytics or clot busters used unless
  contraindicated
• symptomatic treatment
• Drug Table 31-1
• Nursing Care Plan 31-1

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OCCLUSIVE DISORDERS OR PVD

• Raynauds Disease
• periodic constriction of the arteries that
  supply the extremities
• Cause unknown
• Brief spasm of arteries in fingers, toes, nose,
  ears or chin causing ischemia, pain
  paresthesia, coldness.
• Place affected area in warm water, avoid smoking,
  use of peripheral vasodilators

• Thrombosis-a clot in a blood vessel
• Phlebothrombosis-a clot in a vein without
  inflammation
• Embolism-moving, mass/clot , solid or gas within
  the bloodstream
• Usually found in lower extremities due to venous
  stasis caused by inactivity, immobility or trauma
  to the vein

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OCCLUSIVE DISORDERS

• S/S
• Arterial clot white, cold, extremely painful
• Venous clot - phlebothrombosis may be
  asymptomatic
• DVT- mild fever, pain, swelling tenderness to
  affected extremity Homans sign
• DX arteriography or venography with contrast dye

• Treatment
• Arterial clot - IV heparin, narcotics for pain,
  thrombolitic agents, surgery
• Venous thrombosis bed rest, elevate extremity,
  local heat, analgesics, IV heparin, oral
  anticoagulants
• Nursing care monitor heparin therapy labs, s/s
  of bleeding, have antidote available
• for heparin protamine sulfate
• for oral anticoagulants vit K

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DISORDERS OF BLOOD VESSEL WALLS

• VARICOSE VEINS
• Valves become incompetent
• saphenous veins in the legs are usually affected
• Familial tendency, prolonged standing, obesity,
  pregnancy
• S/S tiredness, heaviness in legs esp after
  excessive standing, dark discolored veins

• Treatment exercise, wt loss, TED hose, avoid
  prolonged sitting or standing
• Surgical vein ligation or stripping, see fig
  31-14
• Nursing assessment, teaching regarding risk
  factors

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ANEURYSMS

• A stretching or bulging of an arterial wall
• Most common site is the aorta
• Causes arteriosclerosis, HTN, trauma or
  congenital weakness that affects elasticity of
  arterial wall

• S/S usually asymptomatic may be diagnosed
  during xrays during physical or when the client
  has a massive hemorrhage
• Treatment control HTN surgical intervention
• Nursing control HTN, avoid straining, monitor
  v/s, uop, prepare for surgery

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General Nutritional Considerations

• High levels of LDL increases the risk of CAD
• Persons 2 years of age older are urged to
  follow the Step-One diet to reduce their risk of
  heart disease
• Omega-3 fatty acids, abundant in fish oils,
  lowers serum triglyceride levels platelet
  aggregation
• ETOH intake should remain moderate in order to
  increase HDL cholesterol not have the adverse
  side effects of excessive intake for men -1- 2
  drinks per day for women lt 1 drink per day

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General Pharmacologic Considerations

• MDs may prescribe aspirin, 325mg or 81mg per day
  for clients with CAD to prevent MI
• All NTG preparations are stored in their original
  container not mixed with other medications.
  Make sure the cap is tightly closed after each
  use
• NTG can cause a throbbing headache, flushing
  nausea these effects can usually be relieved by
  decreasing the dose
• Antidote for overdosage of thrombolytic therapy
  is Amicar

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General Gerontologic Considerations

• General physiological changes in the older adult
  predispose them to vascular occlusive disorders
• CAD is the most common cause of death in older
  adults
• Older adults are more sensitive to the
  hypotensive effects of nitrates