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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders
Complications The primary complication of CAD is ACS, which includes unstable angina and MI. Myocardial infarction is discussed in detail in Chapter 32. Coronary artery disease may also result in dysrhythmias and heart failure. Women and other vulnerable populations, such as persons from rural areas, persons with low socioeconomic status, and persons from underserved areas, have higher rates of adverse outcomes from CAD in general. These outcome differences have been attributed to healthcare provider biases such as gen- der and race, limited access to healthcare facilities and resources, delays in seeking care, limits in the diagnosis and treatment of nonobstructive CAD, and increased risks related to social determinants of health. Connection Check 30.1 After a percutaneous coronary angioplasty, what assess- ment should most concern the nurse? A. Back discomfort B. Chest pain C. Capillary refill of less than 3 seconds D. Hypoactive bowel sounds Careful assessment of chest pain and other manifestations of CAD is required to identify those patients with CAD and those patients who have stable angina that may be progress- ing to ACS. The clinical manifestations of CAD are the result of the imbalance of oxygen supply and demand to the myocardial tissue. The most common symptom is chest pain. Other, more nonspecific, symptoms include the following: z Epigastric discomfort z Nausea and vomiting z Diaphoresis z Syncope z Shortness of breath (SOB) z Pain between shoulders/jawline z Change in mental status and unexplained falls in older adults Nursing Diagnoses/Problem List z Decreased tissue perfusion related to decreased cardiac output due to inadequate coronary blood flow z Pain z Fatigue Nursing Interventions ■ Assessments z Vital signs Nursing Management Assessment and Analysis Tachycardia and tachypnea can be manifestations of cardiac ischemia compensating for decreased cardiac output. Hyper- tension is a CAD risk factor. Nitroglycerin and morphine administration, as well as continuing evolving of a cardiac event, can result in hypotension. Oxygen saturation less than 93% is an indication for supplemental oxygen.
z Pain assessment utilizing provoking factors, quality, region/radiation, severity, time (PQRST) Angina can be nonspecific in some patients; establishing loca- tion and quality can aid in the diagnosis of cardiac chest pain and disease progression. Headache can result from nitroglyc- erin administration. z Electrocardiogram and continuous cardiac monitoring Depressed ST segment or flat or inverted T waves are indic- ative of ischemia; ST elevations are indicative of acute injury. Cardiac dysrhythmias may result from ischemia or infarction. z Physical assessment Pallor, clamminess, nausea, vomiting, shortness of breath, and diaphoresis may indicate cardiac ischemia. Xanthomas, raised, waxy, yellowish skin discolorations, are associated with hypercholesterolemia. z Patient history Evaluate CAD risk factors and anginal patterns. Fatigue and weakness may be indicative of CAD. Identify potential noncardiac causes of chest pain, such as gastroesophageal reflux or respiratory disorders. z Recreational drug use Illicit drug use (i.e., cocaine) can cause vasospasm, obstruct- ing blood flow and causing symptoms that resemble CAD. z Depression screening Depression may increase morbidity and mortality. z Laboratory values • Cardiac biomarkers: troponin Troponin levels (a protein released into the bloodstream when there is cardiac muscle damage) rise when the heart sustains an acute injury. Troponin can help differentiate between angina and MI pain. • Creatinine, blood urea nitrogen Assess renal function. The contrast dye used during heart catheterization is nephrotoxic. • Glycosylated hemoglobin (HgbA1c) Hyperglycemia occurs with diabetes and is a risk factor for CAD. • Lipid profiles: cholesterol, triglycerides, LDL, HDL Assess for hyperlipidemia, a risk factor for CAD development. ■ Actions z Administer oxygen to patients with oxygen saturations less than 93%. Supplemental oxygen optimizes oxygen delivery to the myo- cardium. Cardiac dysrhythmias, especially tachycardia, and anxiety increase myocardial oxygen consumption. Oxygen administration to patients with saturations higher than 93% may contribute to poor outcomes. z Obtain ECG with the occurrence of chest pain. Evaluates new anginal episode for evidence of ischemia or injury. In cases of acute chest pain, an ECG within 10 minutes is recommended. z Administer nitroglycerin as ordered. Dilates the coronary arteries to improve flow to the heart and relieve pain z Administer aspirin as ordered. Prevents platelet aggregation
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