very low doses to reach therapeutic levels, whereas oth- ers require very high doses. Pharmacogenetics is the study of how a person’s genes affect responses to med- ications. With scientific advances, genetic testing can now be used to determine responsiveness. In the case of warfarin, some patients are genetically fast metaboliz- ers, which can result in an increased risk of clotting and the need for higher or more frequent doses. In contrast, slow metabolizers have an increased risk of bleeding and require lower or less frequent doses. Patients who are fast or slow metabolizers may also respond similarly to other types of medications. Pharmacogenetic testing is not widely used due to availability, clinician knowledge, and regulatory and reimbursement issues, but it may be valuable. sants such as corticosteroids, azathioprine, cyclosporine, and methotrexate and immunotherapies such as immuno- globulin G (IgG) may be used but have limited supporting evidence. Complications Myocarditis is the most frequent cause of dilated cardio- myopathy. Heart failure, cardiogenic shock, and dysrhyth- mias, including sudden cardiac death, especially in young persons, are also complications. Nursing Management Assessment and Analysis Clinical manifestations of myocarditis, such as SOB, chest pain, fatigue, and dysrhythmias typical of the manifesta- tions of heart failure, are due to the weakened or damaged heart muscle. Nursing Diagnosis/Problem List l Risk for decreased cardiac output related to myocar- dial dysfunction l Pain l Dysrhythmias Nursing Interventions ■ Assessments l Vital signs Hypotension, hypertension, tachycardia, tachypnea, and hypoxia are signs of heart failure. Fever is indicative of infection. l Cardiac rhythm Dysrhythmias are a common and dangerous clinical manifes- tation and must be identified and treated promptly. l Assess for crackles, edema, jugular vein distention (JVD), weight gain, and decreased urine output. These are evidence of the weakened heart muscle seen with heart failure. ■ Actions l Administer antivirals, antimicrobials, immunosuppres- sives, and immunoglobulins as ordered. Medications are administered depending on the cause of myocarditis. l Administer heart failure medications as needed. Heart failure is a common manifestation and must be treated to optimize cardiac output and tissue perfusion. l Provide emotional support. The diagnosis of myocarditis can cause fear and anxiety. ■ Teaching l Complete the full medication treatment regimen. Patients should continue to take medications as directed even if feeling better to ensure an effective/positive result. l Avoid strenuous activities. Athletes should not par- ticipate in competitive sports while inflammation is present and need to be reevaluated in no less than 3 to 6 months before resuming sport. Activity restrictions may reduce the risk of sudden cardiac death. Nursing Diagnoses/Problem List 633
05/04/23 4:58 P Pathophysio The heart is su which protects structures, and sure. The toug dium; the inner The space betw pericardial flui friction betwee becomes inflam The primary go reducing the s diomyopathy a patient is free o able to tolerate PERICARDI Epidemiolog Pericarditis , i nosed in about and 5% of em pain not related pathic (unknow a viral infectio MI, occurring The true prev mine because p seek treatment more in male persons. Recur persons having categorized as sitic), noninfec trauma, drug o carditis can als rent. The prog mortality rate o Clinical Man The most com pleuritic chest and can be dif tends to be re and worsens w scratchy sound auscultated in assess for a fr include the foll l New or wors l ECG change depression (6 l Low-grade f
ers are also prescribed in ACS management. Treatment for nonobstructive CAD is being studied. Statins, angiotensin- converting enzyme (ACE) inhibitors, and beta blockers may be beneficial.
Safety Alert
Medication Safety Alert: Nitroglycerin
Nitroglycerin is a treatment for angina. Patients should be instructed to take this medication as prescribed, typically one tablet or spray under the tongue not to exceed three doses taken 5 minutes apart. If the symptom of angina (chest pain) is not relieved with three doses or if the pain worsens, they should be instructed to call emergency personnel. In addition, patients using medications such as sildenafil citrate (i.e., Revatio, Viagra) should be educated on the increased risk of hypotension with coadministration with nitroglycerin.
A more invasive surgical treatment is coronary artery bypass grafting (CABG) . With CABG, blockages in coronary arteries are bypassed using other arteries from the chest or arm or veins from the legs. In the traditional CABG, patients undergo general anesthesia. A large inci- sion through the sternum is made, and a cardiopulmonary bypass (CPB) is begun through large catheters in the vena cava or right atrium and aorta. A CPB provides continuous
Safety Alerts focus on potential hazardous or high-risk issues. Percutaneous transluminal coronary angioplasty (PTCA) is the procedure most commonly performed to relieve symptoms caused by atherosclerotic changes in the coronary vessels. During this procedure, after the patient receives monitored anesthesia care (MAC), a catheter
Nursing Management provides clear and well-defined nursing care guidance to help you to understand the nurse’s role. Begin with scientific explanations for presenting clinical manifestations, then follow the nursing process to prioritize care. For easy reference, Nursing Interventions are formatted into Assessments , Actions , and Teaching categories with bulleted rationales that explain the ‘hows’ and ‘whys’ of treatment.
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Chapter 30 Coordinating Care for Patients With Cardiac Disorders
Table 30.2 Medications Used in the Treatment of Coronary Artery Disease
Medication Classification
Mechanism of Action
Exemplars
Nursing Implications
HMG-CoA reductase inhibitors (statins)
Atorvastatin (Lipitor) Simvastatin (Zocor)
Monitor: l Cholesterol levels l For side effects such as muscle pain, cramping, and weakness. Severe side effects include liver failure and rhabdomyolysis. Monitor: l Liver function l Urine output amount and color l Myoglobin levels Administered via subcutaneous injections every 2–4 weeks. An alternative for patents who cannot take statins. Teach self-administration technique. Monitor: l Cholesterol levels l For side effects such as back pain, cold/flu symptoms
Statins reduce cholesterol synthesis in the liver and increase clearance of LDL from the blood.
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(Statins)
Medication Tables outline the medications used in the treatment of disorders, detailing Medication Classification , Mechanism of Action , Exemplars , and Nursing Implications .
PCSK9 inhibitors
Evolocumab (Repatha)
Increase LDL breakdown by blocking the action of a protein that destroys receptor cells in the liver that aid in eliminating cholesterol
Uncorrected page proofs may vary upon publication.
Cholesterol absorption inhibitors
Inhibit the absorption of cholesterol through the small
Ezetimibe (Zetia)
Monitor:
Cholesterol levels
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