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ANGINA PECTORIS

Definition

Angina pectoris is a symptom characterized by discomfort in the chest. It is caused by inadequate blood

supply to the myocardium.

1.Stable Angina predictable and consistent pain; occurs in exertion; relieved by rest.

2. Unstable Angina symptom occur more frequently and last longer than stable angina. Pain threshold

is lower, pain may occur at rest

3.Variant Angina or Prinzmetals Angina-pain at rest with reversible ST-segment elevation;caused by

coronary artery vasospasm, it usually occurs when a person is at rest or sleep and not after physical

exertion or emotional stress. It is associated with acute myocardial infarction,severe cardiac arrhythmias

including ventricular tachycardia and fibrillation and sudden cardiac death

Pathophysiology

Myocardial ischemia is caused primarily by an inadequate blood supply or an increased demand for

oxygen. The symptoms of angina differs from myocardial infarction in that angina is relieved by

nitroglycerin and MI is not.

Risk factors

smoking hyperlipidemia

alcohol age (45 for male and 55 female)

obesity race

sedentary life stress

DM personality

Diagnostic tests

ECG

ABG

Cardiac Enzymes

Assessment

Discomfort in chest: Tachycardia

-aching Activity or exertion

-tightness Hypertension

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-heaviness Circulatory status

-dull pain Hypotension

-may radiate to the neck,jaw,shoulder and inner aspect of the upper arms

Associated Nursing Diagnosis

Ineffective cardiac tissue perfusion secondary to coronary artery disease as evidenced by chest pain

Death anxiety

Deficient knowledge about underlying disease and methods for avoiding complications

Noncompliance,Ineffective therapeutic regimen

Nursing Interventions

Identify exact site of distress

Direct patient to stop all activities and sit or rest in bed in a semi-fowlers position if chest pain is

sensed

Administer nitroglycerin: 1 tab every 5-15 minutes x 3 doses, report to MD if no relief; can also be

given prior to an exhausting activity

Encourage deep breathing to induce relaxationMonitor length of time (if not relieved in 15 minutes, other problems should be considered)

Pharmacologic Therapy

Medicine

Nitroglycerine Beta adrenergic blockers Calcium channel blocker Antiplatelet agent

NITROGLYCERINE (Nitrostat, Nitrol, Nitrobid IV)

-A vasodilator ; mainstay for treatment of angina pectoris

-it decrease myocardial oxygen consumption thus decrease ischemia and relieves pain

BETA ADRENERGIC BLOCKERS ( propanol , metropol ,atenolol )

-it helps to decrease myocardial O2 consumption by blocking the -adrenergic sympathetic stimulation

to the heart HR, slow circulation of an impulse through the heart ,BP

Myocardial contractility control chest pain and delay onset of ischemia

Contraindicated(+) asthma

CALCIUM CHANNEL BLOCKERS (amlodipine,verapamil,diltiazem)

- have different effect

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- Decrease SA node automaticity and AV node conductivity resulting in slower HR and decreasedheart muscle contraction.

- Relax the blood vessel causing a decreased BP and increase coronary artery perfusion- Dilates smooth muscle wall of coronary arterioles to increase myocardial O2 supply- Used by patient who cannot take and with side effect with beta blockers and nitrates- Prevent and treat vasospasm- Amlodipine ( NORVASC) and felodipine (PLENDIL) DOC for heart failure

ANTIPLATELET & ANTICOAGULANT ( aspirin,clopidogrel & ticlopidine ,heparin ,GPIIb / IIIa agent)

-To prevent platelet aggregation w/c impedes blood flow

-aspirin- prevent platelet activation and reduce incidence of MI an death from CAD.

-clopedogril & ticlopidine alternative for pt. with allergy on aspirin

-heparin-it prevent the formation of new blood clot , it decreased the occurrence of MI to

pt.with unstable angina.

-GPIIIb / IIIa agent (abciximab,tirofibam,eptifibatide)-for Pt.with unstable angina

It prevents the aggregation by blocking GPIIb/IIIa receptor on platelet to prevent adhesion offibrinogen and other factors to each other forming a clot.

MYOCARDIAL INFARCTION

causes of MI include coronary artery obstruction due to the progressive development of

atherosclerosis; coronary artery spasm; embolism.

Assessment

Chest pain (described as substernal, crushing with radiation to the arm, neck, jaw, or back;pain is unrelieved by nitroglycerine) Dyspnea

Changes in heart area Nausea Vomiting Fever (up to 101F over the first 24 to 48 hours) Increased WBC count and sedimentation rate

Diagnostic test

Echocardiogram use to evaluate ventricular function

-detect hyperkinetic and akinetic wall motion and determine ejection fraction.

-12-lead ECG may show ST elevation as the MI is evolving or Q waves when the MI iscomplete.

Laboratory test

-After the onset of MI, enzyme elevation occurs as follows:

Serum glutamicoxaloacetic transaminase (SGOT) peaks in 24 to 48 hours.(AST)

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Myoglobin found in many tissuesheme protein thet help to transport O2

-found in cardiac and skeletal muscle

-increase between 1-3 hours peak within 12 hrs.

-(-) result repeat after 3 hrs

Creatine Kinase Normal values: Males -38-174 U/L and Females 26-140 U/L Isoenzymes

CKMM- skeletal ( 96-100%) CKBB brain (0%) CKMB cardiac (0-4%)

Troponin normal level is

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Oxygen Nitroglycerin ASA

Administer thrombolytic agents as streptokinase or tissue plasminogen activator (TPA), asprescribed, to limit infarct size.

Provide supplemental oxygen via nasal cannula.3.Monitor vital signs every 1 to 2 hours

4.Monitor cardiac rhythm for dysrhythmias, such as premature ventricular contractions (PVCs),ventricular tachycardia, second-degree type II Atrioventricular (AV) block, and complete heart block.

5.Monitor for signs of congestive heart failure.

6. Maintain intravenous line for emergency access.7. Maintain bedrest, with the patient in Semi-Fowlers position, for the first 24 hours.

Administer medications (eg, digitalis, antiarrhythmics, vasodilators, vasopressors,

anticoagulants, diuretics, potassium, Colace, and sedatives) to limit the potential of complications, as

ordered

8.Institute measures to decrease the oxygen demand (eg, provide a calm and restful environment,

encourage the patient to rest, control pain).

9.Provide patient teaching to identify and reduce risk factors.

10.Prepare the patient for surgical interventions such as percutaneous transluminal coronary

angioplasty (PCTA) or coronary artery bypass graft (CABG), if indicated.

Drug therapy

Goal: to minimize myocardial damage ;prevent heart function and prevent complication

ThrombolyticsIV direct to coronary artery

-to dissolve and lyse thrombus in a coronary artery ( thrombolysis)

-to allow blood flow to the coronary artery again ( reperfusion )

-to minimize size of infarction,amd preserve ventricular fuction.

Streptokinase most frequently used ( ateplase,reteplase,anistreplase)

-increase the amount of circulating plasminogen activator w/c then increase the amout of circulating

and clot bound plasmin.

Ateplase tissue plasminogen activator ; increase the amount of plasminogen on the clot

Analgesic

Morphine sulfate analgesic of choice for acute M.I ;given in IV boluses

-reduced pain and anxiety

-relaxed bronchioles to enhance oxygenation

Angitensin Converting Enzyme Inhibitor

Angiotensin I form when the kidney release rennin in response to decrease BP

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ACE found in the lumen of all blood vessel esp.in the lungs convert angiotensin I angiotensin II

Angiotensin II- vasoconstrictor ;causing kidney to retain Na and excrete K

ACE inhibitor prevent conversion of angiotensin I angiotensin II

Contraindication to use ACE inhibitor

-hypotension

huponatremia

-hypovolemia

-hyperkalemia

Cardiac rehabilitation

-program that target risk reduction by means of education ,individual and group suppot and physicalactivities

Goal:

to improve quality of life of post MI patient

to limit the effect end progression of atherosclerosis

to enhance psychosocial status of the patient

to prevent another cardiac event

PHASES

Phase Ibegin w/ dx.of atherosclerosis ;when pt.is admitted for ACS consist of low level activities andinitial education for pt. and family.

-teaching the S/Sx requiring emergency assistant,medication regimen,rest and activity balance and

follow up check-up.

Phase II occurs after the pt.has been discharged

-last for 4-6 weeks up to 6 months

-OPD program consist of ECG monitored ,exercise training program.

-support and guidance related to treatment

Phase III focused on maintaining CV stability and long term conditioning

-pt. is self directed during this phase

-does not required supervised program

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CONGESTIVE HEART FAILURE

Referred to as Congestive Heart Failure (CHF) or Ventricular Failure Only cardiac disorder on the rise Clinical state in which the heart is unable to maintain the cardiac output necessary to meet the

bodys metabolic demands: Diastolic (ventricle pumps against extremely high afterload as in

hypertension) and Systolic (ventricles are damage and cannot pump leading to extremely high

preload.

Risk factors

Coronary Artery disease COPD

Carditis Hypertension

Post Coronary Bypass Surgery

DM

Diagnostic test: ECG,ABG. Pulse Oximetry, X-ray

Assessment:

Dyspnea upon exertion Orthopnea

Chest pain Peripheral Edema

Distended Neck Veins Fatigue

Paroxysmal Nocturnal dyspnea

Nursing Diagnosis

Activity Intolerance related to imbalance between oxygen supply and demand secondary to

decreased cardiac output

Fatigue secondary to heart failure

Excess fluid volume related to excess fluid or sodium intakeAnxiety related to breathlessness and restlessness secondary to inadequate oxygenation

Powerlessness related to inability to perform role responsibilities secondary to chronic illness

Noncompliance related to lack of knowledge

Deficient knowledge of self-care program related to nonacceptance of necessary lifestyle changes

Nursing Interventions

Monitor patients response to activities. Encourage patient to perform an activity more slowly than

usual for a shorter duration or with assistance

Identify barriers that could limit patients ability to perform an activity and discuss methods of

pacing an activity

Administer diuretics early in the morning so that diuresis does not disturb nighttime rest

Monitor fluid status closely: Auscultate lungs,compare daily weights and monitor input and output

Teach patient to adhere to a low sodium diet. Encourage salt restrictions to 2-3g/day

Restrict fluids as ordered,Strict I& O

Place in high fowlers position

Administer Oxygen as ordered

Monitor for cardiogenic shock

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Drug Of Choice:

1.Lasix- NI: Avoid to rapid IV push causes toxicity

2.Inotropin

3.Lanoxin- NI: Monitor apical pulse for 1 full minute prior to digoxin, hold if

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P WAVE

Atrial depolarization /systole (contraction) Indicates impulse comes from SA node If (-) or abN position, impulse originates outside the SA node

PR INTERVAL Time impulse travels from SAAVBB PF Normal: 0.12-0.20 sec. Short: impulse comes from AV node

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Long: delayed conduction heart block QRS COMPLEX

Ventricular Depolarization Impulse traveled through R & L Ventricle resulting to ventricular contraction Normal:

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ANALYZING ECG

STEP 1: DETERMINE REGULARITY OF R WAVES

-After finding out the patient's medical history, begin by labeling the P wave, PR interval, QRS

complex, QT interval and T wave.

-Determine if the rhythm is regular or irregular. This is done by accessing whether the RR

Intervals and PP intervals are regularly spaced

STEP 2. CALCULATE HEART RATE

-

FOR REGULAR RHYTHM

Big Block Method: (300/# of R waves) in 3-sec strip. 1500/# small boxes bet R

Memory Method: (300,150,100,75,60,50,43,33,30)FOR IRREGULAR RHYTHM:

For 6 sec strip(#of R x 10) For 3 sec strip (#of R x 20) If less than 3 sec, count # of Rs x 40

STEP 3. IDENTIFY & EXAMINE P WAVES

P waves should precede each QRS complex identical or near identical

STEP 4: MEASURE PR INTERVALS

Count # of boxes X 0.04secSTEP 5:MEASURE QRS COMPLEX

# of boxes X 0.04

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CEREBROVASCULAR ACCIDENT

-It is an infarction that occurs in the brain. It is usually caused by a thrombus,embolism or haemorrhage

Pathophysiology

-It occurs when a local area of the brain is deprived of blood. Local or general disorders may cause the

alteration of the blood supply. If cerebral circulation is interrupted extensively,cerebral anoxia or lack of

oxygen to the brain develops.After 10 minutes changes to the brain resulting from cerebral anoxia are

irreversible.

Assessment

Pupil response

Rhythm and depth of respirations

Level of consciousness

Decerebrate posturing

Decorticate posturing

Nursing DiagnosisImpaired physical mobility re

lated to hemiparesis,loss of balance and coordination,spasticity and brain injury

Acute pain related to hemiplegia and disuse

Deficient self-care related to stroke sequelae

Disturbed sensory perception

Impaired swallowing

Total urinary incontinence related to flaccid bladder

Disturbed thought processes related to brain damage

Impaired verbal communication related to brain damage

Risk for impaired skin integrity related to hemiparesis

Interrupted family processes related to catastrophic illness and caregiving burdensSexual dysfunction related to neurologic deficits or fear of failure

Nursing Interventions

Maintain airway

Suction prn

Insert foley catheter

Watch for thrombophlebitis

Monitor VS, watch out for increase in ICP

Keep patient turned to side, change of position every 2 hours

Position to prevent contractures, use measures to relieve pressure, assist in maintaining good body

alignment and prevent compressive neuropathies, provide tennis shoes or therapeutic shoes to prevent

footdrop

Provide elastic hose to prevent deep vein thrombosis

Elevate affected arm to prevent edema and fibrosis

Provide passive Range of Motion exercises

Observe patients for paroxysms of coughing,food dribbling out or pooling in one side of the mouth,and

nasal regurgitation when swallowing liquids ( the client is at risk of aspiration)

Advise patient to take smaller boluses of food and provide thicker liquids or pureed diet as indicated

Provide high-fiber diet and adequate fluid intake

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Monitor I& O

Monitor LOC

Auscultate for breath sounds ( the client is at risk of pneumonia)

Provide safety

Pharmacologic therapy

1.Thrombolytics

2.Diuretics

3.Calcium Channel blockers

GLASGOW COMA SCALE

Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of

recording the conscious state of a person for initial as well as subsequent assessment.

GCS was initially used to assess level of consciousness after head injury, and the scale is now used by

first aid, EMS, and doctors as being applicable to all acute medical and trauma patients. In hospitals it is

also used in monitoring chronic patients in intensive care.

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The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as

their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the

highest is 15 (fully awake person).

Best eye response (E)

There are 4 grades starting with the most severe:

1. No eye opening2. Eye opening in response to pain. (Patient responds to pressure on the patientsfingernail bed; if

this does not elicit a response, supraorbital and sternal pressure or rub may be used.)

3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patientsreceive a score of 4, not 3.)

4. Eyes opening spontaneouslyBest verbal response (V)

There are 5 grades starting with the most severe:

1. No verbal response2. Incomprehensible sounds. (Moaning but no words.)3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational

exchange)

4. Confused. (The patient responds to questions coherently but there is some disorientation andconfusion.)

5. Oriented. (Patient responds coherently and appropriately to questions such as the patientsname and age, where they are and why, the year, month, etc.)

Best motor response (M)

There are 6 grades starting with the most severe:

1. No motor response2. Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm,

extension of wrist,decerebrate response)

3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm,flexion of wrist,decorticate response)

4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist whensupra-orbital pressure applied ; pulls part of body away when nailbed pinched)

5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-lineand gets above clavicle when supra-orbital pressure applied.)6. Obeys commands. (The patient does simple things as asked.)

Interpretation

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the

form "GCS 9 = E2 V4 M3 at 07:35".

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Generally, brain injury is classified as:

Severe, with GCS 8 Moderate, GCS 9 - 12 Minor, GCS 13.

ENDOTRACHEAL SUCTIONING

Endotracheal Suctioning involves the insertion of a catheter into the clients artificial tracheal airway.

Endotracheal Suctioning maintains airway patency, facilitates removal of airway secretions, and

stimulates a deep cough. In the acute health care environment, tracheal suctioning is a sterile process.

In the home setting, the client may be instructed to use a clean suction technique as long as there

are no signs of infection

Purpose:

To maintain a patent airway and prevent airway obstruction

To promote respiratory functions (optimal exchange of oxygen and carbon dioxide into and out ofthe lungs)

To prevent pneumonia that may result from accumulated secretions

Assessment:

Observe for signs and symptoms of lower airway obstruction Secretions in airway, wheezes or crackles on inspiration and/or expiration Ineffective cough Unilateral or Bilateral absence or diminished breath sound Tachypnea Acutely shallow respiration Tachycardia or bradycardia Hypertension or hypotension Cyanosis Decreased level of consciousness

Planning:

Prepare patient Explain procedure and patients participation. Explain importance of coughing during procedure. Assist patient to assume comfortable position for nurse and client, usually semi-fowlers

of Fowlers. If unconscious, place in side-lying position.

Place towel across patients chestImplementation

1.Wash hands and turn suction device set on and set vacuum regulator to appropriate negative

pressure. Wear mask.

2. If using sterile suction kitA. Open package. If sterile drape is available, place it across patients chest

B. Open suction catheter package. Do not allow suction catheter to touch any unsterile surface

C. Unwrap or open sterile basin and place on bedside table. Be careful not t touch inside basin.

Fill with about 100 ml sterile normal saline

3. If indicated, open lubricant and squeeze on sterile catheter package without touching package.

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4. Apply one sterile glove to each hand or apply non sterile to non-dominant hand and sterile glove to

dominant hand.

5. Pick up suction catheter with dominant hand without touching non-sterile surfaces. Pick up

connecting tubing with non-dominant hand.

6. Check the equipment if functioning properly by suctioning small amount of saline from basin

7. Coat distal portion 6-8 cm of catheter with water-soluble lubricant. In some situations, catheter is

lubricated only with normal saline. Nursing assessment indicates needs for lubrication

8. Remove oxygen or humidify delivery device with dominant hand

9. Hyperinflate and/or oxygenate client before suctioning, using manual resuscitation bag or sigh

mechanism on mechanical ventilator

10. Without applying suction, gently but quickly insert catheter with dominant thumb and forefinger

into artificial airway (best to time catheter insertion with inspiration).

11. Insert catheter until resistance is met, then pull back 1 cm.

12. Apply intermittent suction by placing and releasing non- dominant hand thumb over vent of catheter

while rotating back and forth between dominant thumb and forefinger. Encourage patient to cough.

13. Replace oxygen delivery device. Encourage patient to deep breath.

14. Rinse catheter and connecting tubing with normal saline until clear. Use continuous suction.

15. Repeat steps 10-14 as needed to clear secretions. Allow adequate time (at least 1 full minute)between suction passes for ventilation and reoxygenation.

16. Assess patients cardiopulmunary status between suction passes.

17. When artificial and tracheobronchial trees are sufficiently cleared of secretions, perform nasal and

oral pharyngeal suction are performed. When catheter is contaminated, do not reinsert into ET or TT.

18. Disconnect catheter from connecting tubing.

19. Remove towel and place in laundry, or remove drape and discard in appropriate receptacle.

20. Reposition patient.

21. Discard remainder of normal saline into appropriate receptacle. If basin is disposable, discard into

appropriate receptacle. If basin is reusable, place it in soiled utility room.

21. Wash hands and place unopened suction kit on suction machine or at head of bed.

Evaluation

1. Recording and Reporting

Chart in nurses notes:

Respiratory assessment before and after suctioning. Size of suction catheter used. Amount of negative suction pressure used. Duration of suctioning period. Route(s) used to suction. Secretions obtained and odor, amount, color, consistency, frequency of suctioning. Patients tolerance of procedure.

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CARE OF CLIENTS UNDERGOING CHEMOTHERAPY & RADIATION THERAPY

GOALS OF CANCER THERAPY:

CURE:

-Disease-free & live to normal life expectancy

CONTROL:

-Cancer is not cured but controlled over long periods of time

PALLIATIVE:

-Maintain high quality of life when cure & control are not possible

-PROPHYLAXIS:

-Provide tx when no T is detectable but at risk

MODALITIES OF CANCER TREATMENT

CHEMOTHERAPY:

Overall goal is to destroy the cancer cells without excessively damaging the normal cells.

NURSING PRIORITY:

-The aim is to administer an antineoplastic agent dose large enough to eradicate cancer cells but small

enough to limit adverse effecs to safe & tolerable levels

Observe for therapeutic effects (appetite,improved mobility,pain) Observe for adverse effects Dosage is based on clients BW Monitor lab values for evidence of Bone Marrow suppression, Liver FT, Renal FT Avoid contact w/skin. Wear gloves, eyewear & barrier protective clothing Prepare drug on disposal tray or towel

Chemotherapeutic agents

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ALKYLATING AGENTS: Binds to DNA & prevent mitosis & replication Imitate the action of radiation; Does not cross BBB COMMON SE: BONE MARROW SUPPRESSION, NV, ALOPECIA

Cisplatin (PLATINOL) Hyperuricemia, hypo Mg,K,Ca, nephrotoxic SE: Dizziness, tinnitus, numbness

Cyclophosphamide (CYTOXAN) Alopecia, cystitis, hematuria, pulmo toxicity

Melphalan (ALKERAN) Pulmonary toxicity

ANTIMETABOLITES: Take the place of Normal CHON req for DNA synthesis COMMON SE: Bone Marrow Dep, Oral & GI ulceration

Fluorouracil (5-FU) Methotrexate Na (Folex, Mexate)

Alopecia, stomatitis, hyperuricemia, diarrhea, phototoxicity,hepatotoxicity

Assess for glycosuria, GI bleeding, gastric ulceration, CI for 1st tri of preg,avoid alcohol

NURSING CONSIDERATIONS: Give folinic acid or Citrovorum Add leucovorin to prevent toxicity Use sun screen & wear protective covering

ANTI-TUMOR ANTIBIOTICS:

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STOMATITIS: soft toothbrush, avoid extreme temp of food, spices, citrus, smoking, alcohol ALOPECIA/NAIL CHANGES: wear scarf, wig, turban, hat, no hair rollers or dryer SKIN PIGMENTATION : Avoid sun exposure

HEMATOPOEITIC SYSTEM

ANEMIA : Monitor RBC wkly, observe for bleeding, high CHON, rest. LEUKOPENIA: Avoid rectal temp & suppositories (rectal abscess) THROMBOCYTOPENIA: avoid trauma, aspirin

EXTRAVASATION:

Stop Infusion Remove remaining drug in the tubing Aspirate the infiltrated area DO NOT REMOVE NEEDLE Contact physician Instill antidote Apply ice pack & elevate extremity for the 1st 24-48H

RADIATION THERAPY

EXTERNAL BEAM THERAPY (TELETHERAPY)COBALT THERAPY

RADIATION SAFETY PRECAUTIONS:

Private room & bath Plan care so minimal time is spent in the room

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Use lead shield or lead apron Put up sign on the pts door Check linens & materials from the pt for foreign bodies that might be source of radioactivity Lead container & forceps in pts side For dislodged implants, pick up using forcep Observe time, distance, & shield precautions List on chart (type, time inserted, removal time, spec precaution) For systemic radionuclides may cause radioactive secretions Keep linens & trash in pts room til checked for radioactivity