Pathophysiology of Coronary Diseases

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23rd Nov 2017 Medical Reference this

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  1. Describe the pathophysiology of coronary artery disease (what is it / signs & symptoms / treatments / outcomes desired.
  • Coronary Artery disease (CAD) occurs when fatty plaques are built up in arteries and harden with age. This is known as Artherosclerosis which results in a decreased amount of blood being delivered to the heart and increased difficulty for the arteries to dilate (Lewis, 2014). The heart then shifts from an aerobic metabolism to anaerobic metabolism due to the resulting oxygen deprivation from the vessels not being able to keep up with the increased demand for oxygen (Lewis, 2014). Lactic acid then accumulates and leads to acidosis, decreased energy, decreased contraction strength and also decreased force (Lewis, 2014). This chain of events means that less blood leaves the heart which can then lead to myocardial infarction (MI) (Lewis, 2014).

Gender

Signs and Symptoms

Male

  • Crushing
  • Squeezing
  • Tightness in neck, chest, or shoulder blade
  • CAD is highest among white, middle aged men!

Female

  • Jaw, neck, back, and shoulder pain
  • Shortness of breath
  • Vague chest pain
  • Dizziness
  • Palpations
  • Cold sweats
  • Nausea
  • May be more difficult to identify!

Treatment Options:

  • Some examples of medications:
    • Nitrates:
      • Reduce the amount of oxygen that the heart uses.
    • Lipid Lowering Drugs:
      • Inhibit the synthesis of cholesterol in the liver which unexplainably increases hepatic LDL receptors. The liver is then able to remove more LDLs from the blood.
        • Simvastatin (Zocor)
        • Niacin (Niaspan)
        • Gemfibrozil (Lopid)
    • Beta Adrenergic Blockers:
      • Reduce oxygen demands and workload by reducing heart rate and blood flow peripheral resistance (Lewis, 2014).
    • Angiotensin-Converting Enzyme Inhibitors
      • Result in vasodilation and reduced blood volume. These drugs also reverse or prevent ventricular remodeling (Lewis, 2014).
    • Anti-Platelet Drugs:
      • Reduce platelet accumulation and decrease the risk for a blockage to develop in blood vessels.
  • Surgical:
    • Laser angioplasty
    • Coronary artery bypass
    • Shunt placement

Expected Outcomes:

  • Increase in cardiac output
  • Reduction of blood pressure
  • Improving quality of life
  • Reduction of chest pain
  1. Describe the pathophysiology of hypertension. (What is it / signs & symptoms / treatments / outcomes desired / lifestyle changes needed.
  • Hypertension
    • Primary Hypertension
      • Elevated blood pressure (BP) without an identified etiology (Lewis, 2014).
      • Contributing Factors (Lewis, 2014)
        • Increase sympathetic nervous system activity
        • Overproduction of sodium retaining hormones and substances that cause vasoconstriction
        • Increased sodium intake
        • Obesity
        • Diabetes
        • Tobacco use
        • Excessive alcohol consumption
      • Pathophysiology of Primary Hypertension:
        • Increased cardiac output (CO) or Systemic vascular resistance (SVR) increases. This happens due to abnormalities of any of the mechanisms involved in the maintenance of normal BP (Lewis, 2014). The release of renin or angiotensin II causes the blood vessels to increase which consequentially increases blood volume.
      • Signs and Symptoms of Primary Hypertension
        • BP >140/90 on two separate occasions
        • Nausea
        • Headache, typically throbbing and occurring in the morning.
        • Vision problems
      • Treatment
        • Includes lifestyle modifications including:
          • Stress reduction
          • Diet
          • Exercise
          • Limit alcohol intake
          • Tobacco cessation
          • Relaxation techniques
    • Secondary Hypertension
      • Elevated BP with a specific cause that can be corrected
    • Pathophysiology of Secondary Hypertension:
      • Increase in blood volume is due to a specific disease or illness.
    • Signs and symptoms of Secondary Hypertension:
      • Stroke
      • Heart Failure
      • MI
      • Retinopathy
      • Left Ventricular Hypertrophy
    • Treatment
      • Treating the underlying cause
    • Both types of Hypertension can be treated with medications such as:
      • Thiazide diuretics
      • ACE inhibitors
      • Beta adrenergic blockers
  • Although these are some signs listed in our text there are really no definite signs or symptoms because a patient cannot tell if their blood pressure is consistently high just by the way they feel. The damages listed above happen because there are no signs a person can feel on their own to warn them of their hypertension (Lewis, 2014).
  1. Describe the pathophysiology of left sided heart failure / CHF (what is it / signs & symptoms / treatments / outcomes desired / lifestyle changes needed.

Left sided heart failure is due to the left ventricle ineffectively contracting. This causes a decrease in CO and pulmonary edema. These occur because the heart is not pumping effectively causing fluid to build up in the left atrium as well as the lungs (Lewis, 2014).

Signs and Symptoms

  • Crackles heard in the lungs
  • Frothy pink sputum
  • ↓ Attention span
  • Ventricular gallop
  • Difficulty breathing
  • Muscle weakness
  • Edema
  • Fatigue
  • Weight gain
  • Irritability

Treatment Options

  • Lifestyle Modifications
    • ↓ Sodium intake
      • ↓ risk for fluid overload
  • Ace Inhibitors
    • ↓ vascular resistance
  • Diuretics
    • ↓ Preload
    • Advise patient to eat foods high in potassium or consume a potassium supplement to replace fluids lost
  • Digoxin
    • ↑ Heart’s ability to contract
  • Beta-Blockers
    • Prevent cardiac remodeling

(Lewis, 2014)

  1. Create an Education plan for a low sodium diet. (What specifically would you teach this patient about this diet)? Include foods high in sodium / foods to avoid.

Please have a detailed plan that you can use to teach a patient. The plan should have at least 2 patient outcomes listed. You need to bring the plan to clinical so that you can use it with your patient.

  • Educate patient that sodium intake is as follow:
    • Healthy Adult
      • No more than 2300 mg/day
    • Cardiac Patient
      • Less than 1500 mg/day
    • Advise patients not to add salts or seasonings to foods because it can increase sodium intake. They can choose options such as non-sodium seasonings instead! (For Example: Mrs. Dash offers AMAZING no-salt seasonings)
      • Also, advise patient that using herbs for seasoning like garlic, ginger or lemon are good alternatives
    • Foods to Avoid:
      • Frozen meals
      • Limit milk intake to no more than 2 cups a day
      • Cheeses
      • Canned soups and vegetables
        • Advise patient if buying canned vegetables he/she can rinse these prior to eating with water
      • Processed meats
      • Always read your food labels
      • Watch out for medications that contain sodium!
  • Outcomes:
    • Patient 1:
      • Patient will be able to name 3 alternatives to seasoning with salt by end of shift, Tuesday 12pm.
    • Patient 2:
      • Patient will be able to name 3 food choices low in sodium by end of shift, Tuesday 12pm.

(Lewis, 2014)

  1. Create an education plan for low fat, heart healthy diet. (What specifically would you teach this patient about this diet?) Include information on bad fats versus good fats.

Please have a detailed plan that you can use to teach a patient. The plan should have at least 2 patient outcomes listed. You need to bring the plan to clinical so that you can use it with your patient.

  • Daily Fat Consumption
    • 25-35% of daily calories
    • Polyunsaturated should be the primary source
  • Food Choices
    • Adequate intake of foods with omega 3 fatty acids have proven to be good for the heart (American Heart Association)
    • Eat fish at least two times a week (American Heart Association)
      • “Omega-3 fatty acids decrease risk of arrhythmias, which can lead to sudden death. Omega-3 fatty acids also decrease triglyceride levels, slow growth rate of atherosclerotic plaque, and lower blood pressure” (American Heart Association).
    • Eat more:
      • Whole grains
      • Fresh vegetables and fruit
        • If you cannot afford fresh fruit try fruit canned in natural juices versus syrups
      • Low fat cheeses and dairy
    • Avoid processed foods, and those high in saturated fats
      • Foods high in saturated fats include:
        • Butter
        • Bacon
        • Cheese
  • Outcomes:
    • Patient 1:
      • Patient will be able to verbalize ways to decrease fat consumption on a daily basis by end of shift, Tuesday 12pm.
    • Patient 2:
      • Patient will be able to verbalize the need for consumption of Omega 3 fatty acids by end of shift, Tuesday 12pm.
  1. Give examples of situations when you would need to increase oral intake of foods high in potassium.
  • Patients with hypertension on a potassium wasting diuretic, “diarrhea, laxative abuse, vomiting, and ileostomy drainage” would need to increase oral intake of foods high in potassium or take a potassium supplement (Lewis, 2014, p. 297).

Give examples of situations when you would need to decrease oral intake of foods high in potassium.

(Note: this could be in regard to disease processes or medications)

Prepare a list of foods high in potassium. Please bring the list to clinical that you could use to teach the patient.

  • Patients taking “ACE Inhibitors, Potassium Sparing Diuretics or NSAIDS may need to decrease their intake of oral potassium” (Lewis, 2014, p. 296). Also, patients who have “renal disease, burn victims, Addison’s disease, Tumor Lysis Syndrome and those with Adrenal insufficiency” may also need to decrease their intake of oral potassium (Lewis, 2014, p. 296).
  • Foods High In Potassium

Fruits

Vegetables

Other Foods

Apricot, avocado, banana, cantaloupe, dried fruits, grapefruit juice, honeydew, orange, orange juice, prunes and raisins

Baked beans, butternut squash, refried beans, black beans, cooked broccoli, carrots, greens (except kale), canned mushrooms, white and sweet potatoes, cooked spinach, tomatoes or tomato products, and vegetable juices

Bran or bran products, chocolate, granola, milk, nuts, seeds, peanut butter, salt substitutes, salt free broth and yogurt

(Lewis, 2014, p. 1115)

  1. Using the following template, prepare the following medication which many of the patients on 7S take (Remember that these are cardiac patients when looking at the indications of the medication) Please do not copy and paste from medication resource, complete in your own words. Be sure to include your reference: (24) points)

**Do not copy and paste from medication resource, complete in your own words. Be sure to include your reference.

Drug Order:

Generic & Brand Name

Drug Classification:

Drug Action: (How drug works?)

Normal dosage:

Expected Effects/Outcomes: (What symptoms do you want to improve?)

Adverse Effects/Contraindications:

Nursing Responsibilities: On-going assessment data and lab values to be monitored

Nurse will:

Aspirin 81 mg

Classification:

Antiplatelet

Action:

Hinders production of prostaglandins which prevents blood clots. Decreases platelet clumping

Normal dose:

PO: Adults 50–325 mg Q24 hours

Expected effect:

Prevention of blood clots in high risk cardiac patients.

  • Blood in stool
  • Stomach Pain
  • Constipation
  • Gastric bleeding
  • Nausea
  • Hearing assessment
  • Vitals monitoring
  • Assess heart function
  • Monitor hemoglobin
  • Monitor Hematocrit
  • Monitor platelet count
  • Assess urine, vomit and stool for blood

Clopidogrel (Plavix)

Classification:

Antiplatelet

Action:

Hinders production of prostaglandins which prevents blood clots. Decreases platelet clumping

.

Normal dose:

PO: Adults 300 mg initially, then 75 mg once daily; aspirin 75–325 mg once daily should be given concurrently.

Expected effect:

Prevention of blood clots in high risk cardiac patients.

  • Blood in stool
  • Constipation
  • Nausea
  • Gastric bleeding
  • Stomach pain
  • Hearing assessment
  • Vitals monitoring
  • Assess heart function
  • Monitor hemoglobin
  • Monitor Hematocrit
  • Monitor platelet count
  • Assess urine, vomit and stool for blood

Lisinopril (Zestril; Prinivil)

Classification:

ACE inhibitor

Action:

Stops angiotensin I from converting to angiotensin II. This reduces arterial resistance

Normal dose:

PO: Adults 10 mg once daily, can be increased up to 20–40 mg/day

Expected effect:

Decrease in blood pressure.

  • Fatigue
  • Headache
  • Dry cough
  • Angioedema
  • Increase in serum potassium
  • Increase in BUN
  • Increase in Creatinine
  • Obtain baseline BP
  • Obtain baseline pulse rate and rhythm. Reassess frequently
  • Monitor weight
  • Monitor F&Es
  • Monitor WBC
  • Monitor potassium
  • Monitor Renal function
  • Assess patient compliance throughout treatment

Losartan (Cozaar)

Classification:

Angiotensin II receptor blocker

Action:

Blocks vasoconstriction effects of angiotensin II.

Normal dose:

50 mg once daily initially. May be increase to 100mg per day in 1-2 doses

Expected effect:

Decrease in blood pressure. .

  • Vomiting
  • Nausea
  • Increase in serum potassium
  • Increase in BUN
  • Increase in creatinine levels
  • Monitor BP prior to admin. And throughout treatment
  • Monitor weight
  • Monitor F&Es
  • Monitor potassium
  • Monitor renal function
  • Assess patient compliance
  • Medication should be taken with food.

Metoprolol (Lopressor)

Classification:

Antihypertensive

Action:

Blocks stimulation of beta 1 adrenergic receptors.

Normal dose:

25–100 mg/day as a single dose initially or 2 divided doses; may be increased every 7 days as needed up to 450 mg/day

Expected effect:

Decrease in blood pressure and increase in HR, BP, and contraction.

  • Fatigue
  • Dizziness
  • Bradycardia
  • Fluid retention
  • Edema
  • Hypotension
  • Assess arrhythmia prior to and during treatment
  • Continuous ECG monitoring
  • Monitor vitals
  • Assess apical pulse
  • Assess BP
  • Assess liver function

Lovastatin (Mevacor; Altocor)

Classification:

Anti-lipid

Action:

Interferes with cholesterol synthesis by lowering lipid levels

Normal dose:

20 mg once daily with evening meal. May be increased at 4-wk intervals to a maximum of 80 mg/day

Expected effect:

Decrease in cholesterol.

  • Hepatitis
  • Cirrhosis
  • Myalgia
  • Gas
  • Constipation
  • Cramps
  • Nausea
  • Pancreatitis
  • Vomiting
  • Assess cholesterol prior to treatment and Q4 weeks during
  • Monitor liver function
  • Monitor for deficiency in fat soluble vitamins: A, D, E and K
  • Monitor for deficiency in folic acid

Atorvastatin (Lipitor)

Classification:

Anti-lipid

Action:

Interferes with cholesterol synthesis by lowering lipid levels

Normal dose:

10–20 mg once daily initially may be increased every 2–4 weeks up to 80 mg/day;

Expected effect:

Decrease in cholesterol.

  • Hepatitis
  • Cirrhosis
  • Myalgia
  • Gas
  • Constipation
  • Cramps
  • Nausea
  • Pancreatitis
  • Vomiting
  • Assess cholesterol prior to treatment and Q4 weeks during
  • Monitor liver function
  • Monitor for deficiency in fat soluble vitamins: A, D, E and K
  • Monitor for deficiency in folic acid

Amiodarone (Cordarone; Pacerone)

Classification:

Antiarrhythmic

Action:

Prolongs action potential

Normal dose:

PO: Adults 800–1600 mg/day in 1–2 doses for 1–3 weeks then 600–800 mg/day in 1–2 doses for 1 month then 400 mg/day maintenance dose.

Expected effect:

Decrease in arrhythmia

  • Hypotension
  • Bradycardia
  • Worsening arrhythmias
  • Anorexia
  • Nausea
  • Vision disturbances
  • Assess arrhythmia before and during treatment
  • ECG monitoring
  • Monitor vitals
  • Assess for toxicity
  • Measure apical pulse
  • Measure BP
  • Monitor liver function
  • Pt should not consume grapefruit juice while taking this medication

Nitroglycerin (sublingual)

Classification:

Antianginals

Action:

Relaxes smooth muscle and promotes vasodilation

Normal dose:

SL: Adults 0.3–0.6 mg; may repeat every 5 min for 2 additional doses for acute attack.

Expected effect:

Reduction of blood returning to the heart.

  • Hypotension
  • Dizziness,
  • Increased HR
  • Headache
  • Assess vital and monitor them throughout treatment
  • Administer sublingually at first sign of heart attack

Carvedilol (Coreg)

Classification:

Antihypertensive

Action:

Blocks stimulation of beta 1 adrenergic receptors

Normal dose:

Hypertension– 6.25 mg twice daily, may be ↑ q 7–14 days up to 25 mg twice daily or extended-release– 20 mg once daily, dose may be doubled every 7–14 days up to 80 mg once daily

Expected effect:

Decrease in blood pressure and increase in HR, BP, and contraction.

  • Fatigue
  • Bradycardia
  • Dizziness
  • Hypotension
  • Fluid retention
  • Edema
  • Assess arrhythmia prior to and throughout treatment
  • Continuous ECG monitoring
  • Monitor vitals
  • Assess apical pulse
  • Assess BP
  • Assess liver function

Amlodipine (Norvasc)

Classification:

Antihypertensive

Action:

Prevents calcium from crossing myocardial cell membrane and vascular smooth muscle

Normal dose:

PO: Adults 5–10 mg once daily

Expected effect:

Decrease in blood pressure

  • Orthostatic hypotension
  • Headache
  • Dizziness
  • Edema
  • Arrhythmias
  • Assess vitals
  • Monitor ECG throughout treatment
  • Monitor vitals
  • Monitor liver function
  • Pt will need assistance w/ ambulation
  • Monitor F&Es
  • Educate patient on need to decrease sodium and fluids to subsequently decrease edema

Furosemide (Lasix)

Classification:

Loop Diuretic

Action:

Inhibits reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule. This causes increased excretion of water, sodium, calcium, magnesium and chloride.

Expected effects:

Management of edema associated with heart failure and hepatic or renal disease, acute pulmonary edema, treatment of hypertension

(Vallerand, 2013)

  • F&E imbalances
  • Tinnitus
  • Diarrhea
  • Hyperglycemia
  • Nausea
  • Vomiting
  • Liver dysfunction
  • Paresthesia
  • Orthostatic hypotension
  • Assess CBC
  • Assess liver function prior to administration
  • Assess electrolytes prior to administration
  • Monitor BP
  • Monitor Pulse
  • Monitor for hypovolemia
  • Assess for diuresis
  • Assess for polydipsia
  • Assess mucous membranes
  • Assess skin turgor
  • Monitor for edema
  • Monitor weight
  • I&Os

All drugs referenced : (Vallerand, 2013)

References:

American Heart Association: Fish and Omega-3 Fatty Acids. (2014, May 14). Retrieved February 13, 2015, from http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Fish-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp

Lewis, S. M., & Dirksen, S. R. (2014). Medical-surgical nursing: assessment and management of clinical problems (Ninth ed.). St. Louis: Elsevier.

Louie, D., & Wedell, R. (2014). Optimizing heart health. American Nurse, 46(3), 13.

Vallerand, A. H., & Sanoski, C. A. (2013). Davis’s drug guide for nurses (Fourteenth ed.). Phila-delphia: F.A. Davis Company.

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