nursing care of client with coronary artery disease part 2 of 2

NURSING CARE OF CLIENT WITH

ACUTE CORONARY SYNDROME

NURSING DIAGNOSES AND COLLABORATIVE NURSING DIAGNOSES AND COLLABORATIVE NURSING DIAGNOSES AND COLLABORATIVE NURSING DIAGNOSES AND COLLABORATIVE INTERVENTIONSINTERVENTIONS

Maria Carmela L. Domocmat, RN, MSN

Instructor

School of Nursing

Northern Luzon Adventist College

Common Nursing Diagnoses and Common Nursing Diagnoses and Collaborative InterventionsCollaborative Interventions

8/9/2012CLDomocmat 2

Management

8/9/2012Maria Carmela L.Domocmat, RN, MSN 3

� Door to needle time

� Door to balloon time


Goals of care

1. Treat the acute attack immediately

2. Determine location of myocardial infarction

3. Monitor for complications

8/9/2012 5Maria Carmela L.Domocmat, RN, MSN

� cells in ischemic area – are salvageable if

reperfusion therapies and inotropic support is

promptly instituted (Schumacher &

Chernecky, 2006)Chernecky, 2006)

� within 10 min of arrival of suspected AMI –

ingest aspirin and obtain baseline cardiac

serum markers, 12-lead ECG


� Medical management� Reduce risk factors� Restore blood supply � Percutaneous transluminal coronary angioplasty � Directional coronary atherectomy � Laser ablation� Transmyocardial revascularization

� Nursing management� Reduce risk factors

Restore blood supply � Restore blood supply

� Surgical management� Cardiac surgery� Open heart surgery � Coronary artery bypass graft

� Nursing management � before cardiac surgery � Phase I (In-hospital) Rehabilitation Programs� self-care� Phase 2 (Outpatient Exercise Training) Rehabilitation Programs� Phase 2 (Community) Rehabilitation Programs� Home exercise Rehabilitation Programs

�


Medical mgmt

� first-line and initial treatment (Schumacher & Chernecky, 2006; Smetzer, 2010)

� Semi folwer’s position

� O2 (2-4 lpm)

� IV access � IV access

� obtain 12-lead EKG

� VS and pulse oximetry

� labs (serum cardiac markers)

� ECG monitoring

� conduct hx and PE

� reduce pain

� administer meds


Medical mgmt

� first-line and initial treatment cont.

� admit to CCU

� invasive line placement (arterial line, pulmo artery cath)

- to provide further data to monitor ventricular dysfunctiondysfunction

� IABP – intraaortic balloon pump

� for severe L ventricular dysfunction

� to assist ventricular ejection and promote CA perfusion

� anticipate emergency PTCA or CABG

� reperfusion procedures

� if thrombolytics are either CI or unsuccessful


Nursing mgmt: Goals

� Recognize and treat cardiac ischemia

� Admin thrombolytic therapy as ordered, or

ready client for PTCA and observe for

complications complications

� Recognize and treat potentially life-

threatening dysrhythmias


Nursing mgmt: Goals

� Monitor for complications of reduced CO

� Maintain a therapeutic critical care envt

� Identify the psychosocial impact of AMI on

client and familyclient and family

� Educate the client in lifestyle changes and

rehabilitation


Nursing DiagnosesNursing Diagnoses

�� Acute PainAcute Pain

�� Ineffective Tissue perfusion (Cardiopulmonary)Ineffective Tissue perfusion (Cardiopulmonary)

�� Activity IntoleranceActivity Intolerance

�� Ineffective CopingIneffective Coping

�� Potential or dysrhythmiasPotential or dysrhythmias

�� Potential for heart failurePotential for heart failure

�� Potential for recurrent symptoms and extension Potential for recurrent symptoms and extension of injury of injury


related to imbalance between myocardial related to imbalance between myocardial oxygen supply and demandoxygen supply and demand

Acute Pain Acute Pain


Acute Pain Acute Pain

1.1. Obtain description of chest discomfortObtain description of chest discomfort

2.2. Vital signs and cardiac monitoringVital signs and cardiac monitoring

3.3. Check vascular accessCheck vascular access3.3. Check vascular accessCheck vascular access

4.4. Place in semi fowler’s positionPlace in semi fowler’s position

5.5. 12 lead ECG12 lead ECG

6.6. O2 inhalation O2 inhalation


7. Provide pain meds and aspirin7. Provide pain meds and aspirin

a. Nitroglycerine a. Nitroglycerine –– increases collateral blood flow, increases collateral blood flow, redistributes blood flow toward the redistributes blood flow toward the subendocardiumsubendocardium and and causes dilation of the coronary arteriescauses dilation of the coronary arteries

b. Morphine sulfate b. Morphine sulfate –– relieves MI pain, decreases relieves MI pain, decreases b. Morphine sulfate b. Morphine sulfate –– relieves MI pain, decreases relieves MI pain, decreases sympathetic stimulation which decreases O2 sympathetic stimulation which decreases O2 demand and reduces circulating demand and reduces circulating catecholaminescatecholamines

8. Assess the client’s VS and intensity of pain 8. Assess the client’s VS and intensity of pain 5 5 minutes after administration of medsminutes after administration of meds

9. Notify physician 9. Notify physician if patients condition deterioratesif patients condition deteriorates


CLDomocmat 8/9/2012 16

Let’s reviewLet’s review


Let’s review: Acute Pain Let’s review: Acute Pain

1.1. Obtain description of chest discomfortObtain description of chest discomfort

2.2. Vital signs and cardiac monitoringVital signs and cardiac monitoring

3.3. Check vascular accessCheck vascular access

4.4. Place in semi fowler’s positionPlace in semi fowler’s position4.4. Place in semi fowler’s positionPlace in semi fowler’s position

5.5. 12 lead ECG12 lead ECG

6.6. O2 inhalation O2 inhalation

7.7. Provide pain meds and aspirinProvide pain meds and aspirin

8.8. Assess the client’s VS and intensity of pain Assess the client’s VS and intensity of pain 5 5 minutes after administration of medsminutes after administration of meds

9.9. Notify physician if patients condition deterioratesNotify physician if patients condition deteriorates


Ineffective Tissue perfusion Ineffective Tissue perfusion

�� (Cardiopulmonary) related to (Cardiopulmonary) related to interruption of blood flowinterruption of blood flow

•• goal : goal : to to restore perfusionrestore perfusion to the injured area to the injured area to to reduce the size of the infarctreduce the size of the infarct and improve and improve to to reduce the size of the infarctreduce the size of the infarct and improve and improve left ventricular functionleft ventricular function


Ineffective Tissue perfusion (Cardiopulmonary)

related to interruption of blood flow



Ineffective Tissue perfusionIneffective Tissue perfusion

1. Thrombolytic therapy1. Thrombolytic therapy

2. Glycoprotein IIB/IIIA Inhibitors2. Glycoprotein IIB/IIIA Inhibitors

3. 3. Antiplatelets

� Aspirin � Aspirin

� Clopidogrel

4. Beta blockers

5. ACE Inhibitors




-- Tissue Tissue plasminogenplasminogen activator, activator, streptokinase, streptokinase, reteplasereteplase

-- Indicated for patients who have Indicated for patients who have chest pain chest pain of greater than 30 minutes, unrelieved by of greater than 30 minutes, unrelieved by nitroglycerin and nitroglycerin and transmuraltransmural MI (Q wave MI (Q wave MI)MI)


Thrombolytic therapyThrombolytic therapy

�� dissolves thrombus and promote dissolves thrombus and promote reperfusionreperfusion

�� the golden period is the golden period is 30 minutes30 minutes from from “door to needle” or from onset of pain till “door to needle” or from onset of pain till “door to needle” or from onset of pain till “door to needle” or from onset of pain till thrombolytic thrombolytic therapy within 30 minutes therapy within 30 minutes or PTCA within 1 houror PTCA within 1 hour

�� Watch out for signs of Watch out for signs of bleedingbleeding and and hyphypersensitivity reactionersensitivity reaction ( Streptokinase )( Streptokinase )

�� IV infusion IV infusion




-- targets the platelet component of the targets the platelet component of the thrombus to prevent fibrinogen from thrombus to prevent fibrinogen from attaching to activated attaching to activated platelets at the platelets at the attaching to activated attaching to activated platelets at the platelets at the site of the thrombussite of the thrombus

-- Examples: Examples: AbciximabAbciximab, , EptifibatideEptifibatide, , TirofibanTirofiban

-- Administered through IVAdministered through IV


Glycoprotein IIB/IIIA Glycoprotein IIB/IIIA InhibitorsInhibitors Examples: Examples: AbciximabAbciximab, , EptifibatideEptifibatide, , TirofibanTirofiban


AspirinAspirin

� Swallow the tablets with a full glass of water.

�� Taken as regular (not entericTaken as regular (not enteric--coated) lowcoated) low--dose aspirin.dose aspirin.dose aspirin.dose aspirin.� Swallow the extended-release tablets whole with

a full glass of water. Do not break, crush, or chew them.

� Chewable aspirin tablets may be chewed, crushed, or swallowed whole.

� Drink a full glass of water, immediately after taking these tablets.


AspirinAspirin

� If taking aspirin on a regular basis to prevent

heart attack or stroke, do not take ibuprofen

(Advil, Motrin) or other NSAIDs to treat pain

or fever (Ibuprofen can interfere with the anti-or fever (Ibuprofen can interfere with the anti-

platelet effect of low dose aspirin)

� If need only a single dose of ibuprofen, take it

eight hours before or 30 minutes after taking

a regular (not enteric-coated) low-dose

aspirin.


AspirinAspirin

� Ask a doctor before giving aspirin to child or

teenager.

� Aspirin may cause Reye's syndrome (a serious

condition in which fat builds up on the brain, liver, condition in which fat builds up on the brain, liver,

and other body organs) in children and teenagers,

especially if they have a virus such as chicken pox

or the flu.


ClopidogrelClopidogrel

�� PlavixPlavix

�� when combined with when combined with aspirin , more aspirin , more effective in reducing effective in reducing effective in reducing effective in reducing death, MI or stroke death, MI or stroke when compared to when compared to aspirin aloneaspirin alone


Nrg Considerations: Aspirin and

Plavix

� teach: may bleed more

easily or for a longer

time than usual while

you are taking

� if having surgery,

including dental

surgery, tell doctor or

dentist that taking you are taking

clopidogrel. Be careful

not to cut or hurt

dentist that taking

aspirin or Plavix


Beta blockers Beta blockers –– MetoprololMetoprolol

�� reduces myocardial O2 requirement by reduces myocardial O2 requirement by blocking beta receptors and slowing heart rate, blocking beta receptors and slowing heart rate, prolong diastole and increase myocardial prolong diastole and increase myocardial perfusionperfusion

� aka: beta-adrenergic blocking agents� aka: beta-adrenergic blocking agents

� reduces myocardial O2 requirement by blocking beta receptors and slowing heart rate, prolong diastole and increase myocardial perfusion

� Ex: Metoprolol, Acebutolol (Sectral), Atenolol(Tenormin), Bisoprolol (Zebeta), Propranolol(Inderal LA)


Let’s reviewLet’s review


Angiotensin-converting enzyme (ACE)

Inhibitors

�� given within 48 hours of given within 48 hours of MI prevents ventricular MI prevents ventricular remodeling and remodeling and development of CHFdevelopment of CHF

� help relax blood vessels

� Benazepril (Lotensin)

� Captopril

� Enalapril (Vasotec)

� Fosinopril� Fosinopril

� Lisinopril (Prinivil, Zestril)

� Moexipril (Univasc)

� Perindopril (Aceon)

� Quinapril (Accupril)

� Ramipril (Altace)

� Trandolapril (Mavik)


ACE Inhibitors

� In some people the first dose can cause a drop in blood pressure immediately. The following is advice for starting ACE inhibitors:� If taking a diuretic (water tablet), may be advised not to take it

for a day or so before starting an ACE inhibitor.

� After the very first dose, on the first day start an ACE inhibitor: � After the very first dose, on the first day start an ACE inhibitor:

� Stay indoors for about four hours, as occasionally some people feel dizzy.

� If you do feel dizzy, sit or lie down and it will usually ease off.

� If you become very dizzy, contact your doctor immediately.

� Thereafter, there is no need to take any special precautions.

8/9/2012CLDomocmat 39http://www.patient.co.uk/health/ACE-Inhibitors.htm

ACE InhibitorsACE Inhibitors


Let’s review: Let’s review: Ineffective Tissue perfusionIneffective Tissue perfusion



3. 3. Antiplatelets� Aspirin � Aspirin

� Clopidogrel

4. Beta blockers

5. ACE Inhibitors


related to imbalance between oxygen related to imbalance between oxygen supply and demandsupply and demand

Activity Intolerance Activity Intolerance


Activity Intolerance Activity Intolerance

1. Bed rest with commode privilege for only 241. Bed rest with commode privilege for only 24--

48 hours unless with complications.48 hours unless with complications.

2. Explain that the purpose of CCU confinement 2. Explain that the purpose of CCU confinement

is for continuous monitoring and safety during is for continuous monitoring and safety during is for continuous monitoring and safety during is for continuous monitoring and safety during

the early recovery period.the early recovery period.

3. Administer diazepam as ordered3. Administer diazepam as ordered

4. Provide psychosocial support to the patient 4. Provide psychosocial support to the patient

and his family. Calmness and competency are and his family. Calmness and competency are

extremely reassuring. extremely reassuring.


Cardiac RehabilitationCardiac Rehabilitation

�� actively assisting the client in achieving and actively assisting the client in achieving and maintaining a vital and productive life while maintaining a vital and productive life while remaining within the limits of the hearts ability to remaining within the limits of the hearts ability to respond to increases in activity and stressrespond to increases in activity and stress

�� begins the moment a client is admitted to the begins the moment a client is admitted to the �� begins the moment a client is admitted to the begins the moment a client is admitted to the hospital hospital

�� 3 Phases3 Phases�� 1. From acute illness and ends with 1. From acute illness and ends with discharge from discharge from

the hospital the hospital

�� 2. After discharge and continues through 2. After discharge and continues through convalescence at homeconvalescence at home

�� 3. Long term conditioning3. Long term conditioning


Program of Physical ActivityProgram of Physical Activity

1.1. Increase activities gradually after the first 24Increase activities gradually after the first 24--48 hours48 hours

2.2. Early mobilization after an MI. May be allowed Early mobilization after an MI. May be allowed to sit on a chair for increasing periods of time to sit on a chair for increasing periods of time and begins ambulation on the 4and begins ambulation on the 4thth or 5or 5thth daydayand begins ambulation on the 4and begins ambulation on the 4thth or 5or 5thth dayday

3.3. Monitor V/S before activities.Monitor V/S before activities.

4.4. An exercise session is terminated if any one of An exercise session is terminated if any one of the following the following occurs:cyanosisoccurs:cyanosis, cold sweats, , cold sweats, faintness, extreme fatigue, severe dyspnea, faintness, extreme fatigue, severe dyspnea, pallor, chest pain, PR > 100, dysrhythmias, Bp pallor, chest pain, PR > 100, dysrhythmias, Bp > 160/90> 160/90


55 Physical Activity: Physical Activity: Sexual intercourse Sexual intercourse

�� 44--6 weeks post MI or when 6 weeks post MI or when a patient with a patient with uncomplicated MI is uncomplicated MI is capable of walking 2 flights capable of walking 2 flights capable of walking 2 flights capable of walking 2 flights of stairs without difficulty of stairs without difficulty

�� nitroglycerine before sexnitroglycerine before sex

�� avoid concomitant use with avoid concomitant use with SildenafilSildenafil


Sexual intercourse Sexual intercourse

� Perform sexual activity in a cool, familiar

environment

� Refrain from sexual activity during a fatiguing

day, after eating a large meal, or after drinking day, after eating a large meal, or after drinking

alcohol

� If dyspnea, chest pain, dizziness or palpitations

occur, moderation should be observed. If

symptoms persist stop sexual activity.


Sexual intercourse Sexual intercourse

�� assume position with less strain assume position with less strain

�� Ex: woman on top, side lyingEx: woman on top, side lying


Ineffective Coping Ineffective Coping

�� related to effects of acute illness, major related to effects of acute illness, major changes in lifestyle or loss of control changes in lifestyle or loss of control over a body partover a body part

1.1. AnxiolyticsAnxiolytics during the acute phase of illness during the acute phase of illness 1.1. AnxiolyticsAnxiolytics during the acute phase of illness during the acute phase of illness

2.2. Provide opportunity for the patient and family Provide opportunity for the patient and family to explore their concerns to explore their concerns

3.3. Identify clients coping mechanismIdentify clients coping mechanism

1.1. denial, anger and depressiondenial, anger and depression


Promote Nutrition and

Elimination� Provide small frequent feedings

� Low calorie, low cholesterol, low sodium

� Avoid stimulants

� Avoid taking very hot or very cold beverages and gas forming foods to prevent vasovagal

� Avoid taking very hot or very cold beverages and gas forming foods to prevent vasovagal stimulation

� Use of bedpan and straining at stool should be avoided. Avoid valsalva maneuver

� Bedside commode

� Administer stool softeners as ordered


Potential for recurrent symptoms Potential for recurrent symptoms & extension of injury & extension of injury

� Goal: minimal angina while engaging in ADLs and exercise program

� Ix� Percutaneous Transluminal coronary angioplasty � Percutaneous Transluminal coronary angioplasty

(PTCA)

� Coronary artery Bypass graft surgery (CABG)

� Minimally invasive Direct coronary artery bypass (MIDCAB)

� Transmyocardial Laser Vascularization

� Of-pump Coronary Artery Bypass (OPCAB)

� Robotics


Complications of MI

� Dysrhythmias

� Cardiogenic shock

� Thromboembolism

� Pericarditis

� Rupture of the myocardium

� Ventricular aneurysm

� CHF


Potential or dysrhythmiasPotential or dysrhythmias

� Identify

� Assess hemodynamic status

� Monitor cardiac rhythm and CR

� Evaluate for discomfort


DysrhythmiasDysrhythmias

�� most common complication and most major most common complication and most major cause of death among clients with MIcause of death among clients with MI

�� When Dysrhythmias develop the cardiac nurse When Dysrhythmias develop the cardiac nurse must:must:must:must:

�� 1. Identify the Dysrhythmias1. Identify the Dysrhythmias

�� 2. Assess the client’s hemodynamic status2. Assess the client’s hemodynamic status

�� 3. Evaluate the client for chest 3. Evaluate the client for chest discomfortdiscomfort

�� 4. attach to cardiac monitor4. attach to cardiac monitor


Inferior Wall MIInferior Wall MI-- bradycardiabradycardia –– atropineatropine-- second degree AV block second degree AV block –– PacemakerPacemaker

Anterior Wall MIAnterior Wall MI-- 33rdrd degree AV block degree AV block –– PacemakerPacemaker-- 33rdrd degree AV block degree AV block –– PacemakerPacemaker-- Ventricular irritabilityVentricular irritability-- PVC’s PVC’s –– the most common the most common dysrhythmiadysrhythmia in MIin MI

-- notify physician if more than 6 PVC’s notify physician if more than 6 PVC’s occur per minute and client is occur per minute and client is symptomatic (symptomatic (hypotensivehypotensive, chest pain), chest pain)


Potential for heart failurePotential for heart failure

� Goal: regain hemodynamic stability as

evidenced by:

� BP and PR – within client’s acceptable range and

adequate for metabolic demandsadequate for metabolic demands

� Adequate UO

� Mental alertness

� Clear lungs o auscultation

� Palpable peripheral pulses


Potential for heart failure (HF)Potential for heart failure (HF)

� Manage L ventricular failure

� Assess and monitor

� Classfication of Post MI HF (Killip I, II, III, IV)

� Relieve pain� Relieve pain

� Decrease myocardial O2 reqt

� Morphine

� O2

� Intra-aortic balloon pump

� Immediate reperfusion (L sided heart cath; PTCA,

CABG)


Potential for heart failure (HF)Potential for heart failure (HF)

� Manage R ventricular failure

� Enhance R ventricular preload

� IFI – as much as 200 ml/hr

� Monitor CO� Monitor CO

� Note: prevent dev L side HF :

� Aucultate lungs

� PAWP


Decreased Cardiac output Decreased Cardiac output

�� Heart Failure is a relatively common Heart Failure is a relatively common complication after an MIcomplication after an MI

�� results from left ventricular dysfunction, results from left ventricular dysfunction, �� results from left ventricular dysfunction, results from left ventricular dysfunction, rupture of the intrarupture of the intra--ventricular septum, ventricular septum, papillary muscle rupture with papillary muscle rupture with valvularvalvulardysfunction or dysfunction or cardiogeniccardiogenic shockshock


Medical Management for Medical Management for KillipKillip IVIV

�� Goal is to relieve pain and decrease myocardial O2 Goal is to relieve pain and decrease myocardial O2 demand through preload and possibly after load reductiondemand through preload and possibly after load reduction

1.1. IV morphineIV morphine

2.2. O2 therapyO2 therapy –– intubation and mechanical ventilationintubation and mechanical ventilation

3.3. Preload reductionPreload reduction –– nitroglycerin, nitroglycerin, nitroprussidenitroprusside, , 3.3. Preload reductionPreload reduction –– nitroglycerin, nitroglycerin, nitroprussidenitroprusside, , diuretics diuretics –– monitor BP constantlymonitor BP constantly

4.4. VasopressorVasopressor and and InotropesInotropes –– dopamine, dopamine, dobutaminedobutamine ––used to maintain organ perfusion but can increase O2 used to maintain organ perfusion but can increase O2 consumption and can worsen ischemiaconsumption and can worsen ischemia

5.5. IABPIABP


IntraIntra--aortic Balloon Pumpaortic Balloon Pump (IABP)(IABP)

�� used when clients do not respond to drug used when clients do not respond to drug therapy therapy

�� invasive intervention that is used to improve invasive intervention that is used to improve myocardial perfusion during an acute MI, myocardial perfusion during an acute MI, reduce after load and facilitate left ventricular reduce after load and facilitate left ventricular reduce after load and facilitate left ventricular reduce after load and facilitate left ventricular emptyingemptying

�� inflation of balloon during diastole increases inflation of balloon during diastole increases diastolic pressure and improves coronary diastolic pressure and improves coronary perfusionperfusion

�� deflation of the balloon before diastole reduces deflation of the balloon before diastole reduces after load at the time of systolic contractionafter load at the time of systolic contraction



http://www.fda.gov/ucm/groups/fdagov-public/documents/image/ucm064550.gif

YouTube - IABP Intraaortic Ballon Pump.flv

☺☺☺☺ Let’s watch how it works!

Video animation of IABP

Video of IABP in OR


http://www.fda.gov/ucm/groups/fdagov-public/documents/image/ucm064550.gif

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video downloads\videos cardi

OR

IABPIABP: What precautions to take?

� See handout

8/9/2012CLDomocmat 64http://www.fda.gov/ucm/groups/fdagov-public/documents/image/ucm064550.gif

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/news/printer.cfm?id=602

PAWP


r/t r/t phlebitis of the leg & pelvic veinsphlebitis of the leg & pelvic veins

ThromboembolismThromboembolism: Pulmonary Embolism: Pulmonary Embolism


Collaborative Management

� Anticoagulants� Thrombolytics� Move legs, avoid placing pressure under the knees,

elastic stockings� Early ambulation� Early ambulation� Observe for signs and symptoms indicative of

pulmonary embolism� Sudden onset of dyspnea� Chest pain� Coughing� Hemoptysis� Rapid weak pulse� Pallor


PericarditisPericarditis

�� 28% of post MI patients28% of post MI patients

�� 22--4 days post MI4 days post MI

�� inflamed areas of infarction rubs against the inflamed areas of infarction rubs against the pericardial surface causing it to lose pericardial surface causing it to lose pericardial surface causing it to lose pericardial surface causing it to lose lubricating fluidlubricating fluid


PericarditisPericarditis

�� Dressler’s syndrome Dressler’s syndrome (Late (Late PericarditisPericarditis))-- 6 6 weeks to months after MIweeks to months after MI

�� The client presents with fever lasting 1 week or The client presents with fever lasting 1 week or longer, pericardial chest pain, pericardial friction longer, pericardial chest pain, pericardial friction longer, pericardial chest pain, pericardial friction longer, pericardial chest pain, pericardial friction rub, and occasional pericardial effusionrub, and occasional pericardial effusion

�� self limitingself limiting

�� Bed rest, aspirin, prednisone, opioid analgesicsBed rest, aspirin, prednisone, opioid analgesics


Rupture of the myocardium

Mitral Regurgitation, VSD and Ventricular Aneurysm


Mitral Regurgitation ,VSD and Mitral Regurgitation ,VSD and Ventricular AneurysmVentricular Aneurysm

�� MR due to rupture of papillary muscle MR due to rupture of papillary muscle of LVof LV

�� thinning , ballooning and thinning , ballooning and hypokinesiahypokinesia of of �� thinning , ballooning and thinning , ballooning and hypokinesiahypokinesia of of the left the left ventricular wall after a ventricular wall after a transmuraltransmural MIMI

�� the dysfunctional area often becomes filled the dysfunctional area often becomes filled with necrotic debris and clot with necrotic debris and clot


Mitral Regurgitation ,VSD and Mitral Regurgitation ,VSD and Ventricular AneurysmVentricular Aneurysm

�� the aneurysm may rupture causing the aneurysm may rupture causing cardiac cardiac tamponadetamponade and deathand death

�� usually 7usually 7--10 days post MI10 days post MI�� usually 7usually 7--10 days post MI10 days post MI

�� report presence of new murmurreport presence of new murmur

�� PVC’sPVC’s-- due to irritability of necrotic due to irritability of necrotic tissuetissue


Management

�� arteriolar arteriolar vasodilationvasodilation -- to lower systemic to lower systemic pressurepressure

�� IABPIABP

�� surgerysurgery-- 44--6 weeks post MI6 weeks post MI�� surgerysurgery-- 44--6 weeks post MI6 weeks post MI

�� excise ventricular aneurysmexcise ventricular aneurysm

�� replace mitral valvereplace mitral valve

�� repair VSDrepair VSD

�� pericardiocentesispericardiocentesis for for tamponadetamponade


SURGICAL TREATMENT SURGICAL TREATMENT


Surgical Treatment Surgical Treatment

� PCI or PTCA

� Coronary artery Bypass graft surgery

� Off-pump Coronary Artery Bypass � Off-pump Coronary Artery Bypass

� Minimally invasive Direct coronary artery

bypass

� Transmyocardial Laser revascularization

� Open heart surgery


Percutaneous Coronary

Interventions (PCI)


PCI

� AKA: Percutaneous transluminal coronary

angioplasty� Balloon angioplasty

� Laser with balloon angioplasty � Laser with balloon angioplasty

� Stent

� Atherectomy

� Brachytherapy


PTCAPTCA

� an invasive procedure used to eliminate

stenosis in the coronary arteries by

insertion a catheter through the skin and

moving forward through the veins. At the moving forward through the veins. At the

last stage,a balloon catheter is inserted in

the coronary arterial lesion and the balloon

is inflated at the level of occlusion to open

the lumen


PTCA: typesPTCA: types

1. Percutaneous Coronary Laser Angioplasty or Laser with balloon angioplasty

2. Placement of Percutaneous 2. Placement of Percutaneous Coronary Stent

3. Percutaneous Coronary Atherectomy

4. Brachytherapy


Angioplasty stent

http://www.youtube.com/watch?v=77fPzbExkxA&feature=relatedCLDomocmat 8/9/2012 82

PTCA: Lasers with balloon PTCA: Lasers with balloon angioplastyangioplasty�� creates a smoother creates a smoother

lumen of the blood lumen of the blood vesselvessel


Video: Video: Lasers angioplastyLasers angioplasty

PTCA: PTCA: Directional coronary Directional coronary atherectomy atherectomy

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video downloads\videos cardiAtherectomy video


video

Nursing ManagementNursing Management

� Same Preop prep

� Consent for procedure

� NPO 8 hrs� NPO 8 hrs

� Skin prep – shave bilateral groins

� etc


Nursing Nursing Management: Management: Post-op

� VS, monitor for complications (AMI,Spasm)

� Assess for development of crackles, wheezes, tachypnea, frothy sputum, S3 wheezes, tachypnea, frothy sputum, S3 heart sound

� Administer medications as ordered� Anti-coagulation with aspirin/heparin

� SL Nifedipine – to prevent coronary spasm

� Glycoprotein IIb/IIIA – prevent restenosis


Nursing Nursing Management: Management: Post-op

� Monitor for signs of poor organ perfusion� Change in LOC

� Oliguria

� Cool, clammy extremities with decreased pulsesCool, clammy extremities with decreased pulses

� Unusual fatigue

� Recurrent chest pain

� Monitor right atrial pressure , pulmonary artery wedge pressure (measure of preload) by using the Swan Ganz catheter� if < 18mmHg do volume infusion or administer

inotropes


Nursing ManagementNursing Management

� Nursing care of client having PCIAdobe Acrobat

Document


Coronary artery Bypass graft

surgery (CABG)


CABG

�� bypass of a blockage in arterybypass of a blockage in artery

�� use of use of saphenoussaphenous vein or internal vein or internal mammary artery mammary artery (graft of choice because it (graft of choice because it has a 90% patency rate after the procedure)has a 90% patency rate after the procedure)has a 90% patency rate after the procedure)has a 90% patency rate after the procedure)

�� reduces 80reduces 80--90% of symptoms90% of symptoms

�� indicated when clients do not respond to indicated when clients do not respond to medical management of CAD or when medical management of CAD or when disease progression is evidentdisease progression is evident

�� cardiopulmonary bypass neededcardiopulmonary bypass needed


CABG

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Let us watch! Animation of Heart Bypass

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Let us watch! CABG in the OR

8/9/2012CLDomocmat 91http://video.about.com/heartdisease/OPCAB.htm

Animation of Heart Bypass Surgery (CABG)

CABG in the OR

Heart-lung bypass machine or

Extracorporeal circulation (ECC)



Extracorporeal circulation



Extracorporeal circulation

(ECC)


� Nursing care of client undergoing CABGAdobe Acrobat

Document


Off-pump Coronary Artery

Bypass (OPCAB)� "beating heart" surgery

http://video.about.com/heartdisease/OPCAB.htm


OPCAB

http://www.qualityhealth.com/health-encyclopedia/surgeries-procedures/heart-bypass-surgery-seriesCLDomocmat 8/9/2012 100

OPCAB


Minimally Invasive Direct

Coronary Artery Bypass

(MIDCAB)


Minimally invasive Direct

coronary artery bypass

(MIDCAB)

� indicated for clients with a lesion of the left

anterior descending arteryanterior descending artery

� left thoracotomy incision with removal of 4th rib

� dissection of the left IMA and attached to the

still beating heart below the level of the lesion in

the LAD

� no cardiopulmonary bypass needed


TECAB

� Totally Endoscopic, Minimally Invasive Coronary Bypass Surgery : High-Precision Robotic Precision Robotic Surgery Without any Opening of the Chest

� The daVinci robot's "wristed" instruments provide a greater range of motion than the human hand while eliminating physician tremor.


TECAB

http://www.umm.edu/heart/tecab.htm CLDomocmat 8/9/2012 107

TransMyocardial

Laser Revascularization

(TMLR)

� Laser ablation


TMLR

� a procedure used to relieve severe angina or chest pain in very ill patients who aren't candidates for bypass surgery or angioplasty.

� Procedure a surgeon makes an incision on the left breast to expose the � a surgeon makes an incision on the left breast to expose the heart.

� Then, using a laser, the surgeon drills a series of holes from the outside of the heart into the heart's pumping chamber.

� From 20 to 40 mm laser channels are placed during the procedure.

� Bleeding from the laser channels on the outside of the heart stops after a few minutes of pressure from the surgeon's finger.

� In some patients TMR is combined with bypass surgery. In those cases an incision through the breastbone is used.

8/9/2012CLDomocmat 109http://www.americanheart.org/presenter.jhtml?identifier=4782

TMLR

� How does it work?

� How TMR reduces angina still isn't fully understood.

� The laser may stimulate new blood vessels to grow,

called angiogenesis called angiogenesis

� It may destroy nerve fibers to the heart, making

patients unable to feel their chest pain.http://www.americanheart.org/presenter.jhtml?identifier=4782

� The heart feeds itself by taking blood from within its

chambers, just like in reptiles, whose hearts have no

coronary arteries. http://www.texheartsurgeons.com/TMLR.htm


� Indications

� people who are high-risk candidates for a second

bypass or angioplasty.

� people whose blockages are too diffuse to be � people whose blockages are too diffuse to be

treated with bypass alone.

� some patients with heart transplants who develop

atherosclerosis after their transplant.


TMLR: Before


http://www.texheartsurgeons.com/Images/TMLRchanls.jpg

TMLR: After


http://www.texheartsurgeons.com/Images/TMLRchanls.jpg

TMLR


Transmyocardial

revascularization

G:\E CARMELA\


An animation of the transmyocardialrevascularization procedure


Other sources

� Cardiac surgery/Open heart surgery � http://www.medicalvideos.us/play.php?vid=1297

� http://video.about.com/heartdisease/Heart-Lung-Machine.htm

� Atherosclerosis� http://www.youtube.com/watch?v=OHE1ig4k64M&feature

=related=related

� Heart Attack� http://www.youtube.com/watch?v=EQVEdFSlUGU&featur

e=channel

� Coronary Artery Angioplasty (PCI, Heart Stent Surgery)

� http://www.youtube.com/watch?v=N7nghr9TpSU&feature=related


ETC…


Cardiac tamponade

� is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium).

� Cardiac tamponade is a condition involving compression of the heart caused by blood or fluid accumulation in the the heart caused by blood or fluid accumulation in the space between the myocardium (the muscle of the heart) and the pericardium (the outer covering sac of the heart). Blood or fluid collects within the pericardium. This prevents the ventricles from expanding fully, so they cannot adequately fill or pump blood. Cardiac tamponade is an emergency condition that requires hospitalization.


pulsus paradoxus

� an abnormal inspiratory decrease in arterial

blood pressure, seen in cardiac tamponade

and caused by a decreased pulmonary venous

return.return.


http://medical-dictionary.thefreedictionary.com/pulsus+paradoxus

inotropic agent

� any of a class of agents affecting the force of

muscle contraction, particularly a drug

affecting the force of cardiac contraction;

positive inotropic agents increase, and positive inotropic agents increase, and

negative inotropic agents decrease the force

of cardiac muscle contraction.


� Drugs affect the function of the heart in three

main ways. They can affect the force of

contraction of the heart muscle (inotropic

effects); they can affect the frequency of the effects); they can affect the frequency of the

heartbeat, or heart rate (chronotropic

effects); or they can affect the regularity of

the heartbeat (rhythmic effects).


http://www.britannica.com/EBchecked/topic/171942/drug/233954/Drugs-affecting-the-heart?anchor=ref295300

� Inotropic agents

� A drug may be classified by the chemical type of the active ingredient or by the way it is used to treat a particular condition. Each drug can be classified into one or more drug classes.

� Inotropic agents affect the contraction of the heart muscle. Positive inotropes stimulate and increase the strength of heart muscle contraction causing the heart rate to increase. Negative inotropiccontraction causing the heart rate to increase. Negative inotropicagents weaken the force of muscular contractions.

� Inotropic state depends on the amount of calcium in the cytoplasm of the heart muscle wall, as contractility of the heart depends on control of intracellular calcium i.e. control of calcium entry into the cell membrane and calcium storage in the sarcoplasmic reticulum. The main factors controlling calcium entry are activity of voltage gated calcium channels and sodium ions, which affects calcium/sodium ion exchange.

� Positive inotropes usually increase the level of intracellular calcium and negative inotropes decrease it.


Inotropic agents

� Digoxin

� Dobutamine

� Milrinone


pulsus paradoxus

� also paradoxic pulse or paradoxical pulse, is defined as an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration.

� The normal fall in pressure is less than 10 mmHg or 10 torr. When the drop is more than 10mm Hg, it is referred to as pulsus paradoxus. pulsus paradoxus.

� has nothing to do with pulse rate or heart rate. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation/inspiration and an increase during exhalation/expiration.

� is a sign that is indicative of several conditions, including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD).


http://en.wikipedia.org/wiki/Pulsus_paradoxus

CTT


� Pleur-evacⓇ

Adult/Pediatric Chest Drainage Model A-6000. The Pleur-evacChest Drainage Chest Drainage Systems have been the world's most popular units since their inception in 1967. (Courtesy of Deknatel, Inc., Fall River, MA.)


� 1. Standard percutaneous access to the

venous system is performed.


� 2. The Trellis catheter is advanced through

the clot over a standard 0.035" guidewire.


� 3. The distal occluding balloon is inflated.


� 4. After the proximal occluding balloon is

inflated, delivery of the thrombolytic agent

begins.


� 5. The Trellis dispersion wire is activated with

the motor drive unit.


� 6. Clot dispersion continues.


� 7. After clot is dispersed, remaining material

is aspirated through the Trellis catheter.


� 8. The Trellis catheter and guidewire are

withdrawn when treatment is complete.


nursing care of client with coronary artery disease part 2 of 2

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