内科护理学英语考试资料CoronaryArteryDisease

1、Etiology and pathophysiology病因和病理生理病因和病理生理 nAtherosclerosis动脉粥样硬化动脉粥样硬化is the major cause of CAD. n It is characterized by a focal deposit of cholesterol胆固醇胆固醇 and lipids血脂血脂, primarily within the intimal wall of the artery. nThe concept of endothelial injury内皮损伤内皮损伤is central to current theories of

2、 atherogensis. nThe genesis of plague斑块斑块 formation is the result of complex interactions between the components of the blood and the elements forming the vascular wall. Etiology and pathophysiology病因和病理生理病因和病理生理 Development stages 发展过程发展过程 nCAD takes many years to develops. When it becomes symptoma

3、tic, the disease process is usually well advanced. nThe states of development in atherosclerosis are: Fatty streak脂肪条纹脂肪条纹 Raised fibrous plaque resulting from smooth muscle cell proliferation纤维斑块增加纤维斑块增加 Complicated lesion复杂病变复杂病变 Risk factors风险因素 Three most significant risks are: elevated serum li

4、pids血脂血脂, hypertension and cigarette smoking. Risk factors can be categorized as unmodifiable and modifiable Unmodifiable factors: nAge, gender and race nFamily history and heredity Modifiable major risk factors nElevated serum lipids血脂 nHypertension nSmoking nPhysical inactivity Modifiable minor ri

5、sk factors nObesity nDiabetes mellitus糖尿病 nStress and behavior patterns Health promotion and maintenance 健康促进和维护 nIdentification of high-risk nManagement of high-risk nPhysical fitness nHealth education nNutritional management nPharmacologic management Drugs that increase lipoprotein removal Drugs t

6、hat restrict lipoprotein production Clinical manifestation of CAD临床表现 There are three major clinical manifestation of CAD: n angina心绞痛心绞痛 n acute MI心肌梗死心肌梗死 n sudden cardiac death猝死猝死 Angina pectoris心绞痛 nMyocardial ischemia心肌缺血心肌缺血is expressed symptomatically as angina心绞痛心绞痛. More specifically, angi

7、na pectoris is transient短暂短暂 的的chest pain caused by myocardial ischemia心肌缺血心肌缺血. nAngina usually lasts for only a few minutes (3 to 5 minutes) and commonly subsides解除解除 when the precipitating factor (usually exertion) is relieved. Pathophysiology of Angina pectoris病理生理病理生理 nMyocardial ischemia devel

8、ops when the demand for myocardial oxygen exceeds the ability of the coronary arteries to supply it. nThe primary reason for insufficient flow is narrowing of coronary arteries by atherosclerosis. nFor ischemia as a result of atherosclerosis to occur, the artery is usually 75% or more stenosed狭窄狭窄.

9、Pathophysiology of Angina pectoris病理生理病理生理 nWith the total occlusion of the coronary arteries, contractility ceases after several minutes, depriving the myocardial cells of glucose葡萄糖for aerobic metabolism有氧代谢. nAnaerobic metabolism无氧代谢 begins and lactic acid乳酸accumulates. nMyocardial nerves fibers

10、are irritated by the increased lactic acid and transmit a pain message to the cardiac nerves and upper thoracic posterior roots上部胸椎神经后根(the reason for referred cardiac pain to the left shoulder and arm). Precipitating factors激发因素 Extracardiac factors my precipitate myocardial ischemia and anginal pa

11、in including: nPhysical exertion nStrong emotion nConsumption of a heavy meal nTemperature extremes nCigarette smoking nSexual activity nStimulants nCircadian rhythm patterns 昼夜节律模式 Types of angina 1.Stable angina稳定型心绞痛稳定型心绞痛 nStable angina (classic) refers to chest pain occurring intermittently间歇性间

12、歇性over a long period with the same pattern of onset, duration, and intensity of symptoms. nStable angina is usually exercise induced. Pain at rest is unusual. nAn ECG usually reveals ST segment depression ST段压低，段压低， indicating subendocardial ischemia. nStable angina can be controlled with medication

13、s on an outpatient basis. Medication can be timed to provided peak effects during the time of day when angina is liking to occur. Types of angina 2. Unstable angina不稳定型心绞痛不稳定型心绞痛 nUnstable angina (progressive进展的进展的, cresendo渐强的渐强的, or preinfarction angina心肌心肌 梗死前心绞痛梗死前心绞痛) may be the first manifesta

14、tion of CAD. nThe patient with previously diagnosed stable angina will describe a significant change in the pattern of angina. It will be occurring with increasing frequency, easily provoked by minimal or no exercise, during sleep or even at total rest. Types of angina 3.Prinzmetals angina 变异型的心绞痛变异

15、型的心绞痛 nPrinzmetals angina (variant angina), is a rare form of angina, often occurs at rest, usually in response to spasm of a major coronary artery. nFactors precipitate coronary spasm includes increased myocardial oxygen demand and increased levels of a variety of substances (e.g., histamine组胺组胺, a

16、ngiotensin血管紧张素血管紧张素, epinephrine肾上腺素肾上腺素, norepinephrine去甲肾上腺素去甲肾上腺素, prostaglandins前列腺素前列腺素) nWhen spasm occurs, the patient experience pain and marked, transient ST segment elevation. nThe pain may occur during rapid eye movement (REM) sleep快快 速眼动睡眠速眼动睡眠 when myocardial oxygen consumption increas

17、es. Cyclical周期性的周期性的, short bursts of pain at a usual time each day may also occur with this type of angina. Clinical manifestation临床表现 nThe most common initial symptom is chest pain or discomfort. Patient may had a vague sensation, an unpleasant feeling, often described as a constrictive缩窄缩窄, squee

18、zing压缩压缩, heavy, choking, or suffocating sensation. nAlthough most of the person with angina experience discomfort substernally, the sensation may occur in the neck or radiate放射放射to various locations including jaw下巴下巴, shoulders and down the arms. Often people will complaint of pain between the shou

19、lder blades肩胛骨之间肩胛骨之间and dismiss it as not being heart pain. nAssociated symptoms may includes: shortness of breath, cool sweat, weakness, or paresthesia 感觉异常感觉异常 of the arm(s). nRelief of classic angina is usually obtained with rest or cessation of activity. Diagnostic studies辅助检查辅助检查 nChest X-ray

20、nSerum lipid nCardiac enzyme values nECG nNuclear imaging nAngiography nEchocardiography Emergency management chest pain 1.Establish and maintain airway 2.Administer oxygen by nasal cannula if not in respiratory distress; otherwise use high flow (100%) by nonbreather mask. Anticipate need for intuba

21、tion if respiratory distress evident 3.Start 2 IV lines with large-gauge needles 4.Remove clothing; comfort and reassure patient 5.Monitor cardiac rate and rhythm; monitor vital signs including level of consciousness 6.Be prepared to perform cardiopulmonary resuscitation心肺复苏, defirbillation电除颤, exte

22、rnal pacing or cardioversion外部起搏或 电复律 7.Assess severity and location of pain, medicate for pain as order 8.Assess for indications and contraindications for thrombolytic therapy 9.Prepare to initiate thrombolytic therapy溶栓治疗溶栓治疗if indicated Therapeutic management Pharmacologic management药理管理 nAntipla

23、telet aggregation therapy抗血小板聚集治疗: is the first line of pharmacologic intervention in the treatment of angina. Aspirin阿司匹林阿司匹林is the drug of choice. nNitrates硝酸盐: which are commonly classified as vasodilators, are the next step in the treatment of angina. Nitroglycerin硝酸甘油硝酸甘油: it is given sublingua

24、lly for acute angina attacks, usually relieve pain in approximately 3 minutes and has a duration of approximately 20 to 45 minutes. Nitrates produce their principle effects by the following: nDilating peripheral blood vessels nDilating coronary arteries and collateral侧支侧支vessels Pharmacologic manage

25、ment Nitrates硝酸盐硝酸盐 nThe usual recommended dose is 1 tablet taken sublingually (SL)舌下舌下, which can be followed at 5-minute intervals with two more doses. If relief from anginal pain has not been obtained after 3 tables and 15 minutes, the patient should be instructed to seek medical attention. nThe

26、predominant side effect of nitrate drugs is headache from the dilatation of cerebral blood vessels. nOther complications of the vasodilator drugs are orthostatic hypotension体位性低血压体位性低血压(nitrate syncope硝酸晕厥硝酸晕厥) and an aggravation of cerebral vascular insufficiency. Thus, monitor BP and pulse prior t

27、o long-acting nitrates administration (if BP is 30 mm Hg below baseline or 90 mm Hg, withhold medication and notify the doctors)。 Nitrates硝酸盐硝酸盐 nThe patient needs to be instructed in the proper use of sublingual nitroglycerin 1.It should be easily accessible to the patient at all time. 2.For protec

28、tion from degradation退化, it should be kept in a tightly closed dark glass bottle with metal caps. 3.The patient should be instructed to place a nitroglycerin table beneath the tongue and allow it to dissolve. This should cause a fizzing or slightly warm feeling locally. 4.The patient should be warne

29、d that HR may increase and a pounding headache, dizziness头晕, or flushing脸红may occur. 5.The patient should be cautioned against quickly rising to a standing position because postural hypotension may occur after nitroglycerin ingestion. 6.if the pain has not been relieved after 5 minutes, the patient

30、should be told to take another nitroglycerin tablet. This procedure may be repeated for pain relief every 5 minutes, not to exceed the ingestion of 3 tablets. If pain persist after three doses, the patient should seek immediate medical treatment. Therapeutic management Pharmacologic management n-adr

31、energic blocking agents: propranolol普奈洛 尔, metoprolol美托洛尔, nadolol钠多洛而, atenolol 阿替洛尔. nThese drugs produce a direct decrease in myocardial contractility, HR, SVR and BP, all of which reduce the myocardial oxygen demand. nSide effect of these drugs includes brachycardia心 动过缓, hypotension, wheezing a

32、nd GI complaints, weight gain, depression and sexual dysfunction. nThe -adrenergic blockers should not be discontinued abruptly without medical supervision . Pharmacologic management nCalcium-channel blocking agents: nifedipine硝本地平硝本地平, verapimil维拉帕米维拉帕米, diltiazem地尔硫卓地尔硫卓 and nicardipine 尼卡地平尼卡地平 a

33、re the next step in the management of angina. nThe three primary effects of these drugs are: Systemic vascular vasodilatation with decreased SVR Decreased myocardial contractility Calcium-channel blockers nCalcium-channel blockers have a depressant effect on the sinoatrial (SA) node窦房结rate of discha

34、rge and the conduction velocity传导速度through AV node房室结is decreased, thus slowing the HR. Calcium-channel blocking agents地高辛potentiate the action of digoxin地高辛by increasing serum digoxin levels during the early part (first week) of therapy. Therefore serum digoxin levels should be closely monitored up

35、on institution of this therapy, and the patient should be taught the signs and symptoms of digoxin toxicity洋地黄中毒. Nursing diagnosis护理诊断 nPain related to ischemia myocardium nAnxiety related to diagnosis and awareness of being a vitim of heart disease, pain and limited activity tolerance, uncertainti

36、es about the future, diagnostic tests, pending surgery nDecreased CO related to myocardial ischemia affecting contractility nActivity intolerance related to myocardial ischemia Acute intervention 1.Establish and maintain airway 2.Administer oxygen by nasal cannula if not in respiratory distress; oth

37、erwise use high flow (100%) by nonbreather mask. Anticipate need for intubation if respiratory distress evident 3.Start 2 IV lines with large-gauge needles 4.Remove clothing; comfort and reassure patient 5.Monitor cardiac rate and rhythm; monitor vital signs including level of consciousness 6.Be pre

38、pared to perform cardiopulmonary resuscitation心肺复苏, defirbillation电除颤, external pacing or cardioversion外部起搏或 电复律 7.Assess severity and location of pain, medicate for pain as order 8.Assess for indications and contraindications for thrombolytic therapy 9.Prepare to initiate thrombolytic therapy溶栓治疗溶栓

39、治疗if indicated Chronic and home management nThe patient needs to be reassured that a long, productive life is possible. nThe patient needs to be educated regarding CAD and angina, precipitating factors, risk factors, and medication. nEducating the patient and the family about diets that are low in s

40、odium and reduced in saturated fat may be appropriated. nIts important to educate the patient and their family in the use of nitroglycerin. Nitroglycerin硝酸甘油片硝酸甘油片tablets or ointments may be used prophylactically预防预防before an emotionally stressful situation, sexual intercourse or physical exertion.

41、Angina pectoris心绞痛 nMyocardial ischemia心肌缺血心肌缺血is expressed symptomatically as angina心绞痛心绞痛. More specifically, angina pectoris is transient短暂短暂 的的chest pain caused by myocardial ischemia心肌缺血心肌缺血. nAngina usually lasts for only a few minutes (3 to 5 minutes) and commonly subsides解除解除 when the precipitating factor (usually exertion) is relieved. Types of angina 2. Unstable angina不稳定型心绞痛不稳定型心绞痛 nUnstable angina (progressive进展的进展的, cresendo渐强的渐强的, or preinfarcti