SEGUNDA SESIÓN DEL CONSEJO ESCOLAR DE PARTICIPACIÓN
ACCIONES PARA CUMPLIR LOS COMPROMISOS (cite por lo menos dos
Psychosocial aspects of care, page 749
Client Assessment Database
A
CTIVITY/R
EST•Sedentary lifestyle
•Weakness, feeling incapacitated after exercise
•Fatigue
•Activities and sleep disrupted by pain
C
IRCULATION•History of heart disease, hypertension in self or family
E
GOI
NTEGRITY•Stressors of work, family, others, and financial concerns
F
OOD/F
LUID•Nausea, “heartburn,” or epigastric distress with eating, bloat-
ing, gas
•Diet high in cholesterol and fats, salt, caffeine, liquor
•Exertional dyspnea
•Tachycardia, dysrhythmias
•Blood pressure (BP) normal, elevated, or decreased
• Heart sounds:May be normal, late S4or transient late systolic
murmur—suggesting papillary muscle dysfunction—that may be evident during pain
•Moist, cool, pale skin, mucous membranes in presence of
vasoconstriction
•Orthostatic blood pressure changes
•Apprehension, uneasiness
•Belching, gastric distention
D I A G N O S T I C D I V I S I O N
M AY R E P O R T
M AY E X H I B I T
Client Assessment Database
(continued)N
EUROSENSORY•History of dizziness, fainting spells, transient numbness,
tingling in extremities (ischemia anywhere in the body can produce transient neurological symptoms)
P
AINNote: Reports of pain location and severity differ between men
and women.
•Substernal or anterior chest pain that may radiate to jaw,
neck, shoulders, and upper extremities, often to left side more than right. Women may report pain between shoulder blades, back pain.
• Quality:Varies from transient and mild to moderate, heavy pressure, tightness, squeezing, burning. Women may report dull aching pain.
• Duration:Usually less than 15 minutes, rarely more than 30 minutes (average of 3 minutes).
• Precipitating factors:Physical exertion or great emotion, such as anger or sexual arousal; exercise in weather extremes; or may be unpredictable or occur during rest or sleep in unstable angina • Relieving factors:Pain may be responsive to particular relief
mechanisms, such as rest and anti-anginal medications. Women may not respond to these.
•New or ongoing chest pain that has changed in frequency,
duration, character, or predictability, especially unstable, variant, or Prinzmetal’s type.
R
ESPIRATION•Dyspnea associated with activity or rest
•Cough with or without sputum
•Smoking history
S
AFETY•History of falls, fainting spells, or light-headedness with
change of positions
S
EXUALITY•History of erectile dysfunction (ED), decreased libido
•Chest pain during sex
T
EACHING/L
EARNING•Family history or risk factors of CAD; obesity, sedentary
lifestyle, HTN, stroke, diabetes, smoking, hyperlipidemia
•Use or misuse of cardiac, antihypertensive, and over-
the-counter (OTC) drugs
•History of hormone replacement therapy (HRT) in
postmenopausal women
•Use of vitamins or herbal supplements, such as niacin, coen-
zyme Q10, ginger, bilberry, comfrey, garlic, or L-carnitine
•Use or misuse of alcohol or illicit drug use, such as cocaine
or amphetamines
D
ISCHARGEP
LANC
ONSIDERATIONS•Assistance with homemaker or maintenance tasks
•Changes in physical layout of home
➧Refer to section at end of plan for postdischarge considerations.
•Facial grimacing, restlessness
•Placing fist over midsternum
•Rubbing left arm, muscle tension
•Autonomic responses, for example tachycardia, blood pressure
changes
•Increased rate and rhythm, alteration in depth
D I A G N O S T I C D I V I S I O N
CHAPTER 4 CARDIO V ASCULAR—ANGIN A
T E S T
W H Y I T I S D O N E
W H AT I T T E L L S M E
Diagnostic Studies
B
LOODT
ESTS• Cardiac enzymes, including troponin I and cardiac troponin
T, CPK, CK and CK-MB, LDH and isoenzymes LD1, LD2:
Substances released from heart muscle when it is damaged. • Serum lipids, including total lipids, lipoprotein elec-
trophoresis, isoenzymes, cholesterols (HDL, LDL, very low density lipoprotein [VLDL]), triglycerides, phospholipids: A group of tests that make up a lipid profile. • Homocysteine:Amino acid that plays an important role in
blood clotting.
• C-reactive protein (CRP):A marker for inflammation.
• Hemoglobin (Hgb) and hematocrit (Hct):Hgb measures the amount of oxygen-carrying capacity of the red blood cells (RBCs), and the Hct level looks at the relative proportion of RBCs and plasma.
• Coagulation studies, including partial thromboplastin time
(PTT), activated partial thromboplastin time (aPPT), and platelets:Injury to a vessel wall or the tissue initiates the coagulation cascade and formation of a thrombus. • PCO2, potassium, and myocardial lactate:Markers for
metabolic acidity.
O
THERD
IAGNOSTICS
TUDIES• Electrocardiogram (ECG):Record of the electrical activity of the heart to detect dysrhythmias, to identify electrolyte imbalance, to identify any myocardial ischemia present or any damage to myocardial tissue from the past.
• Exercise or pharmacological stress electrocardiography
(also called stress test, exercise treadmill, or exercise ECG):
Raises heart rate and blood pressure by means of exercise. Heart can also be stressed with drugs such as dobutamine or persantine.
• 24-hour ECG monitoring (Holter):Ambulatory ECG recording.
• Echocardiography (also called two-dimensional echocardio-
gram and Doppler ultrasound):Evaluates the left ventricle, including size, valvular function, wall thickness, and pumping action as measured by the EF. May be done at rest or during exercise.
• Coronary magnetic resonance (CMR) scan:Test that uses magnetic fields to produce two- or three-dimensional images of the heart.
• Myocardial perfusion imaging (MPI) scans, which may
include stress MPI and single-photon emission computed tomography (SPECT): Scans the heart using radioactive dyes to show areas of increased metabolic activity and decreased blood flow.
Usually within normal limits. Any elevation indicates myocardial damage.
The presence of lipid abnormalities can increase the risk of CAD.
An elevated level results in increased platelet aggregation. A positive test indicates a potentially increased risk for cardiovascular disease (CVD).
CRP levels have been shown to predict risk of both recurrent ischemia and death among those with stable and unstable angina (Ridker, 2003).
Low Hgb and Hct levels can aggravate angina because of potential for ischemia.
Thrombus formation can potentiate ischemic damage to the myocardium as blood flow is blocked.
May be elevated during anginal attack (all play a role in myocardial ischemia and may perpetuate it).
Often normal when client at rest or when pain-free; depression of the ST segment or T-wave inversion signifies ischemia. Dysrhythmias and heart block may also be present. Significant Q waves are consistent with a prior MI. ST depression without pain is highly indicative of ischemia.
Useful in screening for CAD, evaluating myocardial perfusion, dif- ferentiating between ischemia and scar area of the myocardium, developing a cardiac rehabilitation program, evaluating cardiac status for work capability, and evaluating drug efficacy. Provides other diagnostic information, such as duration and level of activity attained before onset of angina. A markedly positive test is indicative of severe CAD.
Can determine whether pain episodes correlate with or change during exercise or activity.
Detects changes in heart wall motion that occur during myocar- dial ischemia. Normal myocardium becomes hyperdynamic during exercise; ischemic segments become hypokinetic or akinetic. Helps diagnose cardiomyopathy, heart failure (HF), pericarditis, and abnormal valvular action that might be cause of chest pain.
Assesses cardiac chamber volumes and function, as well as muscle mass and is particularly valuable for distinguishing ischemic from nonischemic cardiomyopathy.
MPI is the most widely used imaging test for the evaluation of suspected myocardial ischemia. SPECT is capable of assessing cardiovascular risk with a high degree of accuracy, measuring both ventricular function and relative regional perfusion at rest and with stress.
T E S T
W H Y I T I S D O N E
(continued)W H AT I T T E L L S M E
(continued)Diagnostic Studies
(continued)• Calcium scoring (also called coronary artery calcium scor-
ing computed tomography, or CT, scan):Ultrafast CT scan that measures the amount of calcium in the coronary arteries. • Coronary computed tomography angiography (CTA):
High-resolution, three-dimensional pictures of the moving heart and great vessels.
• Cardiac catheterization with angiography:Assesses patency of coronary arteries, reveals abnormal heart and valve size or shape, and evaluates ventricular contractility. Pressures can be measured within each chamber of the heart and across the valves.
• Chest x-ray:Visualize any infiltrates that may be present in the lung.
Elevated calcium scoring in client with other risk factors, such as family history, hypertension, diabetes, or hypercholesterolemia, is an indication of some level of CAD.
Defines the presence and extent of coronary artery luminal narrowing.
Definitive test for CAD in clients with known ischemic disease with angina or incapacitating chest pain, in clients with choles- terolemia and familial heart disease who are experiencing chest pain, and in clients with abnormal resting ECGs. Abnormal results are present in valvular disease, altered contractility, ven- tricular failure, and circulatory abnormalities. Note: Ten percent of clients with unstable angina have normal-appearing coronary arteries.
Any changes from normal may indicate pulmonary complications or decompensation of cardiac status such as congestive heart failure (CHF).