Chapter 24 Nursing Care of Patients with Occlusive Cardiovascular Disorders

Answers CHAPTER 24 NURSING CARE OF PATIENTS WITH OCCLUSIVE CARDIOVASCULAR DISORDERS AUDIO CASE STUDY Kathy: Angina and Myocardial Infarction 1. Nitroglycerin dilates the arteries in the heart so more blood and oxygen can get to the heart muscle. It also dilates other arteries, so the heart doesn’t have to work so hard to pump blood to them. 2. If the pain is easing but not completely gone, take one nitroglycerin tablet every 5 minutes; take up to 3 tablets. If having pain and symptoms of a heart attack, take one tablet and, if after 5 minutes the pain remains unrelieved, call 911. Do not drive to the hospital so that paramedics can start treatment immediately upon their arrival. 3. Shortness of breath, pain in jaw, indigestion, tired, feeling of heaviness, feeling scared as though something very bad is happening. 4. Emergency percutaneous coronary intervention that includes a balloon angioplasty with stent placement in the cardiac catheterization lab. VOCABULARY 1. (4) 2. (9) 3. (13) 4. (10) 5. (18) 6. (16) 7. (12) 8. (2) 9. (5) 10. (7) 11. (3) 12. (1) 13. (8) 14. (11) 15. (14) 16. (19) 17. (15) 18. (17) 19. (20) 20. (6) ATHEROSCLEROSIS 1. A fatty streak appears on the lining of an artery. This buildup of fatty deposits is known as plaque. Plaque has irregular, jagged edges that allow blood cells and other material to adhere to the wall of the artery. With time, this buildup can cause stenosis of the vessel, which leads to partial or total occlusion of the artery. When this occurs, the area distal to it can become ischemic due to lack of blood flow. This buildup will become calcified and harden, leading to damage of the vessel with loss of elasticity and compliance. 2. Cigarette smoking, hypertension, elevated serum cholesterol, diabetes mellitus, obesity, stress, and sedentary lifestyle. 3. Determine readiness to learn. Example for smoking: Explain what occurs when one smokes, including changes to vessels and effect on blood flow. Determine when patient craves cigarettes most, and teach patient to try a different activity to distract from smoking. Teach patient to avoid caffeine products (e.g., chocolate, cocoa, and caffeinated carbonated drinks). Avoid stimulants. Increase fluid intake, especially during the first 3 days of quitting smoking; this will help wash nicotine out of the system. MYOCARDIAL INFARCTION Corrections are in boldface. Myocardial infarction (MI) is the death of a portion of the heart muscle caused by a blockage or spasm of a coronary artery. When the patient has an MI, the affected part of the muscle becomes damaged and no longer functions properly. Ischemic injury takes several hours before complete necrosis and infarction take place. The ischemic process affects the subendocardial layer, which is the most sensitive to hypoxia. Myocardial contractility is depressed, so the body attempts to compensate by triggering the autonomic nervous system. This causes an increase in myocardial oxygen demand, which further depresses the myocardium. After necrosis, the contractility function of the muscle is permanently lost. If treatment is initiated at the first sign of an MI, the area of damage can be minimized. If prolonged ischemia occurs, the size of the infarction can be large. 1 2 Chapter 24 Answers The area that is affected by an MI depends on which coronary artery is involved. The left anterior descending branch of the left main coronary artery is the area that feeds the anterior wall. The right coronary artery (RCA) feeds the inferior wall and parts of the atrioventricular node and the sinoatrial node. An occlusion of the RCA leads to an inferior MI and to abnormalities of impulse conduction and formation. The left circumflex coronary artery feeds the lateral wall and part of the posterior wall of the heart. Pain is often the most common symptom. The pain may radiate to one or both arms and shoulders, the neck, and the jaw. The patient usually denies that an MI is occurring. Other symptoms may include restlessness; a feeling of impending doom; nausea; diaphoresis; and cold, clammy, ashen skin. The only symptom that might be present in the older adult may be a sudden onset of shortness of breath. Women may have atypical symptoms of an MI. The three strong indicators of an MI are patient history, abnormal electrocardiographic readings, and troponin I levels. Initially, patients are kept on bedrest to decrease myocardial oxygen demand. Patients are medicated promptly when experiencing chest pain. Morphine sulfate is the most widely used narcotic for MI. It helps decrease anxiety, slows respirations, and vasodilates the coronary arteries. Oxygen is given usually at 2 L/min via nasal cannula. Nitroglycerin sublingual, topical, or by intravenous (IV) drip can also be administered. Percutaneous coronary intervention is a frequent treatment option for an occluded coronary artery. A nursing care plan should include factors that may contribute to increased cardiac workload. Patient and family teaching topics include diet, stress reduction, exercise, smoking cessation, and medications. 3. When activity stops, the muscle does not have increased oxygen demand, so the pain begins to subside with rest. 4. Smoking contributes to loss of high-density lipoproteins, which is the best type of cholesterol to have in order to decrease the risk of cardiovascular disorders. The rate of progressive damage to vessels increases with smoking. Smoking also contributes to vasoconstriction, which reduces blood delivery to muscles and can also lead to angina and cardiac arrhythmias. PHARMACOLOGICAL TREATMENT 6. (4) is correct. An exercise stress electrocardiogram demonstrates the extent to which the heart tolerates and responds to the additional demands placed on it during exercise. The heart’s ability to continue adapting is related to the adequacy of blood supplied to the myocardium through the coronary arteries. If the patient develops chest pain, dangerous cardiac rhythm changes, or significantly elevated blood pressure, the diagnostic testing is stopped. (1, 2, 3) are incorrect. 7. (4) is correct. When a patient is apprehensive and afraid, the nurse should listen and encourage patient expression of feelings. This can ease the mental burden and help the patient feel less overwhelmed, alone, and helpless. Listening is an active process even if the patient does most of the talking. (1) is incorrect. Learning is impaired during times of anxiety. (2) is incorrect. Avoiding the subject may indicate to the patient that the nurse does not care. (3) is incorrect. How others have done ignores the fact that, for this person, the experience is unique. 8. (1) is correct. If nitroglycerin tablets are fresh, the patient should feel a tingling or fizzing in the mouth. Tablets usually need to be replaced about every 3 months. (2, 4) are incorrect. Nitroglycerin tablets do not disintegrate or 1. (8) 2. (3) 3. (1) 4. (7) 5. (2) 6. (6) 7. (10) 8. (5) 9. (4) 10. (9) CRITICAL THINKING 1. (1) is correct. Patient Outcome: Patient will exhibit signs of increased arterial blood flow and tissue perfusion. 2. Intermittent claudication is associated with arterial occlusive disease. This is pain in the calves of the lower extremities that occurs with activity or exercise. When there is poor blood supply to the muscles, they are unable to receive increased oxygen to meet the demand of increased activity. Ischemia results. As ischemia increases, a cramping-type pain develops. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (1, 3, 4, 2, 6, 5) is the correct order. 2. (4) is correct. These symptoms are classic signs of pulmonary edema. (1, 2, 3) are incorrect. Respiratory distress may be observed with any respiratory disorder, but the frothy sputum is symptomatic of pulmonary edema. 3. (1, 3, 4) are all symptomatic of atherosclerosis and decreased circulation. (2) is incorrect. Capillary refill is normally less than 3 seconds. (5) is incorrect. Stasis ulcer is a sign of a venous problem. 4. (1, 2, 5, 6) are recommended to reduce cholesterol. (3, 4) are incorrect. They do not help reduce cholesterol. 5. (3) is correct. Lack of sufficient oxygen to the myocardium is the cause of chest pain. (1) causes wasting of heart muscle. (2) causes arrhythmias. (4) will not cause chest pain unless oxygen supply is insufficient to meet the workload. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. Chapter 24 change color when old. (3) is incorrect. Aspirin smells like vinegar when it becomes old. 9. (2) is correct. Fresh vegetables without added salt are low in sodium. (1, 3, 4) are high in sodium. 10. (1, 4, 5) are correct. Hypertension and diabetes mellitus can be controlled with proper diet, exercise, and medications. Smoking can be stopped. (2, 3) cannot be changed. 11. (3, 5, 6) are correct. Saturated fats come primarily from animal and dairy products and some plants, including the “tropical oils” (e.g., palm oil and coconut oil). (1, 2, 4) are incorrect. Avocado, tuna, and olive oil have polyunsaturated fats. See the American Heart Association website. 12. (1, 2, 4) are all found with venous insufficiency. (3) is incorrect because edema (moderate to severe) is a manifestation of venous insufficiency. (5) is incorrect. Hyperemia is an intense reddening of the hands that occurs with warming after exposure to cold in those with arterial spasm/Raynaud disease. 13. (2, 3, 6) are correct. Pain is the primary symptom; cramping is also a feature to a lesser extent; intermittent claudication and other symptoms of occlusive disease are common. (1, 4, 5) are incorrect. Numbness, swelling, and bounding pulses are not characteristic. 14. (2) is correct. (1, 3, 4) are not descriptive of Raynaud disease. Answers 15. (1) is correct. Vasoconstriction must be avoided with Buerger disease. (2, 3, 4) are not related to Buerger disease. 16. Femoral and radial sites are most commonly used for a cardiac catheterization. Jugular and brachial sites can also be considered by the HCP. 3